The literature on the management of refractory status epilepticus is reviewed and a treatment algorithm suggested by researchers at Children's Hospital of Philadelphia, PA. The definition of status epilepticus (according to Wasterlain et al, 2006) is divided into an 'impending' or early stage (5-30 min) and an 'established' stage of status epilepticus (30-60 min). Impending status epilepticus is a continuous generalized convulsive seizure for at least 5 min, or continuous non-convulsive seizures or focal seizures for at least 15 min, or two seizures without full recovery of consciousness between them. Established status epilepticus is a continuous seizure for at least 30 min, or intermittent seizures without full recovery of consciousness for 30 min. In refractory status, seizures persist despite treatment with 2 or 3 anticonvulsant medications for 30 min, 1 hr, 2 hrs or longer. Based on the literature review, the recommended protocol for impending status epilepticus (SE), <5 min, begins with buccal midazolam or rectal diazepam, before arrival at hospital. After 5 min, give lorazepam or diazepam IV, oxygen, and stabilize airway and respiration as needed. Check serum glucose and begin EKG monitoring. For established SE, 5-10 min, repeat benzodiazepine, give fosphenytoin IV. Consider pyridoxine 100 mg IV push, if age <2 years. Obtain lab tests, including CT and neurology consult. For refractory SE, 10 min after fosphenytoin infusion, administer levetiracetam IV or valproate. After 5 min interval without control, give phenobarbital IV. Admit to PICU. Consider coma induction. Inhalation anesthetics will terminate refractory SE and induce burst suppression, but hypotension requiring vasopressors is a problem, and seizures recur when the anesthetic is withdrawn. 
COMMENT. The treatment protocol used at the Philadelphia Children's Hospital for status epilepticus emphasizes the benefits of early intervention, consecutive medications with different mechanisms of action, and avoidance of risk of hypotension. Status epilepticus due to recognized causes (eg febrile SE, meningitis, encephalitis, etc) require specific treatment.