Clinical Commander

Back to dossier
peds.status_epilepticus.v1PRODUCTION
peds.status_epilepticus.v1

Pediatric status epilepticus

pediatricsacutepediatricneonatal
Hard-required inputs
0 / 12
Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Confirm seizure (vs syncope, rigors, PNES); convulsive vs non-convulsive; SE definition met (ILAE 2015; NCS/AES 2016 Glauser)

Inputs
2
Actions
0
Advance rule
Set
Advance when

SE confirmed

Patient inputs (18)

<2 yr — pyridoxine trial, ammonia for IEM; valproate hepatotoxicity if <2 (NCS/AES 2016 Glauser)

All AED dosing weight-based (NCS/AES 2016 Glauser; ESETT Kapur NEJM 2019)

Febrile precipitant; encephalitis (NCS/AES 2016 Glauser)

Breakthrough vs new (NCS/AES 2016 Glauser)

Febrile SE / encephalitis (NCS/AES 2016 Glauser)

Structural cause (NCS/AES 2016 Glauser)

Hypoglycemia is a reversible cause (NCS/AES 2016 Glauser)

Hyponatremia precipitant (NCS/AES 2016 Glauser)

Reversible electrolyte cause (NCS/AES 2016 Glauser)

Hypoxia is a treatable contributor (NCS/AES 2016 Glauser)

Avoid AED-induced hypotension (NCS/AES 2016 Glauser)

Bradycardia from fosphenytoin (NCS/AES 2016 Glauser)

IEM screening in young infant + persistent SE (NCS/AES 2016 Glauser)

Intoxication / accidental ingestion (NCS/AES 2016 Glauser)

Structural lesion (NCS/AES 2016 Glauser)

NCSE detection; titration of stage 3 (NCS/AES 2016 Glauser)

Adherence assessment in known epilepsy (NCS/AES 2016 Glauser)

Prolonged seizure → rhabdo + lactic acidosis (NCS/AES 2016 Glauser)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (14)

14 need judgement
  • informationallife_threateningrefractory_se_after_two_AEDs — AES 2016
    Persistent seizure after Stage 1 benzo + Stage 2 AED (typically >=40 min) (NCS/AES 2016 Glauser; ESETT Kapur NEJM 2019)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningsuper_refractory_se_24h — AES 2016
    Persistent / recurrent seizure >=24 h despite anesthetic infusion (NCS/AES 2016 Glauser)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningrefractory_se
    Failure of benzodiazepine + 1 second-line agent at 30+ min from seizure onset — refractory SE per AES/NCS 2016 + ILAE 2015 definitions (NCS/AES 2016 Glauser PMID 26900382; ILAE 2015 Trinka PMID 26336905)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningsuper_refractory_se
    ≥ 24 h on anesthetic infusion without seizure cessation OR recurrent SE on attempt to wean anesthetic — super-refractory SE per ILAE 2015 (NCS/AES 2016 Glauser; ILAE 2015 Trinka)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningairway_compromise_during_se
    RR / SpO2 deterioration, aspiration during convulsive activity, or inability to protect airway during SE — life-threatening hypoxic injury risk (NCS/AES 2016 Glauser)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningfires_norse_pattern
    New-onset SE in previously well child with prodromal febrile illness 24 h - 2 wk before onset (FIRES); OR new-onset SE in previously well adult/adolescent without clear acute/active structural/toxic/metabolic cause (NORSE) — high mortality + severe morbidity pattern (Hirsch consensus 2018; AES/NCS 2016 Glauser)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverehypoglycemia_at_presentation_se — AES 2016
    Fingerstick BG <60 in infant or <70 in older child during SE (NCS/AES 2016 Glauser)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverefebrile_se_with_altered_mental_status — AES 2016
    Fever + SE + altered baseline in child (NCS/AES 2016 Glauser)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereinfant_refractory_se — AES 2016
    Refractory SE in infant <18 mo (NCS/AES 2016 Glauser)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevererhabdo_after_prolonged_se — AES 2016
    CK >5000 + AKI after prolonged SE (NCS/AES 2016 Glauser)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepersistent_ncse_on_eeg
    Convulsive seizure cessation clinically but cEEG shows ongoing non-convulsive SE (electrographic SE despite no overt motor activity) — common after Stage 2-3 treatment; missed without cEEG (NCS/AES 2016 Glauser)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereautoimmune_encephalitis_features_in_se
    Subacute prodrome (behaviour change, agitation, psychosis, dyskinesia, autonomic dysfunction) + new SE + CSF lymphocytic pleocytosis + MRI temporal/frontal T2/FLAIR changes — high probability of anti-NMDAR or other autoimmune encephalitis (Dalmau Lancet Neurol 2011 PMID 21163445)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepyridoxine_responsive_features
    Neonate / infant (< 18 mo) with refractory SE + EEG burst-suppression + no clear etiology after initial workup — possible pyridoxine-dependent epilepsy OR folinic-acid-responsive seizure; rare but reversible (NCS/AES 2016 Glauser)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatecardiac_compromise_on_fosphenytoin — AES 2016
    Bradycardia or hypotension during fosphenytoin loading (NCS/AES 2016 Glauser)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

