Pediatric Status Epilepticus

Synonym

Seizures

Related Conditions

GCSE = Generalized Convulsive Status Epilepticus

NCSE = Nonconvulsive Status Epilepticus

RSE = Refractory Status Epilepticus

Neonatal SE = Neonatal Status Epilepticus

AED = Anti-Epileptic Drug

1. Description of the problem

Classical definition: seizure activity (continuous or episodic) without complete recovery of consciousness for > 30 minutes.

Operational definition: seizure activity > 5 minutes and persisting. Intervention should not be delayed as seizures > 5 minutes are unlikely to remit spontaneously, and become less likely to respond as the duration increases.

For the ICU, status epilepticus can be considered as convulsive (GCSE) or nonconvulsive (NCSE). Refractory status epilepticus (RSE) = SE that persists after adequate doses of two anticonvulsants. Neonatal SE is difficult to diagnose and treat as neonatal seizures are frequently poorly organized and polymorphic and may require alternative treatment approaches.

GCSE

nearly 80% of pediatric SE can be tonic, clonic, or tonic-clonic seizure activity that involves all extremities.

NCSE

continuous nonmotor seizures

requires EEG for diagnosis

may occur in ambulatory (e.g. absence) or comatose patients

may be difficult to diagnose. Should be considered with prolonged obtundation after seizure cessation or with coma of unclear etiology

diagnosis requires high degree of suspicion. Probably under-recognized

more common in younger children (1 month to 1 year of age)

2. Emergency Management

SE is a medical emergency that requires prompt intervention and stabilization.

Seizure duration inversely associated with treatment responsiveness and favorable outcome.

Management directed to

rapid cessation of seizures
treatment of causal or underlying conditions
prevention of seizure recurrence

Initial stabilization

First priority is to ensure airway patency and control.

nothing placed in patient’s mouth due to risk for aspiration
supplemental oxygen should be provided and respirations assisted as needed
consider RSI for airway protection with hypoxia, hypoventilation, GCS < 8, or concern for aspiration

Position patient so that ongoing seizure activity will not cause physical harm.

Establish IV access ASAP. Consider IO.

Isotonic IVF resuscitation for hypotension or dehydration. Avoid hypotonic solutions.

Do not treat hypertension (which is common with seizure activity). This may be maintaining cerebral perfusion.

Consider hypoglycemia as etiology. In absence of rapid testing, consider empiric dextrose intravenous treatment.

Consider thiamine (50-100 mg IV) prior to dextrose administration in older children at risk of nutritional deficiencies.

Consider electrolyte abnormalities (hyponatremia, hypocalcemia).

High-dose antibiotics should be empirically given to patients at risk of bacterial infection or those with new-onset seizure and fever. Acyclovir if at risk for herpetic infection.

Medications for termination of seizures

Rapid cessation of SE associated with improved response rates and clinical outcomes.

Benzodiazepines

IV lorazepam

recommended dose 0.05-0.1 mg/kg
first-line treatment for all types of convulsive SE except neonatal SE (for which it is second-line)
peak effect at 15 minutes, duration of action is 3-6 hours
if 1st dose not effective, 2nd dose recommended before or concurrent with 2nd line agent.

IV diazepam

less favorable than lorazepam: Shorter duration = 15-30 minutes

IV midazolam

less favorable than lorazepam: Shorter duration = 30-80 minutes
metabolized by cytochrome P450 enzymes: may have variable metabolism and more drug interactions

Diazepam per rectum

0.2-0.5 mg/kg PR
for prehospital care or without IV access
bioavailability ~ 90%
peak effect at 1.5 hours

Midazolam IM

0.1-0.15 mg/kg; max 0.5 mg/kg)
~90% bioavailability and rapidly absorbed
average onset 2-3 minutes, peak at 30 minutes

Midazolam buccal

0.3 mg/kg of IV formulation between gum and cheek
administration is easy and safe. May be more efficacious than rectal diazepam

Midazolam intranasal

0.2-0.5 mg/kg; max 0.5 mg/kg

Fosphenytoin

second line agent for kids > 1 year old
dose 20 phenytoin equivalents per kg – infuse over 6 minutes
if 2nd dose needed, may give 10 phenytoin equivalents over 6 minutes

3. Diagnosis

Swift cessation of seizures is primary goal. Anticonvulsant therapy and patient stabilization should not be delayed to facilitate diagnostic testing.

Blood and urine tests

serum glucose and electrolyte testing

serum anticonvulsant medication levels in children on chronic therapy

blood and urine specimens for culture, especially in febrile patients

serum and urine toxicology testing (for possible ingestions)

serum ammonia, lactate, and serum amino and urine organic acid levels should be checked in infants and children at risk for inborn errors of metabolism

Head CT scan

only after seizures controlled

appropriate with new-onset seizures to those at risk for anatomic abnormalities, mass intracranial lesions, or cerebral edema

Lumbar puncture

only after mass intracranial lesion or cerebral edema excluded, AND seizure activity is controlled

indicated in patients at risk for meningitis or with a new-onset seizure

avoid in patients with evidence or risk for increased ICP, due to risk for downward herniation.

4. Specific Treatment

Please see Figure 1 for the recommended Pediatric Acute and Prolonged Seizure Treatment Algorithm. The pathway is intended to provide a framework for antiepileptic (AED) management for prolonged seizures or status epilepticus only. This is not intended for isolated or frequently repetitive seizures.

Figure 1.n

Pediatric Acute and Prolonged Seizure Treatment Algorithm

5. Disease monitoring, follow-up and disposition

Pathophysiology

Epidemiology

Incidence of status epilepticus in children aged 1 month to 16 years is 17-38 per 100,000 individuals per year.

> 40% of pediatric SE is in children < 2 years old.

Overall mortality rates range between 3-7.2%.

Prognosis

Special considerations for nursing and allied health professionals.

What's the evidence?

Rogers’ Textbook of Pediatric Intensive Care. Editor David Nichols.

Abend, N, Dlugos, D. “Treatment of Refractory Status Epilepticus: Literature Review and a Proposed Protocol”. Pediatric Neurology. vol. 38. 2008. pp. 377-90.

Raj, D, Gulati, S, Lodha, R. “Status Epilepticus”. Indian J Pediatr. vol. 78. 2011. pp. 219-226.

Poukas, VS, Pollard, JR, Anderson, CT. “Rescue Therapies for Seizures”. Curr Neurol Neurosci Rep. vol. 11. 2011. pp. 418-22.

Wermeling, DP. “Intranasal Delivery of Antiepileptic Medications for Treatment of Seizures”. Neurotherapeutics. vol. 6. 2009. pp. 352-58.

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