| Drug | Class | Adult | Paediatric | Notes |
|---|---|---|---|---|
| Lorazepam (first-line)[2] | Benzodiazepine | 4 mg IV bolus over 1–2 min; repeat once at 5–10 min if needed | 0.1 mg/kg IV (max 4 mg per dose) | First-line IV benzodiazepine; longer effective duration than diazepam; use IV diazepam 0.15 mg/kg or rectal 0.2 mg/kg if no IV access; intramuscular midazolam 10 mg if no IV |
| Midazolam (alternative first-line)[2] | Benzodiazepine | 10 mg IM, 10 mg buccal/intranasal, or 0.2 mg/kg IV | 0.2 mg/kg IM/IV (max 10 mg); buccal 0.5 mg/kg (max 10 mg) | Pre-hospital and out-of-hospital first-line where IV access not available; RAMPART trial showed equivalence to IV lorazepam |
| Levetiracetam (second-line)[2] | SV2A modulator | 60 mg/kg IV (max 4500 mg) over 10 min | 60 mg/kg IV (max 4500 mg) over 10 min | ESETT trial — equally effective as fosphenytoin and valproate; preferred for ease of administration, fewer cardiac concerns; renal dose adjustment |
| Sodium valproate (second-line)[2] | Multiple-mechanism ASM | 40 mg/kg IV (max 3000 mg) over 10 min | 40 mg/kg IV (max 3000 mg) | ESETT trial second-line option; avoid in women of childbearing potential without pregnancy prevention programme; hepatic injury and pancreatitis |
| Fosphenytoin (second-line)[2] | Sodium channel blocker | 20 mg PE/kg IV (max 1500 mg PE) at ≤150 mg PE/min | 20 mg PE/kg IV (max 1500 mg PE) at ≤2 mg PE/kg/min | Cardiac monitoring during infusion; hypotension and bradyarrhythmias; preferred over phenytoin where available (less infusion-site morbidity) |
| Midazolam infusion (refractory)[2] | Benzodiazepine continuous infusion | 0.2 mg/kg loading then 0.05–2.0 mg/kg/h titrated to EEG burst-suppression | Loading 0.15 mg/kg then 1–10 µg/kg/min titrated | First-choice anaesthetic agent for refractory CSE; tachyphylaxis common — cycle to propofol or pentobarbital if escalating doses |
| Propofol infusion (refractory)[2] | GABAA agonist anaesthetic | 1–2 mg/kg IV bolus then 1–10 mg/kg/h titrated to EEG | — | Avoid prolonged high-dose infusion (>4 mg/kg/h for >48 h) due to PRIS — propofol infusion syndrome (acidosis, rhabdomyolysis, cardiac failure) |
| Pentobarbital or thiopental (super-refractory)[2] | Barbiturate anaesthetic | Pentobarbital 5 mg/kg IV bolus then 0.5–5 mg/kg/h; thiopental 3–5 mg/kg IV bolus then 3–7 mg/kg/h | — | Super-refractory status; profound hypotension, immunosuppression, ileus; vasopressor support and MDT neuro-ICU care |
Stepwise management of generalised convulsive status epilepticus from first-line benzodiazepine through anaesthetic-induced burst suppression in adults and children.