CASE STUDY I Peer Reviewed

Status Epilepticus: Evaluation and

Management
Rashant V. Mahajan, MD, MPH, MBA

Status epilepticus (SE) is associated with high Fever is a common cause of SE.
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 mortal-
ity. 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
3
in 12% of children with epilepsy. 3
Adverse outcomes, such as post-seizure
neurological abnormalities and aspiration
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 clas-
sified as either generalized or partial:
•G
 eneralized seizures involve the entire
cortex, and consciousness is usually lost.

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• P artial seizures begin in one portion of
the brain and have symptoms related to
that region’s function. These seizures may
remain restricted to one location without
affecting alertness (simple partial seizure);
they may spread to adjacent regions and
affect consciousness (complex partial
seizures); or they may spread across the
entire cortex (secondary generalization).
Seizures are often isolated events that
terminate spontaneously within several
minutes. However, they can present as recur-
rent episodes in close proximity, with recov-
ery between episodes (repetitive seizures);
or they may be continuous, or frequent,
without recovery between epi­sodes (SE).
Status epilepticus. 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.
• Convulsive SE is typically tonic-clonic in
nature and can be generalized or partial
with secondary generalization. Convul-
sive 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. 2,4
Because of the high morbidity and
mortality associated with SE and the recog-
nition that anti-seizure medications are less
effective in terminating prolonged seizures,
some experts have recommended shorten-
ing the minimum seizure duration in the SE
criteria from 30 minutes to 5 minutes. 5
Epilepsy. When two or more unpro- the fever may be secondary to the convulsive Convulsive SE
voked seizures occur more than 24 hours
apart, epilepsy is diagnosed. Epilepsy is
CASE STUDY I Peer Reviewed
CASE STUDY
Table 1. Causes and mortality rate of paediatric status epilepticus
Cause Cases, % Mortality rate
Infection 52 5
Remote 38 0
Lowered antiepileptic drug levels 21 0
Cerebral stroke 10 0
Metabolic abnormality 7 0
Hypoxia 5 0
CNS infection 2 0
Drug overdose 2 0
Adapted from Shorvon SD et al. In: Engel J Jr, Pedley T, eds. Epilepsy: A Comprehensive Textbook. 2008.7
Table 2. Suggested doses for management of metabolic seizures and
status epilepticus in children
Metabolic abnormality Treatment
Hypoglycaemia 2–4 mL/kg IV bolus of 25% glucose
Hyponatraemia 4–6 mL/kg IV bolus of 3% saline
Hypocalcaemia 0.3 mL/kg of 10% IV calcium gluconate over 5 min
Hypomagnesaemia 50 mg/kg of IV magnesium sulfate over 1 h
initially divided into symptomatic and idio- factors, such as cerebral palsy. Intracranial
pathic types and then further classified as infections, such as meningitis and encephali-
generalized and localized on the basis of the tis, can also present with fever and seizures.
clinical presentation along with EEG findings. Children may also have seizures because of
the presence of metabolic abnormalities,
Causes such as hypoglycaemia, hyponatraemia,
hypocalcaemia, and hypomagnesaemia. For
Fever is a common cause of seizures and SE a list of the more common causes of SE in
in children. Some children will present in SE children, see Table 1.
Management Of
with their first febrile seizure. In some cases,
movements. Fever may precipitate seizures
in children who have underlying epilepsy risk Early termination of seizures substantially
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Algorithm – Approach to treatment of the child in convulsive status epilepticus (SE)

Prehospital management
Antiepileptic treatment Assessment and action
Incipient SE (seizure duration < 5 min)
• Observe patient for signs of seizure termination • 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,
if possible
• Loosen clothing
If no termination of seizure within 2 to 3 min:
• A dminister a benzodiazepine if available: • Call 911 or proceed to hospital
Rectal diazepam (0.2–0.5 mg/kg) OR
Buccal midazolam (0.5 mg/kg) OR
IM midazolam (0.2 mg/kg) OR
Intranasal midazolam (0.2 mg/kg) OR
• EMTs and paramedics might consider:
IM lorazepam (0.05–0.1 mg/kg)
or other benzodiazepines
In-hospital management
Antiepileptic treatment Assessment and action
Established SE (seizure duration 5 - 10 min)
• A dminister IV lorazepam (0.05 mg/kg to a maximum of 4 mg total) • Administer oxygen; support airway; monitor breathing, 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,
malformations)
• Consider 2 mL/kg of 25% glucose if the seizure is prolonged;
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, which can present with
refractory seizures
Refractory SE (no termination after 2 medications)
• A
 dminister IV levetiracetam (20–30 mg/kg) OR • M easure antiepileptic blood levels; obtain metabolic profile
IV valproate (20 mg/kg) • Perform CT scan of head and other investigations as clinically
indicated
If seizure continues:
• Consult paediatric neurology, move patient to paediatric ICU, and
• Add phenobarbital (30 mg/kg)
monitor vital signs along with EEG monitoring
Prolonged refractory SE (anaesthetics fail to terminate SE)
• Induce coma with IV midazolam OR pentobarbital • Continue monitoring
If seizure continues:
• Add nasogastric topiramate OR valproate
EMTs, emergency medical technicians; EEG, electroencephalographic.
a
I n an ideal situation, if time permits and if facilities are available, one can obtain blood chemistries; however, treatment should not be delayed. If hypoglycaemia, hyponatraemia, or hypocalcaemia is
suspected, these can and should be treated empirically (see Table 2) rather than waiting for blood test results.

