View source for Status epilepticus (peds)

{{PediatricPage|Status epilepticus}}
==Background==
For a child over 1 month of age
* Categorized as convulsive or non-convulsive 
** Convulsive status epilepticus: tonic-clonic movements with altered mental status, may have focal neuro deficits post-ictally (Todd's paralysis)
** Non-convulsive status epilepticus: seizure activity on EEG without clinical findings
* Status epilepticus is a medical emergency and has a high rate of morbidity and mortality
** Can lead to Cardiac dysrhythmia, [[Hypoxia]], Metabolic abnormalities, [[Acidosis]], Altered autonomic function, [[Rhabdomyolysis]], Neurogenic pulmonary edema, Pulmonary aspiration, Hyperthermia, Permanent neurological damage

==Clinical Features==
*Unresponsive patient with either:<ref>Glauser T, et al. Evidence-Based Guideline: Treatment of Convulsive Status Epilepticus in Children and Adults. Epilepsy Curr. 2016;16(1):48-61. PMID 26900382</ref>
**Seizure >5 min and/or ongoing seizure on presentation
**2 or more seizures without full recovery of consciousness between seizures

==Differential Diagnosis==
===For the Neonate===
* CNS: Perinatal asphyxia, intracranial hemorrhage, [[hydrocephalus]]
* Metabolic: Electrolytes (↓ Na, ↓ Glucose, ↓ Ca++), Pyridoxine dependence, inborn errors of metabolism, mitochondrial disorders
* Infection: [[Meningitis]]/[[Encephalitis]], TORCH infections (Toxoplasmosis, Other (syphilis, varicella-zoster, parvovirus B19), Rubella, Cytomegalovirus, and Herpes))

===For the Pediatric Patient===
* Fever, severe infection (meningitis, encephalitis)
* Anoxic injury
* Electrolyte derangements 
** Hyper or hypoglycemia
** Hyper or hyponatremia
** Hyper or hypocalcemia 
* Traumatic brain injury (TBI)
* Anti-epileptic drug (AED) non-adherence, overdose, withdrawal 
* Toxic exposure (PLASTIC mnemonic)
** P: Pesticides, Propranolol, Phencyclidine (PCP)
** L: Lead, Lithium, Lidocaine, Lindane
** A: Alcohols, Amphetamines
** S: Sugar (hypoglycemics), Salicyclates, Sympathomimetics 
** T: Tricyclic antidepressants, Theophylline
** I: Isoniazid, Iron, Insulin
** C: Cocaine, Camphor, Caffeine
* Structural abnormality of the brain
* Hypoxic-ischemic encephalopathy (HIE)
* Neurodegenerative disorder
* Stroke
* Genetic condition

Consider other causes of [[Pediatric seizure]]

==Evaluation==
===Workup===
*Check a blood glucose
*If indicated, consider:
**Anticonvulsant drug levels
**CMP, CBC, blood gas, calcium, magnesium level
**Blood & urine culture
**CT head if concern for blood, infectious process, mass
**Lumbar puncture if febrile, concerns for meningitis/encephalitis (may be afebrile), or localized/focal neurological findings
**Toxicology studies
**EKG to evaluate for arrhythmias, toxins and electrolyte abnormalities

==Management==
====Prehospital====
*Give Midazolam 0.2 mg/kg/dose IM/intranasal (MAX 10 mg/dose)
*Check blood glucose 
**If blood glucose <3.3 mmol/L (<60 mg/dL): Treat with D25W 2 mL/kg/dose IV (MAX 100 mL/dose) OR D10W 5 mL/kg/dose IV (MAX 250 mL/dose).
**If ≥3.3 mmol/L (≥60 mg/dL): Give second dose of Midazolam 0.2 mg/kg/dose IM/intranasal (MAX cumulative dose of 10 mg in prehospital setting; if max dose given, consult Medical Director/Base Hospital for next step).
*Provide [[O2]] via positive pressure ventilation with BVM/flow inflating bag
**Likely apneic/hypoventilating/hypercapneic
**Only apply CPAP or a non-rebreather if patient stops seizing and has adequate chest rise

====Emergency Department====

{{Initial management of pediatric status epilepticus}}

{{Pediatric anticonvulsants}}


==Medication Dosing==
{{MedicationDose
| drug = Midazolam
| dose = 0.2mg/kg IM/intranasal (max 10mg/dose)
| route = IM/IN
| context = Prehospital first-line for pediatric status epilepticus
| indication = Status epilepticus (peds)
| population = Pediatric
}}
{{MedicationDose
| drug = Dextrose
| dose = D25W 2mL/kg (max 100mL) or D10W 5mL/kg (max 250mL)
| route = IV
| context = If blood glucose <60mg/dL
| indication = Status epilepticus (peds)
| population = Pediatric
}}

==Disposition==
* Criteria for admission 
** Patients with refractory seizures
** Patients who are not responsive within 4-6 hours of arrival to the ED 
* Criteria for discharge
** Patients who have returned to baseline post seizure management
** Patients whose parents/guardians feel comfortable with discharge and have been counseled about what to do if seizure recurs

==See Also==
* [[Seizure (peds)]]
* [[Status epilepticus]] (adult)

==External Links==


==References==
* EIIC-TREKK Bottom Line Recommendations Pediatric Status Epilepticus. April 2022, TREKK; EIIC; For Revision 2024. Version 1.0. https://emscimprovement.center/education-and-resources/peak/peak-status-epilepticus/eiic-trekk-bottom-line-recommendations-pediatric-status-epilepticus/.
* EIIC-TREKK Pediatric Status Epilepticus Algorithm. April 2022 Version: 4.0 Review date: 2024. https://emscimprovement.center/education-and-resources/peak/peak-status-epilepticus/trekk-eiic-pediatric-status-epilepticus-practice-guideline/.
* Kristinsson, George. Status Epilepticus. PEM GUIDES. 7th edition. NYU Langone Health; 2020: 551-557.
* Medical Review Committee. Cincinnati Children's Hospital Medical Center. https://mrc.pemcincinnati.com/status-epilepticus/

[[Category:Pediatrics]]