CASE STUDY

I

Peer revIewed

Status Epilepticus: Evaluation and Management
Rashant V. Mahajan, MD, MPH, MBA

Status epilepticus (SE) is associated with high morbidity and mortality in children. Fever is a common cause of SE and may precipitate seizures in children who have underlying epilepsy risk factors or may signal intracranial infection. Metabolic abnormalities, such as hypoglycemia, can also cause SE. Early termination of SE is the goal of therapy. Non-intravenous benzodiazepines can be initiated at home or en route to the hospital. Use of anticonvulsants depends on the progression of the seizure. Children with SE need to be hospitalized for a comprehensive evaluation of the seizure etiology done in consultation with a paediatric neurologist. When counselling parents, address the social and academic repercussions of epilepsy and emphasize first aid measures and use of medications, such as rectal benzodiazepines. Seizures occur in 10% of children.1 Status epilepticus (SE) — perhaps the most severe type of seizure — is one of the most common neurological emergencies in children and is associated with high morbidity and mortality. The estimated incidence of convulsive SE is between 17 and 23 episodes per 100,000 children per year.2 SE is most common in the first year of life, and febrile seizure is the most common cause. SE occurs as the first seizure
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Fever is a common cause of SE.

pneumonia, are directly related to the length of the seizure episode. Paediatricians who are comfortable with managing seizures, especially SE, can greatly reduce the adverse outcomes associated with prolonged seizures. In this article, I review the acute management of convulsive SE, which is more common than nonconvulsive SE and likely to present as an emergency to practitioners in a clinic setting or in the emergency department (ED). I also provide a clinically useful algorithm that can be initiated in the office and continued in

the ED. Finally, I briefly discuss post-seizure management.

DEfiniTionS
Seizure. A seizure is defined as a transient occurrence of signs and symptoms caused by abnormal excessive or synchronous neuronal activity in the brain. Seizures are initially classified as either generalized or partial: • Generalized seizures involve the entire cortex, and consciousness is usually lost.

in 12% of children with epilepsy.

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Adverse outcomes, such as post-seizure neurological abnormalities and aspiration
JPOG MAy/Jun 2010 • 118

CASE STUDY I CASE STUDY Peer revIewed • Partial seizures begin in one portion of the brain and have symptoms related to that region’s function. In: Engel J Jr. such as hypoglycaemia. they can present as recurrent episodes in close proximity. 2008. factors. Intracranial infections. such as meningitis and encephalitis. and hypomagnesaemia. hypocalcaemia. with recovery between episodes (repetitive seizures). For a list of the more common causes of SE in children. Pedley T. Fever may precipitate seizures in children who have underlying epilepsy risk MAnAgEMEnT of Epilepsy. or they may be continuous. Epilepsy: A Comprehensive Textbook. Some children will present in SE with their first febrile seizure. they may spread to adjacent regions and affect consciousness (complex partial seizures). These seizures may remain restricted to one location without affecting alertness (simple partial seizure).the fever may be secondary to the convulsive ConvUlSivE SE Early termination of seizures substantially JPOG MAy/Jun 2010 • 119 voked seizures occur more than 24 hours apart.3 mL/kg of 10% IV calcium gluconate over 5 min 50 mg/kg of IV magnesium sulfate over 1 h initially divided into symptomatic and idiopathic types and then further classified as generalized and localized on the basis of the clinical presentation along with EEG findings. Children may also have seizures because of the presence of metabolic abnormalities. 2. Causes and mortality rate of paediatric status epilepticus Cause Infection Remote Lowered antiepileptic drug levels Cerebral stroke Metabolic abnormality Hypoxia CNS infection Drug overdose Cases. hyponatraemia. SE can be divided into 2 types: • Non-convulsive SE consists of continuous abnormal electroencephalographic (EEG) activity without convulsive activity in the presence of altered sensorium. However. eds. Status epilepticus. Convulsive SE is defined as either two or more convulsions without complete recovery of consciousness or a single prolonged seizure episode that lasts for at least 30 minutes. % 52 38 21 10 7 5 2 2 Mortality rate 5 0 0 0 0 0 0 0 Adapted from Shorvon SD et al. • Convulsive SE is typically tonic-clonic in nature and can be generalized or partial with secondary generalization. or frequent. or they may spread across the entire cortex (secondary generalization). 5 CAUSES Fever is a common cause of seizures and SE in children. some experts have recommended shortening the minimum seizure duration in the SE criteria from 30 minutes to 5 minutes. can also present with fever and seizures.7 Table 2. without recovery between episodes (SE). In some cases. Epilepsy is . Suggested doses for management of metabolic seizures and status epilepticus in children Metabolic abnormality Hypoglycaemia Hyponatraemia Hypocalcaemia Hypomagnesaemia Treatment 2–4 mL/kg IV bolus of 25% glucose 4–6 mL/kg IV bolus of 3% saline 0. epilepsy is diagnosed. When two or more unpro.4 Table 1. such as cerebral palsy. Seizures are often isolated events that terminate spontaneously within several minutes. movements. Because of the high morbidity and mortality associated with SE and the recognition that anti-seizure medications are less effective in terminating prolonged seizures. see Table 1.

