Society for Pediatric Urgent Care

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Society for Pediatric Urgent Care

PEDIATRIC STATUS EPILEPTICUS

BASICS

DESCRIPTION

  • Ongoing generalized tonic clonic seizures > 5 minutes; or
  • Recurrent seizures without recovery of mental status in between; or
  • 3 or more seizures within one hour.

EPIDEMIOLOGY

Incidence

  • 120-180,000 cases per year in U.S.
  • 4-8 children per 1,000 will experience SE before age 15

RISK FACTORS

  • Epilepsy
  • Fever
  • Developmental delay

GENERAL PREVENTION

  • Antiepileptic medications

PATHOPHYSIOLOGY

  • Metabolic demands increase approximately 7-fold
  • Ongoing seizures rapidly modify neuronal activity and synaptic function
  • Discrete intermittent seizures merge to become continuous
  • This leads to, neuronal injury and reduced responsiveness to benzodiazepines

ETIOLOGY

  • Fever
  • Epilepsy
  • Noncompliance with antiepileptic medications
  • Metabolic (glucose, sodium)
  • Idiopathic

COMMONLY ASSOCIATED CONDITIONS

  • Benign viral infections causing fever
  • Low levels of antiepileptic medications
  • Hypoglycemia
  • Hyponatremia
  • Non-accidental trauma

DIAGNOSIS

HISTORY

  • Duration
  • Medications given prior to arrival
    • Home meds
    • EMS
  • Recent vomiting or diarrhea
  • Improper preparation of infant formula
  • Ingestions

PHYSICAL EXAM

  • ABCs

DIAGNOSTIC TESTS & INTERPRETATION

Lab
Initial Lab Tests: Bedside STAT glucose and sodium

  • Electrolytes if patient has had vomiting or diarrhea
  • Calcium and phosphorus in the young infant

Imaging

  • CT/MRI brain if first time or if focal neurologic exam or if patient not recovering mental status
  • CT if suspected trauma

Diagnostic Procedures / Other

  • Other workup for coma if patient does not improve (tox screen, CT of brain, workup for nonaccidental trauma)

DIFFERENTIAL DIAGNOSIS

  • Pseudoseizures (usually in adolescents)

TREATMENT

MEDICATION

First Line

  • Benzodiazepines
    • Midazolam 0.2 mg/kg IM, 0.1 mg/kg IV/IO
    • Diazepam 0.5 mg/kg PR, 0.2 mg/kg IV/IO
    • Lorazepam 0.1 mg/kg IV/IO
    • Repeat in 5 minutes if still seizing

    Second Line

    • Fos-phenytoin 20 mg/kg of phenytoin-equivalent IV over 10 minutes; or
    • Levetiracetam 20-60 mg/kg IV over 10 minutes; or
    • Valproate 40 mg/kg IV over 10 minutes; or
    • Phenobarbital 20 mg/kg IV over 10 minutes

    COMPLEMENTARY & ALTERNATIVE THERAPIES

    • Treat fever
    • Treat hypoglycemia or hyponatremia
    • Pyridoxine for infants

    DISPOSITION

    Admission Criteria

    • Children with status are generally admitted for monitoring for recurrence
    • Critical care admission criteria
      • Loss of airway
      • Not recovering mental status
      • Intracranial hemorrhage
      • Intoxications

    REFERENCES

    1. Silbergleit, R., Durkalski, V., Lowenstein, D., Conwit, R., Pancioli, A., Palesch, Y., & Barsan, W. 2012. Intramuscular versus intravenous therapy for prehospital status epilepticus. N.Engl.J.Med., 366, (7) 591-600 available from: PM:22335736
    2. Lowenstein, D.H. & Alldredge, B.K. 1998. Current Contcepts-Status epilepticus. New England Journal of Medicine, 338, (14) 970-976
    3. Lowenstein, D.H., Bleck, T., & Macdonald, R.L. 1999. It’s time to revise the definition of status epilepticus. Epilepsia, 40, (1) 120-122

    ADDITIONAL READING

    • Alldredge, B.K., Gelb, A.M., Isaacs, S.M., Corry, M.D., Allen, F., Ulrich, S., Gottwald, M.D., O’Neil, N., Neuhaus, J.M., Segal, M.R., & Lowenstein, D.H. 2001. A comparison of lorazepam, diazepam, and placebo for the treatment of out-of-hospital status epilepticus. N.Engl.J.Med., 345, (9) 631-637 available from: PM:11547716
    • Cock, H.R. 2011. Established status epilepticus treatment trial (ESETT). Epilepsia, 52 Suppl 8, 50-52 available from: PM:21967363
    • Chamberlain JM, Okada P, Holsti M, Mahajan P, Brown KM, Vance C, Gonzalez V, Lichenstein R, Stanley R, Brousseau DC, Grubenhoff J, Zemek R, Johnson DW, Clemon TE, Baren J for the Pediatric Emergency Care Applied Research Network (PECARN). Lorazepam versus diazepam for pediatric status epilepticus: A randomized clinical trial. JAMA 2014; 311(16):1652-1660.

    PEARLS AND PITFALLS

    • Convulsive status epilepticus is a true medical emergency. Time = neurons. Use an established protocol with clear timeframes for escalating therapy.
    • Don’t forget glucose and sodium in children.
    • Consider non-accidental trauma.