TREATMENToptionalDrives dose adjustment
Loading…

Recommended regimen

Pediatric SE — Stage 1 abortive → Stage 2 second-line → Stage 3 anesthetic
axis: peds_se_stage1_to_3
Selected axis "Pediatric SE — Stage 1 abortive → Stage 2 second-line → Stage 3 anesthetic" by default fallback (first axis)
  • lorazepam
    first line
    benzodiazepine
    0.1 mg/kg IV (max 4 mg per dose) • IV • q5 min × 2 max (max: 4 mg per dose, 8 mg cumulative)
    triggers: IV_access_available, Stage_1
    NCS/AES 2016 Glauser — first-line IV benzo; RAMPART Silbergleit NEJM 2012 comparator arm
    rxcui 6470
  • midazolam
    first line
    benzodiazepine
    0.2 mg/kg IM (max 10 mg) OR 0.2 mg/kg IN OR 0.5 mg/kg buccal • IM/IN/buccal • single dose (max: 10 mg)
    triggers: no_IV_access, Stage_1
    RAMPART (Silbergleit NEJM 2012 PMID 22335736) — IM midazolam non-inferior to IV lorazepam; ConSEPT/EcLiPSE Lancet 2019 supports IN/buccal in peds
    rxcui 6960
  • diazepam
    add on
    benzodiazepine
    0.2-0.5 mg/kg PR (max 20 mg) if no IV/IM/IN access • PR • single
    triggers: no_other_access_outpatient_or_home_kit
    Home rescue + EMS (NCS/AES 2016 Glauser)
    rxcui 3322
  • fosphenytoin
    first line
    AED_sodium_channel
    20 PE/kg IV at max 3 PE/kg/min (max 1500 mg PE) • IV • single load (max: 1500 mg PE)
    triggers: benzo_failed_Stage_2
    ESETT (Kapur NEJM 2019 PMID 31774955) — equivalent to LEV and VPA in peds; NCS/AES 2016 Glauser
    rxcui 72236
  • levetiracetam
    first line
    AED
    60 mg/kg IV (max 4500 mg) over 15 min • IV • single load (max: 4500 mg)
    triggers: benzo_failed_Stage_2
    ESETT (Kapur NEJM 2019) — equivalent; preferred when avoiding cardiac monitoring or hepatic metabolism; ConSEPT/EcLiPSE Lancet 2019
    rxcui 114477
  • valproate
    first line
    AED_branched_chain_fatty_acid
    40 mg/kg IV (max 3000 mg) over 10 min • IV • single load (max: 3000 mg)
    triggers: benzo_failed_Stage_2, age_>=2_no_metabolic_disease
    ESETT (Kapur NEJM 2019) — equivalent; AVOID in <2 yr hepatotoxicity, urea cycle disorder, mitochondrial (NCS/AES 2016 Glauser)
    rxcui 11118
  • midazolam_infusion
    first line
    benzodiazepine_infusion
    0.2 mg/kg IV bolus then 0.1-2 mg/kg/h infusion (titrate to seizure cessation or burst-suppression) • IV • continuous (max: 2 mg/kg/h)
    triggers: refractory_SE_Stage_3
    Preferred Stage 3 anesthetic — less hemodynamic impact than pentobarbital (NCS/AES 2016 Glauser)
    rxcui 6960
  • pentobarbital
    rescue
    barbiturate_infusion
    5 mg/kg IV load then 1-3 mg/kg/h • IV • continuous
    triggers: refractory_to_midazolam_infusion
    Burst suppression; hypotension + ileus (NCS/AES 2016 Glauser)
    rxcui 8004
  • ketamine
    rescue
    NMDA_antagonist_anesthetic
    1-2 mg/kg IV load then 1-3 mg/kg/h infusion • IV • continuous
    triggers: super_refractory_SE
    NMDA blockade preserved when GABA receptors downregulated; less hypotension than barbiturate (NCS/AES 2016 Glauser expert consensus)
    rxcui 6130
  • pyridoxine
    rescue
    vitamin_B6
    100 mg IV • IV • single, may repeat
    triggers: neonatal_or_infant_refractory_SE
    Pyridoxine-dependent epilepsy trial in infants <18 mo with refractory SE (NCS/AES 2016 Glauser)
    rxcui 203164
  • dextrose_25
    rescue
    simple_sugar
    0.5-1 g/kg IV • IV • single
    triggers: hypoglycemia_at_presentation
    Reverse hypoglycemia-induced seizure (NCS/AES 2016 Glauser)
    rxcui 4850
  • magnesium_sulfate
    rescue
    electrolyte
    25-50 mg/kg IV (max 2 g) • IV • single
    triggers: hypomagnesemia
    Reverse Mg-deficient seizure (NCS/AES 2016 Glauser)
    rxcui 6585

