Status epilepticus (SE) is a medical emergency that is associated with significant morbidity and mortality.
TYPES OF STATUS EPILEPTICUS
CONVULSIVE STATUS NON-CONVULSIVE STATUS FOCAL STATUS ABSENCE STATUS
≥ 5 minutes of continuous ≥ 10 minutes of continuous Focal epileptic seizure that lasts ≥ Prolonged, generalized convulsive seizure OR ≥ 2 seizure OR ≥ 30 total minutes of 30 minutes OR repeated focal absence seizure that usually discrete seizures between ictal EEG activity in any given epileptic seizures (≥ 30 minutes) last for hours to days. which there is incomplete hour. These patients are at risk for with incomplete recovery Cardinal symptom is altered recovery of consciousness. convulsive status. between seizures. level of consciousness.
Convulsive status is the most common type of status epilepticus (SE). > 50% of SE episodes occur in children with no prior seizure history.
COMMON ETIOLOGIES OF STATUS EPILEPTICUS
ACUTE SYMPTOMATIC (17-52%) REMOTE (16-39%) OTHER
Ø CNS infection Ø Hemorrhage Ø Progressive Ø Perinatal hypoxic- Ø Idiopathic (5-19%) Ø Metabolic (hypoglycemia, Ø Non-compliance neurodegenerative ischemic Ø Trauma hyperglycemia, with AEDs disorders encephalopathy Ø Prolonged febrile hyponatremia, hypocalcemia) Ø Overdose Ø Cerebral migrational Ø Cerebral dysgenesis convulsions (23-30%) Ø Stroke Ø Toxins disorders Ø Sleep deprivation
HISTORY MANAGEMENT OF STATUS EPILEPTICUS IN HOSPITAL § Seizure history: pre- GOAL: stop the seizure and prevent brain injury. Then determine the underlying cause. ictal, ictal, and post- Seizure AIRWAY support ictal phases. NO IV ACCESS stops Monitor, follow- BREATHING – assess breathing, § Past medical history: Lorazepam buccal or PR up investigations 100% O , monitor O saturation previous seizures or 2 2 Midazolam buccal, CIRCULATION – BP, pulse history of epilepsy. intranasal, or intramuscular Establish IV ACCESS Repeat x1 within § Illness symptoms: Diazepam PR Still fever, nausea, Rapid GLUCOSE test 5 minutes or seizing Switch to IV route
vomiting, or diarrhea. 10 minutes Position child on their § Trauma or injury – side to prevent aspiration Still seizing § Medications (AED) 2nd line therapy (see below) § Toxins IV ESTABLISHED 1st line Lorazepam IV Repeat x1 within 5 Monitor, follow-up PHYSICAL EXAM Midazolam IV Still minutes Seizure investigations Diazepam IV seizing stops § ABCs, vitals, level of consciousness, GCS § Rule out CNS Still seizing nd
infections – 2 line agents: Use phenobarbital if fosphenytoin/phenytoin used. § General physical Fosphenytoin IV, IM Use fosphenytoin or phenytoin if phenobarbital exam: source of line Phenytoin IV, IO If still already used. Other considerations: IV valproic acid nd
infection (eg: otitis 2 Phenobarbital IV seizing after
20 minutes or IV levetiracetam. media, upper 5 minutes respiratory tract, lungs, GI tract, or YES Monitor, follow-up urinary tract). Seizure stops within 10 minutes § Neurological exam investigations § Toxidrome indications NO
REFRACTORY STATUS EPILEPTICUS: unresponsive to 2 different INVESTIGATIONS Establish antiepileptic medications (eg: benzodiazepine and phenytoin) goals with § Glucose guidance § CBC with differential from Peds 45 minutes § Electrolytes - Neurology Consult ICU team. Rapid sequence intubation. Monitor § Ca2+, Mg2+, P and Peds ABCs continuously. Midazolam continuous infusion.
§ Liver function tests By 35 Critical Care Maintain phenobarbital and phenytoin at therapeutic levels. § Toxicology screen Seizure
§ Anticonvulsant level Still seizing minutes 45 § EEG stops hour 1 By § Head CT or MRI If no seizures for 24-48 Consider Thiopental/Pentobarbital § Urine, blood, CSF hours: taper midazolam bolus and continuous infusion. cultures
May 2020 Katharine V. Jensen (Medical Student 2021, University of Alberta) & Dr. Natarie Liu (Neurologist & Epileptologist, University of Alberta) for www.pedscases.com