Status Epilepticus in Children Toni Petrillo

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Status Epilepticus in Children Toni Petrillo

  1. 1. Status Epilepticus in Children Toni Petrillo Pediatric Critical Care Children’s Healthcare of Atlanta
  2. 2. Status epilepticus 2  Status epilepticus (SE) presents in a multitude of forms, dependent on etiology and patient age (myoclonic, tonic, subtle, tonic-clonic, absence, complex partial etc.)  Generalized, tonic-clonic SE is the most common form of SE
  3. 3. Status epilepticus 3 Definition  Conventional definition:  Single seizure > 30 minutes  Series of seizures > 30 minutes without full recovery
  4. 4. Status epilepticus 4 Definition  “If appropriate therapy is delayed, SE can cause permanent neurologic sequelae or death …” thus  “ … any child who presents actively convulsing should be assumed to have SE.” Haafiz A. Pediatr Emerg Care 1999;15(2):119-29
  5. 5. Status epilepticus 5 The longer SE persists, the lower is the likelihood of spontaneous cessation the harder is it to control the higher is the risk of morbidity and mortality Treatment for most seizures needs to be instituted after > 5 minutes of seizure activity Bleck TP. Epilepsia 1999;40(1):S64-6
  6. 6. Status epilepticus 6 Causes  Fever  Medication change  Unknown  Metabolic  Congenital  Anoxic  Other (trauma, vascular, infection, tumor, drugs) 36% 20% 9% 8% 7% 5% 15% DeLorenzo RJ. Epilepsia 1992;33 Suppl 4:S15-25
  7. 7. Status epilepticus 7 Drugs which can cause seizures  Antibiotics  Penicillins  Isoniazid  Metronidazole  Anesthetics, narcotics  Halothane, enflurane  Cocaine, fentanyl  Ketamine  Psychopharmaceuticals  Antihistamines  Antidepressants  Antipsychotics  Phencyclidine  Tricyclic antidepressants
  8. 8. Status epilepticus 8 Mortality  Adults  Children 15 to 22% 3 to 15% Reviewed in: Fountain NB. Epilepsia 2000;41 Suppl 2:S23-30
  9. 9. Status epilepticus 9 Prolonged seizures Duration of seizureDuration of seizure LifeLife threateningthreatening systemicsystemic changeschanges DeathDeath TemporaryTemporary systemicsystemic changeschanges
  10. 10. Status epilepticus 10 Respiratory  Hypoxia and hypercarbia - ⇓ ventilation (chest rigidity from muscle spasm) - Hypermetabolism (⇑ O2 consumption, ⇑ CO2 production) - Poor handling of secretions - Neurogenic pulmonary edema?
  11. 11. Status epilepticus 11 Hypoxia  Hypoxia/anoxia markedly increase (triple?) the risk of mortality in SE  Seizures (without hypoxia) are much less dangerous than seizures and hypoxia Towne AR. Epilepsia 1994;35(1):27-34
  12. 12. Status epilepticus 12 Neurogenic pulmonary edema Rare complication Likely occurs as consequence of marked increase of pulmonary vascular pressure Johnston SC. Postictal pulmonary edema requires pulmonary vascular pressure increases. Epilepsia 1996;37(5):428-32
  13. 13. Status epilepticus 13 Acidosis  Respiratory  Lactic  Impaired tissue oxygenation  Increased energy expenditure
  14. 14. Status epilepticus 14 Hemodynamics  Sympathetic overdrive  Massive catecholamine / autonomic discharge  Hypertension  Tachycardia  High CVP  Exhaustion  Hypotension  Hypoperfusion 0 min0 min 60 min60 min
  15. 15. Status epilepticus 15 Cerebral blood flow - Cerebral O2 requirement Blood pressure Blood flow O2 requirement Seizure duration  Hyperdynamic phase  CBF meets CMRO2  Exhaustion phase  CBF drops as hypotension sets in  Autoregulation exhausted  Neuronal damage ensues
  16. 16. Status epilepticus 16 Glucose Glucose Seizure duration 30 min SE SE + hypoxia  Hyperdynamic phase  Hyperglycemia  Exhaustion phase  Hypoglycemia develops  Hypoglycemia appears earlier in presence of hypoxia  Neuronal damage ensues
  17. 17. Status epilepticus 17 Hyperpyrexia  Hyperpyrexia may develop during protracted SE, and aggravate possible mismatch of cerebral metabolic requirement and substrate delivery  Treat hyperpyrexia aggressively  Antipyretics, external cooling  Consider intubation, relaxation, ventilation