outpatient playbook — drug actions (9)

  1. 1. levetiracetam — chronic maintenance (most common peds first-line)
    rxcui 114477
    20-40 mg/kg/d divided BID (max 3000 mg/d typical pediatric); titrate by 10-20 mg/kg/d q1-2 wk • PO • BID
    trigger: Discharge after first SE OR known epilepsy
    Pediatric first-line AED — broad-spectrum, no cardiac monitoring, no hepatic enzyme induction, no drug-interaction burden; EcLiPSE/ConSEPT support efficacy
  2. 2. valproate — chronic maintenance (broad-spectrum, AVOID in < 2 yr / mitochondrial / hepatic / pregnant adolescents)
    rxcui 11118
    15-30 mg/kg/d divided BID-TID; titrate q1-2 wk by 5-10 mg/kg/d to target trough • PO • BID-TID
    trigger: Generalized epilepsy / multiple seizure types AND age ≥ 2 yr AND no hepatic / mitochondrial / pregnancy concerns
    Broad-spectrum alternative to LEV; absolute teratogenicity warning for adolescent females
  3. 3. lamotrigine — chronic (focal + generalized; slow titration to avoid SJS)
    rxcui 28439
    0.3 mg/kg/d wk 1-2 → 0.6 mg/kg/d wk 3-4 → target 5-15 mg/kg/d; SLOW titration mandatory • PO • BID
    trigger: Focal epilepsy OR absence + GTCS OR pregnancy-planning adolescent
    Lower teratogenicity; SLOW titration over 6-8 weeks to avoid Stevens-Johnson syndrome (especially with valproate co-therapy)
  4. 4. ethosuximide — chronic (absence-only)
    rxcui 4135
    15-40 mg/kg/d divided BID (max 1500 mg/d) • PO • BID
    trigger: Pure absence epilepsy without GTCS
    First-line absence per ILAE; ineffective for GTCS — confirm semiology before choosing
  5. 5. oxcarbazepine — chronic (focal epilepsy)
    rxcui 32624
    8-10 mg/kg/d divided BID, titrate to 30-46 mg/kg/d • PO • BID
    trigger: Focal epilepsy
    Better tolerability than carbamazepine; hyponatremia monitoring
  6. 6. intranasal midazolam — home rescue benzo
    rxcui 6960
    0.2 mg/kg IN (max 10 mg); pre-filled 5 mg / 10 mg device • IN • PRN for seizure > 5 min
    trigger: Home / school breakthrough seizure > 5 min
    RAMPART-validated rescue; family + school nurse trained; call 911 after administration
  7. 7. rectal diazepam — home rescue benzo (younger child)
    rxcui 3322
    0.2-0.5 mg/kg PR (max 20 mg); Diastat AcuDial 2.5/5/10/15/20 mg pre-filled syringes • PR • PRN for seizure > 5 min
    trigger: Home breakthrough seizure > 5 min, especially younger child
    Long-standing home rescue option; choose based on family preference + nasal availability
  8. 8. buccal midazolam — home rescue benzo (older child)
    rxcui 6960
    0.5 mg/kg buccal (max 10 mg) • buccal • PRN for seizure > 5 min
    trigger: Home breakthrough seizure > 5 min, older child
    Easier administration than rectal in older child + adolescent
  9. 9. folate 4 mg/d for adolescent females on teratogenic AEDs
    4 mg PO daily • PO • daily
    trigger: Adolescent female of childbearing potential on valproate / carbamazepine / phenobarbital / topiramate
    Reduces neural-tube-defect risk if pregnancy occurs (ILAE pregnancy task force)

