Supportive care
Establish IV/IO access
Check blood glucose
If fever, acetaminophen 15 mg/kg rectally
Benzodiazepine: first dose
IV/IO access establised
Lorazepam 0.1 mg/kg IV or IO (max = 4 mg), OR
Diazepam 0.2 mg/kg IV or IO, (max = 8 mg)
IV or IO access not achieved within 3 minutes:
Buccal midazolam 0.2 mg/kg (max = 10 mg), OR
IM  midazolam 0.1 to 0.2 mg/kg (max = 10 mg), OR
Rectal diazepam (Diastat gel or injection solution given rectally) 0.5 mg/kg (max = 20 mg)
IV/IO access establised
Lorazepam 0.1 mg/kg IV or IO (max = 4 mg), OR
Diazepam 0.2 mg/kg IV or IO, (max = 8 mg)
IV or IO access not achieved within 3 minutes:
Buccal midazolam 0.2 mg/kg (max = 10 mg), OR
IM  midazolam 0.1 to 0.2 mg/kg (max = 10 mg), OR
Rectal diazepam (Diastat gel or injection solution given rectally) 0.5 mg/kg (max = 20 mg)
Lorazepam 0.1 mg/kg IV or IO (max = 4 mg), OR
Diazepam 0.2 mg/kg IV or IO, (max = 8 mg)
Buccal midazolam 0.2 mg/kg (max = 10 mg), OR
IM  midazolam 0.1 to 0.2 mg/kg (max = 10 mg), OR
Rectal diazepam (Diastat gel or injection solution given rectally) 0.5 mg/kg (max = 20 mg)
Give antibiotics if signs of sepsis or meningitis
POC electrolytes, if available
Benzodiazepine: second dose
Antiepileptic: first therapy
Levetiracetam 40 mg/kg IV or IO, OR
Fosphenytoin^ 20 mg PE per kg IV or IO§, OR
Valproate  20 to 40 mg/kg IV or IO, OR
Phenobarbital 20 mg/kg IV or IO, maximum 1 g, (expect respiratory depression with apnea)¥
Levetiracetam 40 mg/kg IV or IO, OR
Fosphenytoin^ 20 mg PE per kg IV or IO§, OR
Valproate  20 to 40 mg/kg IV or IO, OR
Phenobarbital 20 mg/kg IV or IO, maximum 1 g, (expect respiratory depression with apnea)¥
Consider intubation, if not already performed
Pediatric neurology consultation
Antiepileptic: second therapy
Fosphenytoin^ (if not already given) 20 mg PE per kg IV or IO, OR
Valproate (if not already given) 20 to 40 mg/kg IV or IO, OR
Phenobarbital (if not already given) 20 mg/kg IV or IO, (max = 1 g; 10 mg/kg if phenobarbital already given), OR
Levetiracetam (if not already given) 40 mg/kg IV or IO,
If isoniazid toxicity suspected, pyridoxine
Infants (<1 year): 100 mg IV or IO in
Otherwise 70 mg/kg IV or IO (max = 5 g)
Fosphenytoin^ (if not already given) 20 mg PE per kg IV or IO, OR
Valproate (if not already given) 20 to 40 mg/kg IV or IO, OR
Phenobarbital (if not already given) 20 mg/kg IV or IO, (max = 1 g; 10 mg/kg if phenobarbital already given), OR
Levetiracetam (if not already given) 40 mg/kg IV or IO,
Infants (<1 year): 100 mg IV or IO in
Otherwise 70 mg/kg IV or IO (max = 5 g)
^May be ineffective for toxin-induced<unk>  and contraindicated in cocaine toxicity
Defined as <50mg/dL
All seizing patients with hypoglycemia should be treated with 2 mL/kg 25% dextrose
Consider as cause of<unk>  especially if Na <120 mEq/L
Goal of therapy is to correct quickly to >120, slowly thereafter
In actively seizing patient, treatment of choice is 3% NaCl
3% NaCl (513 mEq/1000 mL)
Na deficit in total mEq = [(wt in kg)x(130 – serum Na level)x0.6] over 20min OR
3% NaCl: 4-6 mL/kg over 20min
If no<unk> activity but Na <120 start 4-6 mL/kg 3% NaCl or 20 mL/kg of NS over 1hr
Check Na level after bolus to see if second bolus is necessary
If 3% unavailable, start NS 20mL/kg
In actively seizing patient, treatment of choice is 3% NaCl
3% NaCl (513 mEq/1000 mL)
Na deficit in total mEq = [(wt in kg)x(130 – serum Na level)x0.6] over 20min OR
3% NaCl: 4-6 mL/kg over 20min
If no<unk> activity but Na <120 start 4-6 mL/kg 3% NaCl or 20 mL/kg of NS over 1hr
Check Na level after bolus to see if second bolus is necessary
If 3% unavailable, start NS 20mL/kg
3% NaCl (513 mEq/1000 mL)
Na deficit in total mEq = [(wt in kg)x(130 – serum Na level)x0.6] over 20min OR
3% NaCl: 4-6 mL/kg over 20min
Na deficit in total mEq = [(wt in kg)x(130 – serum Na level)x0.6] over 20min OR
Check Na level after bolus to see if second bolus is necessary
Administer 10% calcium gluconate 0.3 mL/kg over 5-10min
Consider Pyridoxine (vitamin B6) 1g per g of INH ingested  (in D5W IV over 30 min) 
Consider Pyridoxine Responsive<unk> Disorder - 100mg/pyridoxine is generally effective
Seizure 
Epileptic seizure
Febrile seizure
First-time seizure
Status epilepticus
Seizure with known seizure disorder
Syncope
Syncope 