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 CASE STUDY I Peer Reviewed
CASE STUDY

reduces morbidity and mortality, and is the
goal of therapy. The algorithm provides a
guide to the most recent approach to the
treatment of a child in convulsive SE. Most
important is to turn the patient on his or her
side—assuming that there has been no neck
trauma. If in the clinic or ED, perform a rapid
blood glucose test to determine whether
hypoglycaemia is the cause of the seizure.
Prehospital treatment.
that begins at home or during the prehos-
pital transport has been shown to be safe
and effective. Therapy with a benzodiaz-
epine (intramuscular midazolam, buccal
midazolam, intranasal midazolam, or rectal
diazepam) can be initiated in the absence of
intravenous access. Rectal diazepam is often
prescribed for children with febrile seizures
and prolonged or repetitive seizures as a part
of their home care.
In-hospital treatment. Use of anticon-
vulsants depends on the progression of the
seizures. Although most seizure episodes,
6
even in patients with poorly controlled
• Minimal systemic adverse effects
• Use by nonintravenous route, if possible.
A multidisciplinary team including, but
not limited to, paediatric emergency and criti-
cal care specialists is necessary for general
supportive care. These providers attend to
the airway, breathing, and circulation; treat
underlying causes; and prevent and treat
systemic complications.
Treatment In addition to a rapid blood glucose test
to rule out hypoglycaemia, it is important to
test for hyponatraemia, hypocalcaemia, and
hypomagnesaemia at the initial evaluation
and to treat these conditions appropriately
(Table 2). However, empiric treatment should
not be delayed while waiting for test results.
Post-seizure evaluation
management. Children with SE need to be
hospitalized for a comprehensive evaluation
of the seizure etiology, which must be done
in consultation with a paediatric neurologist.
Evaluation should include a detailed history,
developmental history, family history, and
exposure to any medications or recent travel.
seizure-causing condition. It is also important
to counsel parents about the adverse effects
of medications and the social and academic
repercussions of epilepsy. In most instances,
restriction of physical activity is unnecessary;
however, a responsible adult needs to be pres-
ent when the child is bathing or swimming.
First aid measures and use of medications,
such as rectal benzodiazepines, along with
fever management, should be emphasized.
Fortunately, most children who are adherent
to medications tend to have normal IQs and
can be expected to lead normal lives.
© 2009 CMP Healthcare Media LLC. Ini-
tially published in Consultant for Paedia-
and tricians Dec 2009;8(12):421-424
About the Author
Dr Mahajan is Associate Professor in the departments
of paediatrics and emergency medicine, 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, both in
Detroit.

epilepsy, tend to terminate spontaneously, In addition, based on the etiology, cerebro-

it is impossible to predict which seizure
episodes will progress to SE. Thus, health
care providers should anticipate and be ready
to initiate further medical treatment.
The principles that guide medication
spinal fluid analysis, MRI, or CT scanning,
along with electroencephalography, is often
indicated. Subsequent management, includ-
ing type of antiepileptic medication, will
depend on the cause of the seizure and type
For More Information
Appleton R, Choonara I, Martland T, et al. The treatment
of convulsive status epilepticus in children. The Status
Epilepticus Working Party, Members of the Status
Epilepticus Working Party. Arch Dis Child. 2000;83:415–
419.

choices for convulsive SE include: of epilepsy indicated by the EEG findings. Guidelines for status epilepticus treatment. Epilepsy.
com/professionals. 2009. http://professionals.epilepsy.
• Ability to be administered rapidly Parents require support and accurate com/page/table_epilepticus_guidelines.html. Accessed
• Fast penetration of the brain information about the prognosis of the November 5, 2009.

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