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Ongoing seizure ≥5 min in a child (ILAE 2015 SE definition; NCS/AES 2016 Glauser); ≥2 seizures without recovery to baseline in a child (ILAE 2015 SE definition); Post-ictal child not returning to baseline — concern for non-convulsive SE (NCS/AES 2016 Glauser).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Pediatric status epilepticus** (peds.status_epilepticus.v1).
Phenotype framing: Febrile SE / breakthrough epilepsy / structural / metabolic / encephalitis / intox / anti-NMDAR / mitochondrial / pyridoxine-dependent (infant) (NCS/AES 2016 Glauser)
Scope: Confirm seizure (vs syncope, rigors, PNES); convulsive vs non-convulsive; SE definition met (ILAE 2015; NCS/AES 2016 Glauser)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Pediatric SE — Stage 1 abortive → Stage 2 second-line → Stage 3 anesthetic**.
1. lorazepam 0.1 mg/kg IV (max 4 mg per dose) IV q5 min × 2 max (benzodiazepine, first line) — NCS/AES 2016 Glauser — first-line IV benzo; RAMPART Silbergleit NEJM 2012 comparator arm
2. midazolam 0.2 mg/kg IM (max 10 mg) OR 0.2 mg/kg IN OR 0.5 mg/kg buccal IM/IN/buccal single dose (benzodiazepine, first line) — RAMPART (Silbergleit NEJM 2012 PMID 22335736) — IM midazolam non-inferior to IV lorazepam; ConSEPT/EcLiPSE Lancet 2019 supports IN/buccal in peds
3. diazepam 0.2-0.5 mg/kg PR (max 20 mg) if no IV/IM/IN access PR single (benzodiazepine, add on) — Home rescue + EMS (NCS/AES 2016 Glauser)
4. fosphenytoin 20 PE/kg IV at max 3 PE/kg/min (max 1500 mg PE) IV single load (AED_sodium_channel, first line) — ESETT (Kapur NEJM 2019 PMID 31774955) — equivalent to LEV and VPA in peds; NCS/AES 2016 Glauser
5. levetiracetam 60 mg/kg IV (max 4500 mg) over 15 min IV single load (AED, first line) — ESETT (Kapur NEJM 2019) — equivalent; preferred when avoiding cardiac monitoring or hepatic metabolism; ConSEPT/EcLiPSE Lancet 2019
6. valproate 40 mg/kg IV (max 3000 mg) over 10 min IV single load (AED_branched_chain_fatty_acid, first line) — ESETT (Kapur NEJM 2019) — equivalent; AVOID in <2 yr hepatotoxicity, urea cycle disorder, mitochondrial (NCS/AES 2016 Glauser)
7. midazolam_infusion 0.2 mg/kg IV bolus then 0.1-2 mg/kg/h infusion (titrate to seizure cessation or burst-suppression) IV continuous (benzodiazepine_infusion, first line) — Preferred Stage 3 anesthetic — less hemodynamic impact than pentobarbital (NCS/AES 2016 Glauser)
8. pentobarbital 5 mg/kg IV load then 1-3 mg/kg/h IV continuous (barbiturate_infusion, rescue) — Burst suppression; hypotension + ileus (NCS/AES 2016 Glauser)
9. ketamine 1-2 mg/kg IV load then 1-3 mg/kg/h infusion IV continuous (NMDA_antagonist_anesthetic, rescue) — NMDA blockade preserved when GABA receptors downregulated; less hypotension than barbiturate (NCS/AES 2016 Glauser expert consensus)
10. pyridoxine 100 mg IV IV single, may repeat (vitamin_B6, rescue) — Pyridoxine-dependent epilepsy trial in infants <18 mo with refractory SE (NCS/AES 2016 Glauser)
11. dextrose_25 0.5-1 g/kg IV IV single (simple_sugar, rescue) — Reverse hypoglycemia-induced seizure (NCS/AES 2016 Glauser)
12. magnesium_sulfate 25-50 mg/kg IV (max 2 g) IV single (electrolyte, rescue) — Reverse Mg-deficient seizure (NCS/AES 2016 Glauser)

