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: tonic-clonic movements with altered mental status, may have focal neuro deficits post-ictally (Todd's paralysis)
    • Non-convulsive status epilepticus: 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

  • Unresponsive patient with either:
    • 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

Consider other causes of Pediatric seizure

Evaluation

Workup

  • Check a blood glucose
  • If indicated, consider:
    • Anticonvulsant drug levels
    • CMP, CBC, blood gas, calcium, magnesium level
    • Blood & urine culture
    • CT head if concern for blood, infectious process, mass
    • Lumbar puncture if febrile, concerns for meningitis/encephalitis (may be afebrile), or localized/focal neurological findings
    • Toxicology studies
    • EKG to evaluate for arrhythmias, toxins and electrolyte abnormalities

Management

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).
  • Provide O2 via positive pressure ventilation with BVM/flow inflating bag
    • Likely apneic/hypoventilating/hypercapneic
    • Only apply CPAP or a non-rebreather if patient stops seizing and has adequate chest rise

Emergency Department

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

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

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