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

Phase 0 (0-5 minutes)

• ABC's
• Maintain airway; suction, jaw thrust
• Provide O2 via non-rebreather mask, 10-15 L/min
• Establish IV access, give bolus if perfusion inadequate

Phase 1 (5-15 minutes)

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).

Emergency Department

• Give a benzodiazepine (if two doses not already given prior to ED arrival). Give a second dose for ongoing seizure after 5 minutes. Do not give more than two doses (apnea risk).
  • With IV/IO access: Lorazepam 0.1 mg/kg/dose IV/IO (MAX 4 mg/dose) OR Midazolam 0.1 mg/kg/dose IV/IO (MAX 10 mg/dose)
  • No IV/IO Access: Midazolam 0.2 mg/kg/dose IM/intranasal (MAX 10 mg/dose)
• Check blood glucose and respond as above if not already done
• Give acetaminophen 15 mg/kg/dose (MAX 650 mg) if febrile

Phase 2 (15-50 minutes)

• Give Levetiracetam, Phenytoin/Fosphenytoin or Valproic acid (equally efficacious for status epilepticus)
  • Levetiracetam is preferred given quick administration, favorable side effect profile, and less drug interactions
• If still seizing 5 minutes following medication infusion, choose another second-line agent to give and contact a referral site
  • Do not combine Phenytoin and Fosphenytoin

Phase 3 (50 minutes onwards)

• If two second-line therapies fail, discuss further management with Pediatric Referral Site
• Prepare for airway support given apnea risk
• Consider third-line options; continuous IV infusion of Midazolam, Pentobarbital, Propofol OR Ketamine

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
• Status epilepticus

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/.