Setting playbook (outpatient) — Pediatric neurology follow-up within 1 week of post-SE discharge — chronic AED titration, breakthrough-seizure home rescue plan, family + school education, psychosocial screen, SUDEP counseling, ketogenic-diet evaluation if super-refractory history (AES/NCS 2016 Glauser; ILAE chronic-epilepsy management)
13. levetiracetam — chronic maintenance (most common peds first-line) 20-40 mg/kg/d divided BID (max 3000 mg/d typical pediatric); titrate by 10-20 mg/kg/d q1-2 wk PO BID — Discharge after first SE OR known epilepsy (Pediatric first-line AED — broad-spectrum, no cardiac monitoring, no hepatic enzyme induction, no drug-interaction burden; EcLiPSE/ConSEPT support efficacy)
14. valproate — chronic maintenance (broad-spectrum, AVOID in < 2 yr / mitochondrial / hepatic / pregnant adolescents) 15-30 mg/kg/d divided BID-TID; titrate q1-2 wk by 5-10 mg/kg/d to target trough PO BID-TID — Generalized epilepsy / multiple seizure types AND age ≥ 2 yr AND no hepatic / mitochondrial / pregnancy concerns (Broad-spectrum alternative to LEV; absolute teratogenicity warning for adolescent females)
15. lamotrigine — chronic (focal + generalized; slow titration to avoid SJS) 0.3 mg/kg/d wk 1-2 → 0.6 mg/kg/d wk 3-4 → target 5-15 mg/kg/d; SLOW titration mandatory PO BID — Focal epilepsy OR absence + GTCS OR pregnancy-planning adolescent (Lower teratogenicity; SLOW titration over 6-8 weeks to avoid Stevens-Johnson syndrome (especially with valproate co-therapy))
16. ethosuximide — chronic (absence-only) 15-40 mg/kg/d divided BID (max 1500 mg/d) PO BID — Pure absence epilepsy without GTCS (First-line absence per ILAE; ineffective for GTCS — confirm semiology before choosing)
17. oxcarbazepine — chronic (focal epilepsy) 8-10 mg/kg/d divided BID, titrate to 30-46 mg/kg/d PO BID — Focal epilepsy (Better tolerability than carbamazepine; hyponatremia monitoring)
18. intranasal midazolam — home rescue benzo 0.2 mg/kg IN (max 10 mg); pre-filled 5 mg / 10 mg device IN PRN for seizure > 5 min — Home / school breakthrough seizure > 5 min (RAMPART-validated rescue; family + school nurse trained; call 911 after administration)
19. rectal diazepam — home rescue benzo (younger child) 0.2-0.5 mg/kg PR (max 20 mg); Diastat AcuDial 2.5/5/10/15/20 mg pre-filled syringes PR PRN for seizure > 5 min — Home breakthrough seizure > 5 min, especially younger child (Long-standing home rescue option; choose based on family preference + nasal availability)
20. buccal midazolam — home rescue benzo (older child) 0.5 mg/kg buccal (max 10 mg) buccal PRN for seizure > 5 min — Home breakthrough seizure > 5 min, older child (Easier administration than rectal in older child + adolescent)
21. folate 4 mg/d for adolescent females on teratogenic AEDs 4 mg PO daily PO daily — Adolescent female of childbearing potential on valproate / carbamazepine / phenobarbital / topiramate (Reduces neural-tube-defect risk if pregnancy occurs (ILAE pregnancy task force))

