IV/IO access. Treat hypotension, but NOT hypertension
A B C
Arterial blood gas?
All children in SE develop acidosis. It often resolves rapidly with termination of SE
It may be difficult to intubate a child with active seizures
Stop or slow seizures first, give O 2 , consider BVM ventilation
If using paralytic agent to intubate, assume that SE continues
Na, Ca, Mg, PO 4 , glucose
Liver function tests, ammonia
Anticonvulsant drug level
Always defer LP in unstable patients, but never delay antibiotic/antiviral treatment if indicated
Indicated for focal seizures or focal deficit or focal EEG, history of trauma or bleeding disorder
Treatment of convulsive status epilepticus. Recommendations of the Epilepsy Foundation of America's Working Group on Status Epilepticus. JAMA 1993;270(7):854-9.
Give glucose (2-4 ml/kg D25%, infants 5 ml/kg D10%), unless normo- or hyperglycemic
Hyperglycemia has no negative effect in SE
(as long as significant hyperosmolality is being avoided)
The longer you wait to administer anticonvulsants, the more anticonvulsants you will need to stop SE
Most common mistake is ineffective dose
Anticonvulsants - Rapid acting
Lorazepam 0.1 mg/kg i.v. over 1-2 minutes
Diazepam 0.2 mg/kg i.v. over 1-2 minutes
If SE persists, repeat every 5-10 minutes
High lipid solubility
Thus very rapid onset
Thus rapid loss of anticonvulsant effect
Adverse effects are persistent:
Low lipid solubility
Action delayed 2 minutes
Anticonvulsant effect 6-12 hrs
Less respiratory depression than diazepam
May be given i.m.
Benzodiazepine - Rectal
0.3 to 0.5 mg/kg rectal gel, typically reaches anticonvulsant levels within 5-10 minutes
Intravenous solution given rectally is equally effective
(and much cheaper)
Seigler RS. J Emerg Med1990;8(2):155-9.
5 mg Diastat rectal gel $ 78.00
5 mg diazepam intravenous solution $ 1.40
Benzodiazepine - Intramuscular
0.2 mg/kg i.m.
Aqueous solution is rapidly absorbed, anticonvulsant effect begins after 2 minutes
Can be given, but lacks water solubility, thus later onset than midazolam
Chamberlain JM. Pediatr Emerg Care 1997;13(2):92-4.
Towne AR. J Emerg Med 1999;17(2):323-8.
Anticonvulsants - Long acting
20 mg/kg i.v. over 20 min
Extravasation causes severe tissue injury
Onset 10-30 min
May cause hypotension, dysrhythmia
20 mg PE/kg i.v. over 5-7 min PE = phenytoin equivalent
Extravasation well tolerated
Onset 5-10 min
May cause hypotension
If in doubt, measure free phenytoin!
Phenytoin is largely protein bound
(> 90%, varies with serum protein concentration)
Free phenytoin = active phenytoin
(anticonvulsant and toxic effects)
Toxicity more likely with hypoalbuminemia (usually if < 2 g/dL)
Total phenytoin: 10 - 20 mcg/ml
Free phenytoin: 0.8 - 1.6 mcg/ml
Anticonvulsants - Long acting
20 mg/kg i.v. over 10 - 15 min
Onset 15-30 min
May cause hypotension, respiratory depression
Initial choice of long acting anticonvulsants in SE Is patient an infant? Is patient already receiving phenytoin? Yes No At high risk for extravasation ? (small vein, difficult access etc.)? Phenobarbital Yes No Phenytoin Fosphenytoin
If SE persists
Propofol infusion 5-10 mg/kg/hr after bolus 2 mg/kg
Midazolam infusion 1 - 10 mcg/kg/min after bolus 0.15 mg/kg
Pentobarbital infusion 1-3 mg/kg/hr after bolus 10 mg/kg
Paraldehyde: no longer allowed for human use
Non - convulsive status epilepticus
How do you tell that patient’s seizures have stopped?
Non - convulsive SE ?
Neurologic signs after termination of SE are common:
Abnormal Babinski reflex
May be asymmetrical
Non - convulsive SE ?
Up to 20% of children with SE have non - convulsive SE after tonic - clonic SE
After you start high flow oxygen via a partial rebreather mask, suction the airway and position the head in mild hyperextension with jaw thrust, O 2 saturation reads around 60%, and the child looks blue. He is still seizing . You see no chest rise and hear no air entry.
What is your plan of action?
Case Scenario (2c)
Saturation improves to about 85% with BVM ventilation, the pt looks less blue but not pink. Fairly violent seizure activity continues.
Per your order, the first dose of lorazepam is going into the IV, but pt continues to seize and is cyanotic
You give rocuronium 1 mg/kg rapidly iv, and expertly intubate the child. He is now being ventilated, pink and not seizing any more
Good job! Anything else to be done? What information are you eagerly waiting for?
Case Scenario (2d)
Have to assume ongoing electrical seizures. What is the sodium?
Blood sugar is 180 mg/dL, Na is 118 mEq/L
Neuromuscular blockade is beginning to wear off, there is still seizure activity
Case Scenario (2e)
After 20 mg/kg phenobarbital, and halfway into an infusion of 3% NaCl, seizure activity slows, and then stops
You consider a CT, plan an LP, start antibiotics
You have a high index of suspicion for ongoing electrical seizures (non-convulsive SE) in this infant
Suggested Reading 1. Fountain NB. Status epilepticus: risk factors and complications. Epilepsia 2000;41 Suppl 2:S23-30. 2. Treatment of convulsive status epilepticus. Recommendations of the Epilepsy Foundation of America's Working Group on Status Epilepticus. JAMA 1993;270(7):854-9. 3. Bassin S, Smith TL, Bleck TP. Clinical review: status epilepticus. Crit Care 2002;6(2):137-42. 4. Bleck TP. Management approaches to prolonged seizures and status epilepticus. Epilepsia 1999;40(1):S64-6. 5. DeLorenzo RJ, Towne AR, Pellock JM, et al. Status epilepticus in children, adults, and the elderly. Epilepsia 1992;33 Suppl 4:S15-25. 6. Haafiz A, Kissoon N. Status epilepticus: current concepts. Pediatr Emerg Care 1999;15(2):119-29. 7. Lowenstein DH, Bleck T, Macdonald RL. It's time to revise the definition of status epilepticus. Epilepsia 1999;40(1):120-2. 8. Orlowski JP, Rothner DA. Diagnosis and treatment of status epilepticus. In: Fuhrman BP, Zimmerman JJ, editors. Pediatric Critical Care. St. Louis: Mosby; 1998. p. 625-35.