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Available directed history of the seizure episode and the child’s previous medical history should be obtained and the child examined buy generic depakote 250 mg line. Blood glucose concentration should be checked with a dextrostick to allow rapid detection of hypoglycemia. Further diagnostic studies are selected as indicated based on the above information as well as child’s age. Blood laboratory evaluation including electrolytes, calcium, magnesium, and phosphorous level may be helpful in deter- mining cause, particularly in the setting of intercurrent illness or other cause of metabolic abnormality; complete blood count may reveal an elevated white blood cell count resulting from infection or the seizure activity itself. If the child is on anticonvulsant medications for an already recognized seizure disorder, drug levels should be determined, as low levels could be associated with increased seizure activity and SE. Following stabilization of the child, additional history should be obtained, including course of current seizure activity (time and nature of onset, phenotypic characteristics including any focality), duration of seizure activity prior to medical attention, mental status after cessation of seizure activity; fever or intercurrent ill- ness, prior history of seizures, head injury, intoxication or toxic exposure, CNS abnormality or illness, birth history and developmental delay, and other medical history. A rapid directed examination should be performed looking for signs of sepsis or meningitis, evidence of head or other CNS injury, and evidence of neu- rocutaneous syndromes. Spinal fluid analysis should be performed if meningitis is suspected based on clinical presentation, history, and age. If there is a concern of increased intra- cranial pressure or a structural lesion that would contraindicate lumbar puncture, antibiotics should be administered and neuroimaging obtained prior to lumbar puncture. Neuroimaging is generally indicated for SE after assuring the child is stable clinically, particularly if the child does not have a history of previous seizures or if the cause of SE is unknown. If readily available, MRI is a preferred imaging mod- ality, but CT scan would allow detection of conditions needing urgent intervention such as hemorrhage, edema, or mass lesion. An EEG should be considered if there is any concern that the child may have ongoing seizure activity, either related to 52 Thiele continued altered awareness or focality on examination, or if there is a concern of pseudoseizure. An EEG may also be necessary if neuromuscular paralysis is used in treatment of SE, or if suppressive therapy is required for refractory SE. Pharmacologic Management of SE Several medications have been shown to be effective in treating SE (Table 3). The ideal medication would be a drug that is safe and easily administered, acts rapidly, is effective for many hours, and produces minimal sedation.