Emergency Department Management of Status Epilepticus in Pediatric Patients (Pharmacology CME)

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Publication Date: July 2025 (Volume 22, Number 7)

CME Credits: 4 AMA PRA Category 1 Credits™, 4 ACEP Category I Credits, 4 AAP Prescribed Credits, 4 AOA Category 2-B Credits. CME expires 07/01/2028.

Specialty CME Credits: Included as part of the 4 credits, this CME activity is eligible for 2 Pharmacology CME credit, subject to your state and institutional approval.

Authors

Peer Reviewers

Abstract

Pediatric status epilepticus requires prompt recognition and treatment in the emergency department. When left untreated, status epilepticus can lead to neuronal death, neuronal injury, and alteration of neuronal networks, depending on the type and duration of the seizures. This issue reviews the International League Against Epilepsy definition of status epilepticus and provides recommendations for the evaluation and management of pediatric patients presenting to the emergency department in status epilepticus.

Case Presentations

A 48-day-old boy presents to the emergency department for poor feeding…

• The mother tells you the infant is breastfed, and that she thinks that he is not getting enough milk.
• On examination, the boy’s vital signs are: rectal temperature, 36.6°C; heart rate, 180 beats/min; blood pressure, 80/40 mm Hg; respiratory rate, 40 breaths/min; and oxygen saturation, 95% on room air. Tonic-clonic movements of the arms and legs with deviation of the eyes are noted, during which the infant is not interacting with the parent. This activity has been going on for 5 minutes. The neurologic examination is otherwise nonfocal. The airway is intact, and the infant is breathing spontaneously. Capillary refill is 3 seconds. Tympanic membranes are normal, and the anterior fontanelle is open and flat. No scalp swelling or skin bruising is noted.
• Based on the patient’s age and presentation, what differential diagnoses should be considered? What testing should be performed in the first 5 minutes following presentation? What medication or treatment will abort seizure activity?

A 7-month-old girl presents to the emergency department with fever and a seizure lasting 5 minutes…

• The girl’s mother tells you the child is fully immunized and has had a runny nose for the past 3 days and fever for 1 day.
• On examination, the girl’s vital signs are: temperature, 39.4°C; heart rate, 150 beats/min; blood pressure, 82/50 mm Hg; respiratory rate, 32 breaths/min; and oxygen saturation, 94% on room air. The girl’s airway is intact and she is breathing spontaneously, with clear breath sounds bilaterally. Her capillary refill is 2 seconds. Her tympanic membranes are normal, and her anterior fontanelle is open and flat. No scalp swelling or skin bruising is noted. The neurologic examination is nonfocal, and no further seizure activity is noted.
• Based on the patient’s age and presentation, what is the most likely differential diagnosis? Does this patient require a lumbar puncture? What medications should you consider administering?

A 6-year-old medically complex boy with a ventriculoperitoneal shunt and seizure disorder presents to the emergency department with seizure activity...

• The patient takes levetiracetam at home for seizures. Diazepam per rectum was given by the mother, but seizure activity persists.
• On examination, the boy’s vital signs are: temperature, 36.4°C; heart rate, 132 beats/min, blood pressure, 165/85 mm Hg; respiratory rate, 24 breaths/min; and oxygen saturation, 95% on room air. The boy’s airway is intact, and he is breathing spontaneously. Capillary refill is 2 seconds. The patient has tonic-clonic movements of the bilateral upper and lower extremities, with eyes deviated to the left. The neurologic examination is otherwise nonfocal.
• You order a bedside glucose test, comprehensive metabolic panel, magnesium, phosphorus, urine toxicology and urinalysis, computed tomography brain, and shunt x-rays.
• How does the presence of a ventriculoperitoneal shunt impact the differential diagnosis? Does the presence of the shunt change management? What medication should you give next?

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