Status Epilepticus in Children Flashcards
What is Status Epilepticus
Greater than 5 minutes of continuous clinical and/or electrographic seizure activity OR recurrent seizure activity without recovery returning to baseline seizures
What are the causes of status epilepticus in children
Infection, fever, metabolic disturbances, medication, congenital malformations
What types of status epilepticus happens most often in children
Remote symptomatic and acute symptomatic
What are the systemic complications in early stage status epilepticus (within the first 30 mins), after 30 mins
High blood pressure, high glucose, metabolic and respiratory acidosis, increase in cerebral brain fluid, increase in oxygenation, increased ICP/ Low blood pressure, low glucose, respiratory failure decreased cerebral fluid, decrease in oxygenation, organ failure
What are the 5 phases of management of Status Epilepticus
Phase 1: 0-5 min (stabilization phase)// Phase 2: 5-20 min (Initial therapy)//Phase 3: 20-40 mins (Secondary therapy)// Phase 4: 40-60 mins (refractory/third therapy)// Phase 5: greater than 24 hours (super refractory/fourth therapy)
What are important labs in phase 1 of SE
Serum chemistries, CBC and blood culture, blood and urine toxicology, AED levels as needed, metabolic and genetic testing as needed, OBTAIN EEG
What would cause a patient to need intubation in phase 1 SE
Inadequate Oxygen consumption and ventilation, Increased ICP, refractory SE
How would hypovolemia be treated in patients with SE
10-20 ml/kg of NS
How is hypoglycemia treated in patients with SE, hyponatremia, hypocalcemia
0.5 grams/kg/dose OR 2 mL/Kg of D25% for children greater than 2 years, 5 ml/kg of D10% for children less than 2 years old/ 3% NaCl though a central line or 0.9% through a peripheral line/ 20-25 ml/kg calcium chloride
For phase 2 what benzodiazepine are used in children to treat SE
Midazolam, lorazepam, and diazepam (control seizures 80% of the time)
T/F: There is no efficacious advantage between lorazepam and diazepam IV for children but lorazepam is safer to less respiratory depression
True (lorazepam only used in neonates)
What controls seizures the quickest if IV is not available
IM midazolam
What is the dose for IV lorazepam and diazepam
Lorazepam 0.1 mg/kg slow IVP, Rate: 2 mg/min; max 4 mg/dose,Dilute 1:1 with D5, NS, SWFI
Diazepam 0.1 -0.3 mg/kg slow IVP, Rate: 1-2 mg/min; max 10 mg/dose, May repeat x 1 dose
What is the dose for IM Midazolam and max dose for the day
Midazolam 0.2 mg/kg x 1 dose, Max 10 mg/dose • Use concentration 5 mg/mL (undiluted), May repeat x 1 dose
What is the dose for buccal midazolam
0.3-0.5 mg/kg (max 10 mg). Use 5 mg/mL concentration (IV form)
What is the intranasl midazolam dose
0.2 mg/kg (max 10 mg), Use 5 mg/ml concentration (IV form), No more than 0.5 mL per nostril, Administer using mucosal atomization device (MAD), Add additional 0.1 mL to account for empty space in MAD
What is the intranasl midazolam dose
0.2 mg/kg (max 10 mg), Use 5 mg/ml concentration (IV form), No more than 0.5 mL per nostril, Administer using mucosal atomization device (MAD), Add additional 0.1 mL to account for empty space in MAD
What are the adverse effects of using benzodiazepines
Respiratory depression, hypotension, sedation, apnea, IV site reaction if given IV
Which BZD is seizure recurrence most common, how can this be mitigated
Diazepam, frequent re-dosing
If IV lorazepam, diazepam or IM midazolam is not available what can be given
IV phenobarbital, buccal or intranasal midazolam, rectal diazepam
What is the second line therapy for pediatric early SE
Phenytoin Load: 20 mg/kg IV (max rate: 1 mg/kg/min) x 1 dose OR Fosphenytoin Load: 20 mgPE/kg IV or IM (IV max rate: 3 mgPE/kg/min) x 1 dose (preferred)
What are the adverse effects of fosphenytoin and phenytoin
Hypotension, bradycardia, vasodilation, arrhythmias, necrosis with extravastations, transient ataxia, blurred vision and dizziness
What should be monitored if a patient is receiving phenytoin and forsphenytoin
BP, HR, EKG, IV infusion site
What is therapeutic range for phenytoin and fosphenytoin
Total: 8-15 mcg/ml, Free 1-2 mcg/ML
What are the ideal times of serum levels for phenytoin and fosphenytoin
IM: 4 hours afterload
IV: 2 hours after load
What is the phenytoin correction for low albulmin (adjusted phenytoin concentration) or for free levels that can’t be obtained
Measured phenytoin/ {(0.25 X Albumin) +0.1}
-0.25 is .15 if renal sufficiency
What is another alternative that can be given for SE, adverse effects
Leviteracetam: 60 mg/kg/dose IV x 1 dose (1:1 conversion oral to IV dose/ dose adjustment in renal insufficiency)/ agitation, aggression hostility
What patients cant receive valproic acid,dose, therapeutic range
Infants less than 2 years of age, 40 mg/kg/dose IV x 1 dose with dextrose or saline, 50-100 mcg/ml
What are the adverse effects of valproic acid
Nausea, vomiting, diarrhea,Sedation, tremor, increased weight, Hyperammonemia, metabolic acidosis • Liver toxicities
What is the last resort if failed and/or phenytoin, levetiracetam, or valproic acid are not available, dose
Phenobarbital, 15-20 mg/kg/dose IV x 1 dose
What is the therapeutic range for phenobarbital, adverse effects, monitoring parameters
20-40 mcg/mL/Hypotension, respiratory depression, sedation, Long-term: neurologic and cognitive impairment/ HR, BP, RR
What is the most common way to treat a patient in refractory or superrefractory SE, other options
Midazolam Loading dose followed by continuous infusion,Increase infusion every 5-15 min preceded by bolus dose/ Phentobarbital Loading dose 10 – 15 mg/kg followed by continuous infusion, Reduce infusion every 2-4 hrs after 12 hrs of burst suppression, propofol Loading dose: 1-2 mg/kg/dose IV followed by continuous infusion
What are the absolute last resort (super refractory SE)
Propofol, inhaled anesthetics, and ketamine
What is first line for second therapy in neonates for SE
Phenobarbital
What are the steps for treating SE
1) IV Lorazepam or Diazepam; IM Midazolam
2) Repeat the benzodiazepine
3) Fosphenytoin, Leveritacetam, Valproic acid, Phenobarbital
What is needed to treat refractory SE
Midazolam or Penotbarbiatal infusions (probably needs to be intubated)