  18. 18. Status epilepticus 18 Other alterations  Blood leukocytosis (50% of children)  Spinal fluid leukocytosis (15% of children)  ⇑ K+  ⇑ creatine kinase  Myoglobinuria
  19. 19. Status epilepticus 19 Oxygen, oral airway. Avoid hypoxia! Consider bag-valve mask ventilation. Consider intubation IV/IO access. Treat hypotension, but NOT hypertension A B C
  20. 20. Status epilepticus 20 Treatment  Arterial blood gas?  All children in SE have acidosis. It often resolves rapidly with termination of SE  Intubate?  It may be difficult to intubate the actively seizing child  Stop or slow seizures first, give O2, consider BVM ventilation  If using paralytic agent to intubate, assume that SE continues
  21. 21. Status epilepticus 21 Initial investigations  Labs  Na, Ca, Mg, PO4 , glucose  CBC  Liver function tests, ammonia  Anticonvulsant level  Toxicology
  22. 22. Status epilepticus 22 Initial investigations  Lumbar puncture  Always defer LP in unstable patient, but never delay antibiotic/antiviral rx if indicated  CT scan  Indicated for focal seizures or deficit, history of trauma or bleeding d/o
  23. 23. Status epilepticus 23 Treatment  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)
  24. 24. Status epilepticus 24 Treatment  Hyponatremia:  Give 5 cc/kg of 3% (hypertonic saline)  Hypocalcemia:  Give 20-25 mg/kg of Calcium Chloride
  25. 25. Status epilepticus 25 Treatment  The longer you wait with anticonvulsant, the more anticonvulsant you will need to stop SE  Most common mistake is ineffective dose
  26. 26. Status epilepticus 26 Anticonvulsants  Rapid acting plus  Long acting
  27. 27. Status epilepticus 27 Anticonvulsants - Rapid acting  Benzodiazepines  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
  28. 28. Status epilepticus 28 Benzodiazepines  Diazepam  High lipid solubility  Thus very rapid onset  Redistributes rapidly  Thus rapid loss of anticonvulsant effect  Adverse effects are persistent:  Hypotension  Respir depression  Lorazepam  Low lipid solubility  Action delayed 2 minutes  Anticonvulsant effect 6-12 hrs  Less respiratory depression than diazepam  Midazolam  May be given i.m.
  29. 29. Status epilepticus 29 Anticonvulsants - Long acting  Phenytoin  20 mg/kg i.v. over 20 min  pH 12 Extravasation causes severe tissue injury  Onset 10-30 min  May cause hypotension, dysrhythmia  Cheap  Fosphenytoin  20 mg PE/kg i.v. over 5-7 min PE = phenytoin equivalent  pH 8.6 Extravasation well tolerated  Onset 5-10 min  May cause hypotension  Expensive
  30. 30. Status epilepticus 30 Anticonvulsants - Long acting  Phenobarbital  20 mg/k g i.v. over 10 - 15 min  Onset 15-30 min  May cause hypotension, respiratory depression
  31. 31. Status epilepticus 31 Initial choice of long acting anticonvulsants in SE Is patient an infant? Is patient already receiving phenytoin? Is patient an infant? Is patient already receiving phenytoin? YesNo At high risk for extravasation ? (small vein, difficult access etc.)? Phenobarbital YesYesNoNo Phenytoin Fosphenytoin
  32. 32. Status epilepticus 32 If SE persists  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
  33. 33. Status epilepticus 33 Non - convulsive status epilepticus  How do you tell that patient’s seizures have stopped?
  34. 34. Status epilepticus 34 Non - convulsive SE ?  Neurologic signs after termination of SE are common:  Pupillary changes  Abnormal tone  Babinski  Posturing  Clonus  May be asymmetrical
  35. 35. Status epilepticus 35 Non - convulsive SE ?  Up to 20% of children with SE have non - convulsive SE after tonic - clonic SE
  36. 36. Status epilepticus 36 Non - convulsive SE ?  If child does not begin to respond to painful stimuli within 20 - 30 minutes after tonic - clonic SE, suspect non - convulsive SE  Urgent EEG
  37. 37. Status epilepticus 37 References  Haafiz A, Kissoon N. Status epilepticus: current concepts. Pediatr Emerg Care 1999;15(2):119-29.  Bleck TP. Management approaches to prolonged seizures and status epilepticus. Epilepsia 1999;40(1):S64-6.  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.

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