Status Epilepticus: Clinical Analysis of a Treatment Protocol Based on Midazolam and Phenytoin

Judith C.D. Brevoord MD; Koen F.M. Joosten MD, PhD; Willem F.M. Arts MD, PhD; Roos W. van Rooij MD; Matthijs de Hoog MD, PhD


J Child Neurol. 2005;20(6):476-481. 

In This Article

Material and Methods

This retrospective study was performed in the pediatric intensive care unit of the Erasmus Medical Center-Sophia Children's Hospital, a tertiary university pediatric hospital. All children diagnosed as having generalized convulsive status epilepticus who were admitted to the pediatric intensive care unit from January 1995 to December 2001 were eligible for inclusion in the study.

Generalized convulsive status epilepticus was defined as a single seizure lasting more than 30 minutes or multiple seizures relapsing within 30 minutes without recovery of consciousness between each seizure. Cessation of seizure activity was defined as no clinical evidence of seizures during at least 30 minutes. Children treated according to our protocol were included. Children who received initial rectal diazepam were not excluded. Patients treated with other initial antiepileptic medications were excluded from analysis. The treatment protocol consisted of a stepwise use of midazolam and phenytoin, with each subsequent step taken if seizures persisted. For the purpose of this study, we categorized the following levels of antiepileptic therapy:

Level 1: Rectal midazolam 0.5 mg/kg (diluted intravenous solution via short catheter) or 0.1 mg/kg intravenously. after 10 minutes: midazolam 0.1 mg/kg intravenously

Level 2: After 10 minutes: phenytoin 20 mg/kg intravenously in 20 minutes

Level 3: After phenytoin load: midazolam 0.2 mg/kg intravenously followed by midazolam 0.1 mg/kg/hour continuously, increased by 0.1 mg/kg/hour every 10 minutes, after extra loading of 0.1 mg/kg, to a maximum of 1 mg/kg/hour

Level 4: Phenobarbital 20 mg/kg intravenously or pentobarbital 2 to 5 mg/kg intravenous load, 1 to 2 mg/kg/hour continuously intravenously

Level 4 could be taken earlier by the attending physician if temporary cessation of seizures was not obtained after several steps of increasing midazolam with loading.

For each patient demographic variable, a history of seizures, underlying diseases, and use of antiepileptic medication were abstracted from patient files. Changes in vital parameters that needed intervention (eg, artificial ventilation) were recorded and described in relation to administration of medication. Patients were categorized using a previously described definition for etiology ( Table 1 ).[31] The Pediatric Index of Mortality (PIM) was used as a measure of the severity of illness.[32] Mortality was defined as death within 3 months after admission to the pediatric intensive care unit. Relationships between etiology, Pediatric Index of Mortality score, and level of therapy needed to control generalized convulsive status epilepticus were tested using a χ2 test with a significance level of .05.


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.