Emergency Management Protocol

Perform standard stabilization: support respiration, maintain blood pressure, gain IV access, and identify/treat underlying causes (Level A).

Administer a benzodiazepine as the initial therapy of choice. Options: IV lorazepam (4 mg), IV diazepam (10 mg), or IM midazolam (10 mg) (Level A).

IM midazolam (10 mg for >40 kg) has superior effectiveness compared to IV lorazepam and is established as efficacious (Level A).

Administer an adequate single full dose rather than multiple smaller doses (Level A).

A second full dose of IV lorazepam or IV diazepam may be repeated once (Level A).

Administer a single dose of: IV fosphenytoin (20 mg PE/kg, max 1500 mg PE), IV valproic acid (40 mg/kg, max 3000 mg), or IV levetiracetam (60 mg/kg, max 4500 mg).

Be aware that second therapy is significantly less effective than the first (7% vs 55% success), and third therapy is substantially less effective (2% success) (Level A).

Consider repeating second-line therapy or anesthetic doses (thiopental, midazolam, pentobarbital, or propofol) with continuous EEG monitoring (Level U).

Monitor for respiratory depression and cardiac symptoms, which are the most common treatment-emergent AEs (Level A).