Prolonged seizure activity is a true medical emergency Although the duration of seizures used to define status has varied over time, an accepted definition for the purposes of clinical practice defines SE as a single unremitting seizure lasting longer than minutes or frequent clinical seizures without an interictal return to the baseline clinical state This corresponds with the time at which urgent treatment should be initiated, which is the new focus of the definition With this proactive, management based definition, following stabilization of the ABCs, further treatment is directed at stopping any seizure activity This section will focus on three elements of seizure management: prevention and preparation, antiepileptic medication use, and post stabilization measures Prevention and Preparation PEM providers often encounter patients who start seizing during the ED visit Many of these patients are patients with known epilepsy, some are being treated with antiepileptic drugs (AEDs), and for some increased seizure frequency or a breakthrough seizure is the reason for the ED encounter The PEM clinician will be best advised to assess these patients promptly and be able to answer the following questions: What AEDs is this patient taking, what is the dosage and when is the next dose due? Were any doses missed? Were any doses possibly un(der)absorbed (e.g., vomiting or diarrhea)? Are the parents aware of any recent AED levels of any of the medications involved? When in doubt, AED levels should be obtained promptly Subtherapeutic levels of AEDs are found in nearly a third of pediatric epilepsy patients actively seizing in the ED Furthermore, some AEDs, including phenytoin, carbamazepine, gabapentin, tiagabine, and vigabatrin, can precipitate generalized convulsive SE, particularly the myoclonic type, as well as nonconvulsive (absence) SE What is the active seizure plan for this patient? Many children with refractory epilepsy have their own status epilepticus (SE) plan, which may different that the one proposed for first time seizures These patients should be advised to seek such a plan with their primary neurologist if they have not yet done so History of prior SE episodes, including whether certain AEDs were successful or failed, may guide the PEM clinician in decisions about treatment If any drug needs to be loaded on an active alert patient, it should be loaded promptly in the fastest way possible (which may very well be oral administration) Also, oral administration is less likely to generate excessive sedation and respiratory depression