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

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

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

External Links

References

  1. ↑ Baxter P. et al. Pyridoxine‐dependent and pyridoxine‐responsive seizures. Developmental Medicine & Child Neurology 2001, 43: 416–42
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