Pediatrics, Status Epilepticus

Author; Grace M Young, MD, Associate Professor, Departement of Pediatrics, University of Maryland
Medical Center
Grace M Young, MD, is a member of the following medical societies : American Academy of Pediatrics and
American College of Emergency Physicians
Editor(s) : Garry Wilkes, MD, Director, Emergency Medicine, Adjunct Associate Professor, Edith Cowan
University, Departement of Emergency Medicine, Bumbury Health Service; Mary L Windle, ParmD,
Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy
Editor, eMedicine.com, Inc; Wayne Wolfarm, MD, MPH, Clinical Associate Professor, Departements of
Pediatrics, Children’s Hospital and University of Cincinnati; John Halamka, MD. Chief’ Information
Officer, CareGroupHealthcare System, Assistant Professorof Medicine, Depertment of Emergency
Medicine , Beth Israel Deaconess Medical Center, Assistant Professor of Medicine, Harvard Medical School;
and Richard G Bachur, MD, Assistant Professor of Pediatrics, Harvard Medical School; Associate Chief
and Fellowship Director, Division of Emergency Medicine, Children’s Hospital of Boston.

TREATMENT

Prehospital Care :

 Secure the airway

 Administor supplemental 100% oxygen

 Infuse Isotonic intravenous fluids and glucose

 Immobilize the cervical spine in patient with possible trauma

 Consider PR diazepam (0,5 cm/kg/dose) or IM midazolam (0,1 – 0,2 mg/kg/dose; not to exceed a
cumulative dose of 10 mg)

Emergency Departement Care : The principles of treatment are to terminate the seizure while resuscitating
the patient, treating complications, and preventing recurrence

 Assessment and stabilization of ABC;s concurrent with management of the seizure is imperative
 Administer 100% oxygen by facemask, assist ventilation, and use artificial airways (eg.
Endotracheal intubation) as needed. Suction secretions and decompress the stomach with a
nasogastric tube.
 Immobilize the cervical spine if trauma is suspected.
 Closely monitor vital sign, cardiorespiratory function, and oxygen saturation.
 Perform rapid blood glucose assay (eg.Dextrostix) at bedside.
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 Establish intravenous access. Use intraosseus (IO) infusion if intravenous access is not
immediately available in the child younger than 6 years. Most available anticonvulsants may be
administered intravenously or intraosseously.

o Infuse isotonic intravenous fluids 20 ml/kg with glucose (eg. 200 mL dextrose 5% in
normal saline {D5NS} IV over 1 h for a 10-kg child).

o Consider treatment with the following agents

 Dextrose – 0.25-0.5 g/kg/dose(1-2 mL of 25%dextrose) IV for hypoglycemia;
not to exceed 25 g/dose
 Naloxone – 0.1 mg/kg/dose IV preferably (if needed may administer IM/SC) for
narcotic overdose
 Thiamine – 100 mg IM for possible deficiency
 Pyridoxine – 50-100 mg IV/IM for possible deficiency
 Antibiotics – if meningitis is strongly suspected, initiate treatment with
antibiotics prior to cerebrospoinal fluid (CSF) analysis or CNS imaging.

 Administer anticonvulsant medication. The optimal protocol for management of status epilepticus
begins with benzodiazepine. In the United states, lorazepam is the first drug of choice in patients
with intravenous or intraosseous access. For patients without parenteral access, intramuscular
midazolam is best. If the seizures cease no further drugs are immediately necessary, and the
etiology of status epilepticus should be investigated. If seizures continue, administer intravenous
phenytoin or parenteral fosphenytoin. If these are not effective, administer intravenous
phenobarbital titrated to induce barbiturate coma. Finally, consider general anesthesia with
pentobarbital or midazolam.

o The goal is prompt cessation of seizure activity. Patiently allow infused anticonvulsants
to act before using additional anticonvulsants. Proceed to the next drug if seizure activity
continues.

o Lorazepam (0.05-0.1 mg/kg IV/IO slowly infused over 2-5 min) has rapid onset and long
duration of anticonvulsant action. It is preferred over diazepam.

o Phenytoin (18-20 mg/kg IV/IO) or fosphenytoin (15-20 mg/kg IV/IO) loading doses:
These long-acting anticonvulsants usually are infused if benzodiazepines do not stop the
seizures. Phenytoin and fosphenytoin are effective for most idiopathic generalized
seizures and for posttraumatic, focal, or psychomotor status epilepticus. Use a slow rate of
infusion (< 1 mg/kg/min or <50 mg/min) to avoid hypotension or cardiac arrhytmias.
A full loading dose should be delivered unless the patient is known to have a current
therapeutic level.

o Midazolam (0.1-0.2 mg/kg IM)is most effective when intravenous or intraosseuous access
is not immediately available. Midazolam is the only benzodiazepine that can be
administered safely intramuscularly with equivalent rapid onset and moderate duration of
action.

o Phenobarbital (20-25 mg/kg IV/IO) is effective for febrile and neonatal status epilepticus
and may be infused after lorazepam or other benzodiazepines if the child is likely to have
these types of seizures. Phenobarbital’s major disadvantages are that it significantly
depresses mental status and causes respiratory difficulty. Obtain serum anticonvulsant
levels prior to administering addiotional long-acting anticonvulsants such as phenytoin or
fosphenytoin.

 General anesthesia

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 o Pentobarbital (5-10 mg/kg IV/IO loading dose followed by 0.5-3 mg/kg/h) or midazolam
(0.2 mg/kg IV/IO loading dose followed by 0.75-10 mcg/kg/min)
o All children must be intubated and paralyzed, have continuous cardiorespiratory and EEG
monitoring, and be in a pediatric critical care setting.