2 mg/kg) OR • EMTs and paramedics might consider: IM lorazepam (0. if time permits and if facilities are available. a In an ideal situation. however. electroencephalographic. monitor breathing. emergency medical technicians. EEG. one can obtain blood chemistries. if possible • Loosen clothing • Call 911 or proceed to hospital Incipient SE (seizure duration < 5 min) If no termination of seizure within 2 to 3 min: • Administer a benzodiazepine if available: Rectal diazepam (0.10 min) • Administer IV lorazepam (0.5 mg/kg) OR IM midazolam (0. circulation • Wait 5 min before adding IV fosphenytoin (30 mg/kg) • Obtain intravenous access • Check bedside glucose levela • Conduct more thorough history/physical examination (reflexes. JPOG MAy/Jun 2010 • 120 . treatment should not be delayed. or hypocalcaemia is suspected. obtain metabolic profile • Perform CT scan of head and other investigations as clinically indicated • Consult paediatric neurology. malformations) • Consider 2 mL/kg of 25% glucose if the seizure is prolonged. which can present with refractory seizures Refractory SE (no termination after 2 medications) • Administer IV levetiracetam (20–30 mg/kg) OR IV valproate (20 mg/kg) If seizure continues: • Add phenobarbital (30 mg/kg) • Measure antiepileptic blood levels. If hypoglycaemia.05–0. support airway. hypoglycaemia caused by seizure may need to be treated • Consider empiric treatment with 100 mg IV pyridoxine (if < 2 y of age) for undetected pyridoxine deficiency.05 mg/kg to a maximum of 4 mg total) • Administer oxygen. move patient to paediatric ICU. these can and should be treated empirically (see Table 2) rather than waiting for blood test results. hyponatraemia.2–0.2 mg/kg) OR Intranasal midazolam (0.1 mg/kg) or other benzodiazepines In-hospital management Antiepileptic treatment Assessment and action Established SE (seizure duration 5 .5 mg/kg) OR Buccal midazolam (0. and monitor vital signs along with EEG monitoring • Continue monitoring Prolonged refractory SE (anaesthetics fail to terminate SE) • Induce coma with IV midazolam OR pentobarbital If seizure continues: • Add nasogastric topiramate OR valproate EMTs.CASE STUDY I Peer revIewed Algorithm – Approach to treatment of the child in convulsive status epilepticus (SE) Prehospital management Antiepileptic treatment • Observe patient for signs of seizure termination • • • • Assessment and action Perform quick physical assessment Turn the patient to one side (if no neck trauma) Clear the area of any sharp objects Suction or clear vomit/saliva/food/debris from the mouth.