Non-pharmacologic actions:
- Pediatric neurology + epileptologist partnership for refractory cases (ILAE chronic-epilepsy management)
- Dietitian referral if ketogenic diet considered — 4:1 ratio fat:non-fat; close monitoring (Cervenka Neurology 2017)
- Mental-health referral if PedsQL Epilepsy positive OR PHQ-A ≥ 10 OR caregiver burden elevated (ILAE psychosocial consensus)
- School Seizure Action Plan + nurse training on rescue benzo + post-ictal positioning (ILAE school-management)
- Driving / employment counseling for adolescents (state-specific) (ILAE driving consensus)
- SUDEP discussion documented in chart (AAN SUDEP 2017)
- Genetic testing (epilepsy panel / WES) if early-onset / refractory / family history / developmental regression (ILAE genetics consensus)
- Epilepsy surgery evaluation if drug-resistant epilepsy (2 AEDs failed at therapeutic levels) (ILAE drug-resistant definition + surgery referral)
- Vagal nerve stimulator / responsive neurostimulator consideration if surgery not feasible (ILAE neuromodulation consensus)
- Patient + family resources — Epilepsy Foundation, local support groups, school IEP advocacy (ILAE patient-empowerment)

AVOID / contraindication checks:
- Valproate_avoid_under_2_yr_hepatotoxicity (NCS/AES 2016 Glauser; FDA black box)
- Fosphenytoin_cardiac_monitoring_bradycardia_hypotension (NCS/AES 2016 Glauser)
- No_IV_phenytoin_extravasation_risk_use_fosphenytoin (NCS/AES 2016 Glauser)
- LEV_renal_dose_adjust (ESETT Kapur NEJM 2019)
- Pentobarbital_hemodynamic_intensive_monitoring (NCS/AES 2016 Glauser)

Monitoring

Regimen monitoring:
- cEEG during stage 3 (NCS/AES 2016 Glauser)
- continuous telemetry (NCS/AES 2016 Glauser)
- q1h neuro check (NCS/AES 2016 Glauser)
- lactate CK AED levels (NCS/AES 2016 Glauser)
- pyridoxine trial documentation (NCS/AES 2016 Glauser)

Setting (outpatient) monitoring:
- Pediatric neurology q3-6 mo for stable epilepsy; q1-3 mo if refractory or recent SE (ILAE chronic-epilepsy management)
- AED levels at steady state + dose changes + breakthrough seizures (AES/NCS 2016 Glauser)
- Seizure-frequency log + side-effect inventory at every visit (ILAE chronic-epilepsy management)
- AED-specific labs — VPA: LFT + ammonia + platelets q3-6 mo; CBZ/OXC: Na + CBC q3-6 mo; LTG: rash check at every titration step (ILAE AED-monitoring consensus)
- CGM not applicable; consider seizure-tracking wearable + smartphone log (ILAE digital-health emerging)
- Annual EEG if seizure-free × 2 yr to inform AED-wean decision (ILAE AED-wean consensus)
- MRI brain repeat if breakthrough or new neuro deficits (ILAE imaging consensus)
- Mental-health rescreen annually OR sooner if new symptoms (ILAE psychosocial consensus)

