Status epilepticus

Question 1

StE - definition

Answer 1

Prolonged seizure lasting over 30 mins or recurrent seizures during which the pt does not fully regain consciousness within a 30 min period
- But in practical terms, once a child has been fitting for >5min, the chances of the seizure lasting >30min are dramatically increased. Common practice to start tx at this point

Question 2

StE - symptoms (2)

Answer 2

1. Convulsive (medical emergency), or

2. Non-convulsive (dx with EEG, consider in comatose pts, includes absence seizures or partial/focal seizures)

Question 3

StE - etiology

Answer 3

1. Regular occurrence in child with a known/difficult epilepsy
2. Fever
3. Subtherapeutic anticonvulsant levels
4. CNS infections
5. Trauma, poisoning, metabolic abnormalities

Question 4

StE - initial tx

Answer 4

1. Protect airway
2. Maintain oxygenation
3. Terminate seizure activity using
   - Clonazepam (0.25-0.5mg) IV, over 2-5 mins, repeat once 15 mins later if StE continues, or
   - Diazepam (0.1-0.25mg/kg up to 20mg) over 2-5mins, repeat once 15 mins later if StE continues, or
   - Midazolam (0.15-0.2mg/kg up to 10mg) IM or IV, over 2-5 mins, or
   - Midazolam (0.2-0.3mg/kg up to 10mg), buccally or intranasally, repeat once 15 mins later if StE continues
4. Each drug should immediately be followed by:
   - Phenytoin 15-20mg/kg IV not exceeding 25mg/min with continuous monitoring of ECG and BP, or
   - Phenobarbitone 15-20mg/kg IV, not exceeding 100mg/min, or
   - Sodium valproate 15-30mg/kg up to 800mg, slow IV injection over 3-5 mins, followed by continuous infusion
5. If seizures continue (refractory status epilepticus), transfer pt to ICU, where an infusion of clonazepam, midazloam, propofol or thiopentone may be used

Question 5

StE - ix

Answer 5

After emergency life-supporting therapies, perform:

1. EEG after clinical seizures have been controlled - to exclude ongoing nonconvulsive StE
2. CT brain, MRI brain
3. Lumbar puncture (with caution)
4. Bloods (6) = FBE, UEC, calcium and magnesium, BGL, blood and urine toxicology, ABG
5. Anticonvulsant levels in those on anticonvulsants

Question 6

StE - further mx (3)

Answer 6

1. Once the seizure has stopped, the child may have a respiratory arrest
2. Roll into recovery position, keep oxygen running, watch SpO2 and check other vital signs carefully
3. Do not transfer the child or perform potentially dangerous procedures (e.g. LP) until child has GCS that is both improving and >9