This section will focus on patients with generalized convulsive status The first priority in the seizing patient is to address airway, breathing, and circulation (see Chapter A General Approach to the Ill or Injured Child ) An adequate airway is necessary to allow for effective ventilation and oxygenation Patients with impaired consciousness are at risk for obstruction (the tongue, oral secretions, emesis), aspiration (loss of protective reflexes), and hypoventilation Simple maneuvers such as the jaw thrust or suctioning of the oropharynx may improve the compromised airflow The use of adjunctive airways (oral or nasopharyngeal) may also help maintain an adequate airway In patients who are actively seizing, it may be difficult to insert these adjuncts and may cause injury if the intervention is forced Furthermore, in patients for whom trauma is a possibility, these maneuvers must be undertaken with cervical spine (C-spine) immobilization In patients in whom the airway remains unstable despite these actions, endotracheal intubation is warranted When it is necessary to use a muscle relaxant to intubate a seizing patient, one should use the shortest-acting agent possible The presence of motor activity may be the only clinical manifestation of seizure, and a longacting muscle relaxant will mask the ongoing seizure activity One should consider alternatives to succinylcholine in the setting of prolonged seizures because of the potential risk of hyperkalemia related to rhabdomyolysis While securing the airway takes priority over other clinical assessment elements, one will lose the ability to assess whether the clinical seizure activity has stopped in a medically paralyzed child Parameters such as heart rate are notoriously unreliable Missed “iatrogenic nonconvulsive status epilepticus” will result in neuronal death despite lack of clonic or tonic features The clinician must consider interventions to avoid these dilemmas For example, a patient may have a potentially short-lived apneic episode following the rapid administration of a benzodiazepine When possible, such a drug should be administered over to minutes rather than rapid infusion, and short apneic/hypopneic episodes that may follow can often be managed with a short period of bag–mask ventilation prior to endotracheal intubation If endotracheal intubation does take place, many institutions offer an urgent limited-lead EEG that can help evaluating background activity for possible ongoing seizure If not available, an emergent EEG should be obtained Intubated patients often receive continuous infusions of a benzodiazepine after endotracheal intubation to maintain sedation However, continuous infusions of benzodiazepines may also be used in the treatment of refractory seizures Aligning the dose of a benzodiazepine infusion with the latter protocol may further mitigate the risk of ongoing “subclinical” seizure and neuronal death