Shorvon SD. health care providers should anticipate and be ready to initiate further medical treatment.epilepsy. http://professionals. and shortterm outcome of convulsive status epilepticus in childhood: prospective population-based study. including type of antiepileptic medication.368:222–229. Abend NS. Overview: definitions and classifications of seizure emergencies. Outcome of convulsive status epilepticus: a review. 2006. Huh JW. Childhood convulsive status epilepticus: epidemiology. should be emphasized. The principles that guide medication choices for convulsive SE include: • Ability to be administered rapidly • Fast penetration of the brain For More Information Appleton R. In addition. The Status Epilepticus Working Party. family history. Scott RC.22(5 suppl):9S–13S. Pellock JM. Epilepsy: A Comprehensive Textbook. Helfaer MA. 2007. 2007. morbidity. 7. Use of anticonvulsants depends on the progression of the seizures. Lancet. In-hospital treatment. 2009. along with electroencephalography. REfEREnCES 1. Most important is to turn the patient on his or her side—assuming that there has been no neck trauma. hypocalcaemia. Anticonvulsant medications in the pediatric emergency room and intensive care unit. Fortunately. In addition to a rapid blood glucose test to rule out hypoglycaemia. 2007.8(12):421-424 About the Author Dr Mahajan is Associate Professor in the departments of paediatrics and emergency medicine. Arch Dis Child. intranasal midazolam. Pedley T. Subsequent management. com/page/table_epilepticus_guidelines. Chin RF. Novorol CL. These providers attend to the airway. Nelson Textbook of Pediatrics. A multidisciplinary team including. 6. 2008. or CT scanning. Children with SE need to be hospitalized for a comprehensive evaluation of the seizure etiology. DeLorenzo RJ. The treatment of convulsive status epilepticus in children. 2007:2457–2478. if possible. Treatment that begins at home or during the prehospital transport has been shown to be safe and effective. Thus. both in Detroit. Arch Dis Child. cause. and is the goal of therapy. a responsible adult needs to be present when the child is bathing or swimming. Scott RC. 2. Neville BG. Acute physiologic changes. Parents require support and accurate information about the prognosis of the seizure-causing condition. Evaluation should include a detailed history. paediatric emergency and critical care specialists is necessary for general supportive care. The algorithm provides a guide to the most recent approach to the treatment of a child in convulsive SE. Martland T. com/professionals. 18th ed. restriction of physical activity is unnecessary. it is impossible to predict which seizure episodes will progress to SE. eds. such as rectal benzodiazepines. Johnston MV. but not limited to. it is important to test for hyponatraemia. 2009. and circulation. Guidelines for status epilepticus treatment. First aid measures and use of medications. based on the etiology. Pediatr Emerg Care. Behrman RE.83:415– 419. 3. Incidence. Pellock JM. Seizures in childhood. If in the clinic or ED. In: Engel J Jr. or rectal diazepam) can be initiated in the absence of intravenous access. 2008:747. is often indicated. management and outcome. Acta Neurol Scand Suppl. most children who are adherent to medications tend to have normal IQs and can be expected to lead normal lives. Although most seizure episodes. Choonara I. developmental history. 4. Therapy with a benzodiazepine (intramuscular midazolam. will depend on the cause of the seizure and type of epilepsy indicated by the EEG findings. eds. along with fever management. and hypomagnesaemia at the initial evaluation and to treat these conditions appropriately (Table 2). 6 • Minimal systemic adverse effects • Use by nonintravenous route. Epilepsy. Philadelphia: Lippincott Williams & Wilkins. treat underlying causes. However. Stanton BF. and mortality of status epilepticus. et al. Post-seizure evaluation and management. and exposure to any medications or recent travel. breathing. © 2009 CMP Healthcare Media LLC. even in patients with poorly controlled epilepsy. however. et al. Chin RF. perform a rapid blood glucose test to determine whether hypoglycaemia is the cause of the seizure. and Vice Chief and Research Director in the department of paediatric emergency medicine at Wayne State University School of Medicine and Children’s Hospital of Michigan. It is also important to counsel parents about the adverse effects of medications and the social and academic repercussions of epilepsy. 2000. Members of the Status Epilepticus Working Party. NLSTEPSS Collaborative Group. In: Kliegman RM. Initially published in Consultant for Paediatricians Dec 2009.CASE STUDY I CASE STUDY Peer revIewed reduces morbidity and mortality. MRI. Philadelphia: Saunders. which must be done in consultation with a paediatric neurologist. cerebrospinal fluid analysis. J Child Neurol. Prehospital treatment. 2nd ed. tend to terminate spontaneously. empiric treatment should not be delayed while waiting for test results.html.92:948–951. 5. Neville BG. JPOG MAy/Jun 2010 • 121 . buccal midazolam. In most instances.24:705–718. Accessed November 5.186:21–24. Peckham C. Jenson HB. and prevent and treat systemic complications. Chin RF. Rectal diazepam is often prescribed for children with febrile seizures and prolonged or repetitive seizures as a part of their home care. Dlugos DJ.

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