PEDIATRIC REVIEW OF STATUS EPILEPTICUS
I. INTRODUCTION
· Definition: > 30 min. of constant or repetitive seizing without recovery
· 2 types of status epilepticus exist:
i. Convulsive (clinical) – usually generalized tonic-clonic seizures. Has the highest morbidity (subsequent CNS deficits) & mortality
1. A clinical diagnosis
ii. Non-convulsive (subclinical– either absence or partial-complex seizures. Highly undiagnosed; less morbidity & mortality
1. May be difficult to clinically diagnose; seen on EEGs
II. ETIOLOGY
· Many different etiologies:
i. Infection (meningoencephalitis in all age groups)
ii. Febrile seizure in otherwise healthy child
iii. Progressive neurologic disease
iv. Known epilepsy: sub-therapeutic drug levels, stress
v. Hypoxia
vi. Metabolic disturbance: low dexi, Ca, Mg, Na; high uremia, IEMs
vii. Structural disturbance: cyst, abscess, tumor
viii. Toxins: EtOH ingestion/withdrawal, drugs
ix. Vascular disturbance: old infarct, AVM, hemorrhage, stroke
x. Psych: pseudoseizures
III. PRESENTATION
· Depends on the variety of status epilepticus
i. Convulsive SE presents with GTCs that last > 30 minutes or that repeatedly occur without resolution between seizures
ii. Non-convulsive SE may simply present as an extended staring spell or focal CNS deficit (e.g. arm twitch) that does not resolve
IV. MANAGEMENT
· Depends on the duration of the seizure
i. Monitor patient with EEG if possible to watch for ablation of spike/wave complexes characteristic of seizure activity (either convulsive or non-convulsive)
· 0 to 5 minutes
i. Usually, we don’t know it’s SE at this point
ii. Ensure safety of patient
iii. Monitor cardiopulmonary function and vital signs
iv. Give oxygen
v. Obtain history and perform complete physical examination
vi. Note time
· 5 to 10 minutes
i. Obtain intravenous access and start a short-acting agent
ii. Give Lorazepam: 0.05 to 0.1 mg/kg (Maximum dose, 4 mg) or Diazepam: Pediatric, 0.2 to 0.5 mg/kg Adult, 5 to 10 mg/dose
iii. Give 2 mL/kg of 50% glucose and B vitamins
1. In case this is a related metabolic phenomenon
iv. Labs-CBC, BMP, drug levels, Utox
· >10 minutes
i. Start a long acting agent
ii. Neonatal patient: Phenobarbital 20 mg/kg
iii. Pediatric and adult patients: Phenytoin 20 mg/kg (Prescribe as: Fosphenytoin at 20 mg phenytoin equivalents/kg)
· >30 minutes
i. Intubate, ventilate, and secure vital sign monitoring
ii. Load with second long-acting agent
1. Phenobarbital 10 mg/kg. May give additional 5- to 10-mg doses until 40 mg/kg or max dose of 1 g is reached
iii. IV Valproate may be used as a 3rd line agent
iv. Start Midazolam 0.05-0.10 mg/kg IV drip as a last resort (place the patient into a medically-induced coma)
1. NOTE: buccal and intranasal Midazolam are also options
V. POTENTIAL SEQUELAE
· Respiratory compromise/hypoxia
· Muscle breakdown leading to myoglobinuria and renal failure
· Hypo/hyperthermia
· Drug toxicity from anticonvulsants-respiratory depression, arrhythmia
· Morbidity and Mortality more associated with the underlying cause of the seizure (e.g. abscess à sepsis, tumor à mass effects, etc.)
VI. PHARMACOTHERAPY SPECIFICS
· Lorazepam
i. Route: Intravenous, IO
ii. Dose: 0.05 to 0.1 mg/kg up to 4 mg/dose
iii. Rate: IV push over 2 min; can be given 5 to 10 minutes apart
iv. Maximum dose: 4.0 mg
v. Onset of action: 2 to 3 minutes
vi. Duration: Usually 12 to 24 hours
vii. Side effects: Confusion, drowsiness, respiratory depression, hypotension
· Diazepam
i. Route: Intravenous, IO, PR
ii. Dose: Pediatric: 0.2 to 0.5 mg/kg
1. Adult: 0.2 mg/kg (10 mg average adult dose)
iii. Rate: May repeat every 15 to 30 minutes
iv. Maximum dose: Usually not more than three doses given at 5 mg/min
v. Onset of action: 1 to 3 minutes; PR doses take 1 to 2 hours
vi. Duration of action: 5 to 15 minutes
vii. Side effects: Somnolence, confusion, hypotension, ataxia, bradycardia, respiratory depression
· Phenytoin (not used as often anymore due to skin irritation if infiltrated)
i. Route: Intravenous, IO
ii. Dose: 20 mg/kg
iii. Maximum dose: 1,000 mg
iv. Rate: <0.5 mg to 1.0 mg/kg per min to a maximum rate of 50 mg/min
v. Onset of action: 10 to 30 minutes after infusion
vi. Duration of action: 12 to 24 hours
vii. Side effects: Hypotension, respiratory depression, risk of cardiac arrhythmia, skin irritation if infiltrating
· Fosphenytoin
i. Route: Intravenous, intramuscular
ii. Dose: 20 mg/kg phenytoin equivalents
iii. Rate: Children: 3 mg/kg per min phenytoin equivalents
1. Adult: 150 mg/min phenytoin equivalents
iv. Onset of action: Within 2 to 3 minutes after loading dose
v. Duration: 12 to 24 hours
vi. Side effects: Pruritus, paresthesia in groin area
· Phenobarbital:
i. Route: Intravenous, IO
ii. Dose: 20 mg/kg
iii. Maximum dose: Additional 5 to 10 mg/g dose every 20 minutes until maximum dose of 40 mg/kg or total dose of 1 g
iv. Rate: <100 mg/min
v. Onset of action: 10 to 20 minutes; intramuscular may take up to 2 to 4 hours
vi. Duration of action: 1 to 3 days
vii. Side effects: Respiratory depression, hypotension, circulatory collapse
· Valproate PO or PR
i. Dose: NG: 67 mmg/kg; RP: 200 mg suppositories; enema: 60 mg/kg
ii. Side effects: gastrointestinal irritation, tremor, ataxia, liver failure, pancreatitis
· Valproate IV
i. Dose: In valproate-naive patient, 15 mg/kg divided qid
· Midazolam
i. Route: IV (oral, intravenous available)
ii. Dose: 0.05 to 0.1 mg/kg IV
iii. Rate: Load with 0.2 mcg/min and titrate continuous infusion to 0.4 to 0.6 mcg/kg per min
iv. Onset of action: IV within 5 to 10 minutes
v. Duration: 1 to 6 hours
vi. Side effects: hypotension, bradycardia, central nervous system and respiratory depression
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