Status epilepticus (peds)

This page is for pediatric patients. For adult patients, see: Status epilepticus.

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
• 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

• 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

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

Pediatric seizure

• Epileptic seizure
  • First-time seizure
  • Seizure with known seizure disorder
  • Status epilepticus
  • Temporal lobe epilepsy
  • Non-compliance with or "outgrowing" AEDs
• Non-epileptic seizure
  • Febrile seizure
  • Brain inflammation
    • Meningitis
    • Encephalitis
    • CNS abscess
    • Intracranial hemorrhage
    • Neurocysticercosis
  • Increased ICP
    • Seizure with VP shunt
    • Hydrocephalus
    • Intracranial mass
  • Toxicologic
    • Alcohol withdrawal
    • Benzodiazepine withdrawal
    • Toxic ingestion
  • Metabolic abnormalities: hyponatremia, hypernatremia, hypocalcemia, hypomagnesemia, hypoglycemia, hyperglycemia
  • Pyridoxine responsive seizure
  • Eclampsia
  • Posterior reversible encephalopathy syndrome
  • Impact seizure (head trauma)
• Other mimics
  • Psychogenic nonepileptic seizure (pseudoseizure)
  • Syncope (peds)
  • Breath-holding spell
  • Hyperventilation syndrome
  • Migraine headache
  • Movement disorders
  • Narcolepsy/cataplexy
  • Post-hypoxic myoclonus (Status myoclonicus)
  • Infantile Spasms/West Syndrome

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

Initial management of pediatric status epilepticus

Timeline	General Considerations	Seizure Treatment
0-5 minutes	Supportive care ABC's Maintain airway; suction, jaw thrust Provide O2 via positive pressure ventilation with BVM/Mapleson Likely apneic/hypoventilating/hypercapneic Only apply CPAP or a non-rebreather if patient stops seizing and has adequate chest rise Establish IV/IO access Check blood glucose If fever, acetaminophen 15 mg/kg rectally	Benzodiazepine: first dose IV/IO access established Lorazepam 0.1 mg/kg IV (max 4 mg) if IV/IO access, OR Diazepam 0.2 mg/kg IM (max 10 mg) if no access IV or IO access not achieved within 3 minutes: Buccal midazolam 0.2 mg/kg (max 10 mg), OR IM midazolam 0.2 mg/kg (max 10 mg), OR Rectal diazepam (Diastat gel or injection solution given rectally) 0.5 mg/kg (max 20 mg)
5-10 minutes	Give antibiotics if concern for sepsis or meningitis POC electrolytes, if available	Benzodiazepine: second dose
10-15 minutes	All equally efficacious for status epilepticus Levetiracetam is preferred given quick administration, favorable side effect profile, and less drug interactions Do not combine Phenytoin and Fosphenytoin	Antiepileptic: first therapy Levetiracetam 60 mg/kg IV/IO (max 4500mg) over 5 min, OR Fosphenytoin^ 20 mg PE/kg IV/IO (max 1500mg) over 10 min, OR Valproate 40 mg/kg IV/IO (max 3000mg) over 10 min, OR Phenobarbital 20 mg/kg IV/IO, (max 1 g) over 20 min, (expect respiratory depression with apnea)¥
15-30 minutes	Consider intubation, if not already performed Consider NG tube to decompress stomach prior to intubation Pediatric neurology consultation	Antiepileptic: second therapy (if medication not already given) Fosphenytoin^ 20 mg PE/kg IV/IO (max 1500mg) over 10 min, OR Valproate 40 mg/kg IV/IO (max 3000mg) over 10 min, OR Phenobarbital 20 mg/kg IV/IO (max 1 g) over 20 min 10 mg/kg if phenobarbital already given, OR Levetiracetam 60 mg/kg IV/IO (max 4500mg) over 5 min If isoniazid toxicity suspected, pyridoxine Infants (<1 year): 100 mg IV or IO in Otherwise 70 mg/kg IV or IO (max = 5 g)
>30 minutes	Intubate patient, if not already performed Consult referral site / PICU for admission and continuous EEG	Antiepileptic: third therapy Midazolam 0.2mg/kg IV bolus (max 10mg), followed by 0.2mg/kg/hr (max 10mg/hr) infusion drip Increase infusion rate by 0.2mg/kg/hr (max 10mg/hr) every 10 minutes until burst suppression or max dose of 2mg/kg/hr (max 100mg/hr)

^May be ineffective for toxin-induced seizures and contraindicated in cocaine toxicity

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

Pediatric Anticonvulsants Table

Drug	Dose	Infusion Rate (Minutes)	Age	Comments/Cautions
Levetiracetam	60 mg/kg/dose IV/IO MAX: 4500 mg/dose	≥5	Any	Most commonly used agent
Fosphenytoin	20 mg phenytoin equivalent (PE)/kg/dose IV/IO/IM MAX: 1000 PE/dose	≥10	Any	Choose alternate drug if on phenytoin at home; may decrease BP/HR; not for toxin-induced seizures
Valproic acid	40 mg/kg/dose IV/IO MAX: 3000 mg/dose	≥10	≥2 years	Caution in patients with liver dysfunction, mitochondrial disease, urea disorder, thrombocytopenia, or unexplained developmental delay
Phenytoin	20 mg/kg/dose IV/IO MAX: 1000 mg/dose	≥20	Any	Choose alternate drug if on phenytoin at home; may decrease BP/HR; not for toxin-induced seizures
Phenobarbital	20 mg/kg/dose IV/IO MAX: 1000 mg/dose	≥20	<6 months	First line for most neonatal seizures. Respiratory depression, especially in combination with benzodiazepines

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)

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.