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
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
Lowenstein, D.H. & Alldredge, B.K. 1998. Current Contcepts-Status epilepticus. New England Journal of Medicine, 338, (14) 970-976
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.
