airway, consideration should be given to airway adjuncts and airway positioning Noninvasive end-tidal CO2 monitoring can provide valuable assessment but providers must know how to recognize ineffective ventilation wave forms rather than simply relying on ETCO2 number Intravenous (IV) access should be established promptly; however, because of the potential for increased ICP, fluid therapy should be used judiciously until a more thorough evaluation is performed The child with active convulsions should be protected from trauma It is unusual for the child with a brief seizure to arrive in the ED actively convulsing because, by definition, such seizures last for less than minutes Therefore, the actively convulsing child is usually already in a prolonged or serial seizure state, and pharmacologic intervention to terminate the seizure is required Establish IV access, and draw blood for diagnostic studies If hypoglycemia is documented by rapid glucose assay or if rapid determination is unavailable, give IV glucose in a dose of mL/kg of 25% dextrose in water, or mL/kg of 10% dextrose (use only the latter in infants) If hyponatremia is suspected based on a history of frequent vomiting or diarrhea or dilution of infant formula, emergent point-of-care testing for sodium should be performed Seizures caused by hypoglycemia or hyponatremia are unlikely to be treated successfully with anticonvulsant medications without addressing the underlying cause In neonates or in children with suspected isoniazid toxicity, IV pyridoxine 100 mg may be administered In most situations, benzodiazepines are the first drug of choice for acute seizures because of their effectiveness and rapidity of action Overall effectiveness is approximately 70% in children, and approximately 15% of children will require assisted ventilation after receiving benzodiazepines for SE While lorazepam (Ativan) is the historically preferred agent by neurologists because of its long duration of action, recent evidence has not demonstrated superiority over midazolam (Versed) or diazepam (Valium), and lorazepam causes prolonged sedation The ED provider may prefer to use midazolam because it has the advantage of more rapid return to baseline mental status Midazolam is also reliably absorbed when administered intramuscular (IM) or intranasal (IN) because of its unique ring structure IM midazolam (10 mg for >40 kg, mg for 13 to 40 kg) or IN midazolam (Versed) of 0.2 mg/kg (maximum 10 mg/dose) has been shown to be effective A second dose should be administered if the seizures not stop within minutes Lorazepam is given in a dose of 0.1 mg/kg IV (usual maximum mg/dose); it has an onset of action of to minutes, and the duration of anticonvulsant effect is 12 to 24 hours Lorazepam causes sedation for several hours in children, which may make it difficult to assess the patient’s