Follow-up plan: Pediatric neurology, AED titration, family training (rescue benzo at home — diazepam rectal, midazolam buccal/IN) (NCS/AES 2016 Glauser; RAMPART Silbergleit NEJM 2012); MRI as needed
- Close-out criterion: Follow-up + family education arranged

Monitoring phase: cEEG, neurochecks, vitals, ammonia, lactate, CK, AED levels (NCS/AES 2016 Glauser)

Disposition

Current setting: outpatient — Pediatric neurology follow-up within 1 week of post-SE discharge — chronic AED titration, breakthrough-seizure home rescue plan, family + school education, psychosocial screen, SUDEP counseling, ketogenic-diet evaluation if super-refractory history (AES/NCS 2016 Glauser; ILAE chronic-epilepsy management)

Disposition criteria:
- Stable chronic epilepsy management — seizure-free OR seizure-controlled at family + neurology shared target, family demonstrating competence with rescue benzo + Seizure Action Plan, mental-health screens negative, age-appropriate transition planning underway (ILAE chronic-epilepsy management)

Escalation triggers (move to higher acuity):
- Breakthrough SE despite home rescue → ED + admit + AED-level audit + adherence deep-dive (AES/NCS 2016 Glauser)
- New refractory seizures despite 2 AEDs at therapeutic levels → drug-resistant epilepsy classification + epilepsy-surgery referral (ILAE drug-resistant definition)
- New developmental regression / behavior change → autoimmune-encephalitis workup + genetic + metabolic workup (Dalmau 2011 + ILAE)
- AED side effect requiring discontinuation (rash, hepatotoxicity, blood dyscrasia, mood) → cross-titrate to alternative; never stop abruptly (ILAE AED-safety)
- Suicidal ideation on AED (especially levetiracetam, topiramate) → mental-health urgent referral; routes to psych.depression.core.v1 / psych.suicidality.ed.core.v1 (FDA AED suicidality warning)
- Pregnancy on teratogenic AED → urgent neurology + MFM + genetic counseling; do NOT abruptly stop AED (ILAE pregnancy task force)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Persistent seizure after Stage 1 benzo + Stage 2 AED (typically >=40 min) (NCS/AES 2016 Glauser; ESETT Kapur NEJM 2019)
- [LIFE_THREATENING] Persistent / recurrent seizure >=24 h despite anesthetic infusion (NCS/AES 2016 Glauser)
- [LIFE_THREATENING] Failure of benzodiazepine + 1 second-line agent at 30+ min from seizure onset — refractory SE per AES/NCS 2016 + ILAE 2015 definitions (NCS/AES 2016 Glauser PMID 26900382; ILAE 2015 Trinka PMID 26336905)

Citations

- NCS/AES 2016 (Glauser) + ESETT NEJM 2019 + RAMPART NEJM 2012 + ILAE 2015 + EcLiPSE/ConSEPT Lancet 2019 + Dalmau anti-NMDAR Lancet Neurol 2011 [PMID:26900382](https://pubmed.ncbi.nlm.nih.gov/26900382/)
- Cited evidence (PMID 31774955) [PMID:31774955](https://pubmed.ncbi.nlm.nih.gov/31774955/)
- Cited evidence (PMID 22335736) [PMID:22335736](https://pubmed.ncbi.nlm.nih.gov/22335736/)
- Cited evidence (PMID 26336905) [PMID:26336905](https://pubmed.ncbi.nlm.nih.gov/26336905/)
- Cited evidence (PMID 31005385) [PMID:31005385](https://pubmed.ncbi.nlm.nih.gov/31005385/)

Last reconciled with current guidelines: 2026-05-14.
References
  • NCS/AES 2016 (Glauser) + ESETT NEJM 2019 + RAMPART NEJM 2012 + ILAE 2015 + EcLiPSE/ConSEPT Lancet 2019 + Dalmau anti-NMDAR Lancet Neurol 2011 — PMID:26900382
  • Cited evidence (PMID 31774955) — PMID:31774955
  • Cited evidence (PMID 22335736) — PMID:22335736
  • Cited evidence (PMID 26336905) — PMID:26336905
  • Cited evidence (PMID 31005385) — PMID:31005385