Management of Status Epilepticus (IAP 2025 Updates)

Definition And Temporal Thresholds

Adopts a dual-timepoint framework to standardize intervention.
Timepoint $t_{1}$ (Treatment Initiation): Fixed at 5 minutes; marks the threshold where spontaneous seizure termination is unlikely and urgent pharmacological intervention must begin.
Timepoint $t_{2}$ (Neuronal Injury Threshold): Fixed at 30 minutes for convulsive status epilepticus (SE); defines the window beyond which prolonged ictal activity causes irreversible cellular injury and permanent synaptic reorganization.

Phase	Timing	Recommended Interventions And Dosages	Key Principles
First-Line	5-15 mins	- Lorazepam: $0.1 mg/kg$ IV (max 4 mg).- Midazolam: $0.2 mg/kg$ IM/IN/buccal (if IV access is unavailable).	Strictly limit benzodiazepines to a maximum of two doses to prevent life-threatening respiratory depression and avoidable intubations. IN/buccal midazolam is preferred over rectal diazepam due to faster mucosal absorption.
Second-Line	15-20 mins	- Levetiracetam: $40 - 60 mg/kg$ IV over 5-10 mins.- Sodium Valproate: $20 - 40 mg/kg$ IV over 5-10 mins.- Fosphenytoin/Phenytoin: $20 mg PE/kg$ IV.	Equiefficacy concept applies based on large trials (ESETT, ECLIPSE). Phenytoin is no longer the absolute preferred choice; Levetiracetam and Valproate are prioritized for superior cardiorespiratory stability. Valproate is contraindicated if mitochondrial cytopathy or urea cycle defects are suspected.
Third-Line	>30 mins	- Midazolam Infusion: Load $0.1 - 0.2 mg/kg$ , then maintain at $1 - 5 mcg/kg/min$ .- Ketamine/Isoflurane: Considered for refractory cases.	Prepare for intubation and urgent transfer to the Pediatric Intensive Care Unit (PICU).

Seizures persisting 10-15 minutes after a second-line anti-seizure medication (ASM) load define RSE, mandating immediate PICU admission.
Early Ketamine Integration: Positioned earlier in RSE pathways to target NMDA-receptor upregulation caused by prolonged seizure activity.
Continuous Video-EEG (cEEG): Urgently indicated to diagnose Non-Convulsive Status Epilepticus (NCSE), which affects up to 30% of children presenting with persistent, unexplained post-ictal encephalopathy.
New-Onset Refractory Status Epilepticus (NORSE) Protocol: Early initiation of immunomodulatory agents (corticosteroids, IVIG) within 48-72 hours is recommended for children presenting without an obvious infectious trigger.

Brivaracetam is emerging as an effective, well-tolerated conditional second-line option.
An empirical pyridoxine trial should be administered concurrently in neonates or suspected metabolic cases.
Integrate the Phoenix Criteria for recognizing and managing concurrent sepsis-associated SE.