The loading dose of valproate is 40 mg/kg, maximum 3,000 mg/dose The loading dose for levetiracetam is 60 mg/kg, maximum 4,500 mg/dose VPA may be particularly useful for patients with a known seizure disorder, who are currently using VPA, and low serum concentrations are suspected IV phenobarbital is another option if none of previously described second-line options are available Phenobarbital, like other barbiturates, may cause significant sedation, respiratory depression, and hypotension The loading dose of phenobarbital is 20 mg/kg, sometimes given in two divided doses The total drug dose is given over to 10 minutes IV (maximum 30 mg/min in an adult), or IM in the absence of IV access Onset of action is usually within 15 to 20 minutes and lasts more than 24 hours Patients with SE that lasts for more than 30 to 60 minutes present a special problem The best available evidence suggests that irreversible neuronal injury occurs within this timeframe, so the clinician should be more aggressive at 30 minutes Further management should be done, when possible, in conjunction with a neurologist, an intensivist, and with continuous EEG monitoring Options include an additional second-line agent, continuous infusion of benzodiazepines, barbiturate coma, or general anesthesia With prolonged seizures, the duration of postictal drowsiness and confusion may also be protracted However, the child who fails to arouse within 15 to 30 minutes after cessation of seizures should be evaluated carefully to rule out nonconvulsive SE Children with SE, even if successfully treated in the ED, should be admitted to the hospital for monitoring and observation Rarely, a child may enter the ED in absence status In this case, the child may be sitting in a confused or dreamy state Such attacks may last for hours or even days The drug of choice in the treatment of absence status is a benzodiazepine at the dosages outlined above At times, a child may present with continual focal seizure activity (with or without clouding of consciousness), a condition known as epilepsia partialis continua The treatment for partial seizures is less urgent than that for generalized seizures, and such seizures are often intractable to anticonvulsant medication In such cases, fosphenytoin in a dose of 15 to 20 mg/kg can be infused slowly All such patients should be admitted to the hospital for further observation and evaluation Other pharmacologic attempts to control these focal seizures should be performed in the hospital The decision to initiate long-term prophylactic therapy with anticonvulsant medications is based on a consideration of a number of factors, including the patient’s age, type of seizure, risk of recurrence, coexisting medical conditions,