Consultations:After initial emergency stabilization,consider consultation with the following

specialist:

 Pediatric emergency or critical care specialist or general pediatrician

 Pediatric neurologist

 Pediatric neurosurgeon if needed

MEDICATION

Benzodiazepines, hydantoins, and barbiturates have anticonvulsant properties. Choose a parenteral

preparation with rapid onset and long duration of action with the least amount of sedation and
respiratory depression. Titrate for clinical response by waiting an adequate length of time for
attainment of therapeutic levels in the brain.

Drug Category : Benzodiazepines – By increasing the action of gamma-aminobutyric acid (GABA),

which is a major inhibitory neurotransmitter in the brain, may depress all levels of CNS, including
limbic and reticular formation.

Lorazepam (Ativan) -- Sedative hypnotic with short onset of effects

and relatively long half-life.
Preferred over diazepam because of significantly longer duration of
Drug Name
action and equivalent rapid onset of action.
Important to monitor patient's blood pressure after administering dose.
Adjust prn.
4mg/dose IV slowly over 2-5 min; repeat in 10-15 min prn; not to
Adult Dose
exceed 8 mg/dose
Infants and children: 0.1 mg/kg IV slowly over 2-5 min; repeat prn in
10-15 min at 0.05 mg/kg; not to exceed 4 mg/dose
Pediatric Dose
Adolescents: 0.07 mg/kg IV slowly over 2-5 min; repeat in 10-15 min
prn; not to exceed 4 mg/dose
Documented hypersensitivity; preexisting CNS depression,
Contraindication
hypotension, or narrow-angle glaucoma
Toxicity of benzodiazepines in CNS increases when used concurrently
Interactions
with alcohol, phenothiazines, barbiturates, and MAOIs
Pregnancy D – Unsafe in pregnancy
Caution in renal or hepatic impairment, myasthenia gravis, organic
Precautions
brain syndrome, or Parkinson disease
Diazepam (Valium) -- For treatment of seizures. Depresses all levels
of CNS (eg, limbic and reticular formation), possibly by increasing
GABA activity. Effective for prehospital use as PR administration.
Has a long half-life but rapidly redistributes from the CNS. Requires
Drug Name
administration of the longer-acting phenytoin or phenobarbital
because of very short duration of seizure control.
Do not administer >1-2 mg/min IVP in children or > 5 mg/min in
adults.

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 5-10 mg IV q10-20min; not to exceed 30 mg in an 8-h period; may
Adult Dose
repeat in 2-4 h prn
0.2-0.5 mg/kg/dose IV/IO administered over 2-5 min; repeat q15-
Pediatric Dose 30min; not to exceed a total cumulative dose of 10 mg; repeat in 2-4 h
prn; alternatively, o.5 mg/kg PR, then 0.25 mg/kg in 10 min prn
Contraindication Documented hypersensitivity; narrow-angle glaucoma
Increases CNS toxicity with coadministration of phenothiazines,
barbiturates, ethanol, opiates, or MAOIs; cimetidine, disulfiram,
Interactions fluoxetine, isoniazid, ketoconazole, metoprolol, propanolol, oral
contraceptives, propoxyphene, and valproic acid may increase effect of
benzodiazepines due to decreased metabolism
Pregnancy D – Unsafe in pregnancy
Caution with other CNS depressants, low albumin levels, or hepatic
disease (may increase toxicity); monitor for respiratory depression,
may precipitate porphyria attack; monitor for respiratory depression;
mild effects on blood pressure and cardiac output may be seen, which
Precaution
may be significant in patients with preexisting cardiac dysfunction;
ataxia, irritability, and sedation are common adverse effects; patients
ocassionally may have psychotic reactions or suicidal ideation after
use.
Midazolam (Versed) -- Used as alternative in termination of refractory
status epilepticus. Because midazolam is water soluble, takes
approximately 3 times longer than diazepam to peak EEG effects. Thus,
7Drug Name
clinician must wait 2-3 min to fully evaluate sedative effects before
initiating procedure or repeating dose. DOC for child without immediate
IV or IO access (available IM).
2.5-5 mg IV once
Refractory SE: 200mcg/kg (0.2 mg/kg) IV bolus infused over 2-5 min,
Adult Dose
followed by 45-660 mcg/kg/h (0.75-11 mcg/kg/min) continuous IV
infusion
0.2 mg/kg IM; or 0.05-0.2 mg/kg IV/IO; may repeat q10-15min; not to
exceed a cumulative dose of 10 mg, alternatively, 0.15 mg/kg IV
Pediatric Dose
initially, followed 1 mcg/kg/min continuous IV infusion; titrate dose
until clinical seizure activity controlled
Documented hypersensitivity; preexisting hypotension; narrow-angle
Contraindication
glaucoma; sensitivity to propylene glycol (the diluent)
Sedative effects may be antagonized by theophyllines; opiates and
erythromycin may accentuate sedative effects of midazolam due to
decreased clearance; increases CNS toxicity with coadministration of
Interactions
phenothiazines, barbiturates, and MAOIs; cimetidine, disulfiram,
fluoxetine, isoniazid, ketoconazole, metoprolol, oral contarceptives,
propanolol, and valproic acid may increase effect of benzodiazepines
Pregnancy D – Unsafe in pregnacy
Caution in CHF, pulmonary disease, renal impairment, and hepatic
Precaution failure; adverse effects include drowsiness, dizziness, nausea,
vomiting, and respiratory depression