Status epilepticus (peds)

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Background

For a child over 1 month of age

• Categorized as convulsive or non-convulsive
  • Convulsive status epilepticus: patient will have tonic-clonic movements with altered mental status, may have focal neuro deficits post-ictally (Todd's paralysis)
  • Non-convulsive status epilepticus: patient will have seizure activity on EEG without clinical findings

Clinical Features

• Defined as: an unresponsive patient with either one of the following
  • Seizure >5 min and/or ongoing seizure on presentation
  • 2 or more seizures without full recovery of consciousness between seizures

Differential Diagnosis

• 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

Evaluation

Workup

• Check a blood glucose
• Consider an electrolyte panel, a blood gas, CBC, calcium level, LFTs
• If appropriate collect anticonvulsant drug levels
• Consider blood & urine culture
  • Data for lumbar puncture routinely is not conclusive - consider it in a febrile patient with signs of meningitis or localized neuro findings (perform once patient is stabilized)
• Consider toxicology studies
• Consider EKG to evaluate for arrhythmias, toxins and electrolyte abnormalities
• May consider head imaging once patient is stabilized

Management

• ABC's
• Provide O2 via non-rebreather mask, 10-15 L/min
• Give benzodiazepines as early as possible
  • Monitor for respiratory depression
• Give acetaminophen 15 mg/kg/dose (MAX 650 mg) if febrile

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

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/.