Status Epilepticus in Children

Question 1

What is Status Epilepticus

Answer 1

Greater than 5 minutes of continuous clinical and/or electrographic seizure activity OR recurrent seizure activity without recovery returning to baseline seizures

Question 2

What are the causes of status epilepticus in children

Answer 2

Infection, fever, metabolic disturbances, medication, congenital malformations

Question 3

What types of status epilepticus happens most often in children

Answer 3

Remote symptomatic and acute symptomatic

Question 4

What are the systemic complications in early stage status epilepticus (within the first 30 mins), after 30 mins

Answer 4

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

Question 5

What are the 5 phases of management of Status Epilepticus

Answer 5

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)

Question 6

What are important labs in phase 1 of SE

Answer 6

Serum chemistries, CBC and blood culture, blood and urine toxicology, AED levels as needed, metabolic and genetic testing as needed, OBTAIN EEG

Question 7

What would cause a patient to need intubation in phase 1 SE

Answer 7

Inadequate Oxygen consumption and ventilation, Increased ICP, refractory SE

Question 8

How would hypovolemia be treated in patients with SE

Answer 8

10-20 ml/kg of NS

Question 9

How is hypoglycemia treated in patients with SE, hyponatremia, hypocalcemia

Answer 9

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

Question 10

For phase 2 what benzodiazepine are used in children to treat SE

Answer 10

Midazolam, lorazepam, and diazepam (control seizures 80% of the time)

Question 11

T/F: There is no efficacious advantage between lorazepam and diazepam IV for children but lorazepam is safer to less respiratory depression

Answer 11

True (lorazepam only used in neonates)

Question 12

What controls seizures the quickest if IV is not available

Answer 12

IM midazolam

Question 13

What is the dose for IV lorazepam and diazepam

Answer 13

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

Question 14

What is the dose for IM Midazolam and max dose for the day

Answer 14

Midazolam 0.2 mg/kg x 1 dose, Max 10 mg/dose • Use concentration 5 mg/mL (undiluted), May repeat x 1 dose

Question 15

What is the dose for buccal midazolam

Answer 15

0.3-0.5 mg/kg (max 10 mg). Use 5 mg/mL concentration (IV form)

Question 16

What is the intranasl midazolam dose

Answer 16

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

Question 17

What is the intranasl midazolam dose

Answer 17

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

Question 18

What are the adverse effects of using benzodiazepines

Answer 18

Respiratory depression, hypotension, sedation, apnea, IV site reaction if given IV

Question 19

Which BZD is seizure recurrence most common, how can this be mitigated

Answer 19

Diazepam, frequent re-dosing

Question 20

If IV lorazepam, diazepam or IM midazolam is not available what can be given

Answer 20

IV phenobarbital, buccal or intranasal midazolam, rectal diazepam

Question 21

What is the second line therapy for pediatric early SE

Answer 21

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)

Question 22

What are the adverse effects of fosphenytoin and phenytoin

Answer 22

Hypotension, bradycardia, vasodilation, arrhythmias, necrosis with extravastations, transient ataxia, blurred vision and dizziness

Question 23

What should be monitored if a patient is receiving phenytoin and forsphenytoin

Answer 23

BP, HR, EKG, IV infusion site

Question 24

What is therapeutic range for phenytoin and fosphenytoin

Answer 24

Total: 8-15 mcg/ml, Free 1-2 mcg/ML

Question 25

What are the ideal times of serum levels for phenytoin and fosphenytoin

Answer 25

IM: 4 hours afterload
IV: 2 hours after load

Question 26

What is the phenytoin correction for low albulmin (adjusted phenytoin concentration) or for free levels that can’t be obtained

Answer 26

Measured phenytoin/ {(0.25 X Albumin) +0.1}

-0.25 is .15 if renal sufficiency

Question 27

What is another alternative that can be given for SE, adverse effects

Answer 27

Leviteracetam: 60 mg/kg/dose IV x 1 dose (1:1 conversion oral to IV dose/ dose adjustment in renal insufficiency)/ agitation, aggression hostility

Question 28

What patients cant receive valproic acid,dose, therapeutic range

Answer 28

Infants less than 2 years of age, 40 mg/kg/dose IV x 1 dose with dextrose or saline, 50-100 mcg/ml

Question 29

What are the adverse effects of valproic acid

Answer 29

Nausea, vomiting, diarrhea,Sedation, tremor, increased weight, Hyperammonemia, metabolic acidosis • Liver toxicities

Question 30

What is the last resort if failed and/or phenytoin, levetiracetam, or valproic acid are not available, dose

Answer 30

Phenobarbital, 15-20 mg/kg/dose IV x 1 dose

Question 31

What is the therapeutic range for phenobarbital, adverse effects, monitoring parameters

Answer 31

20-40 mcg/mL/Hypotension, respiratory depression, sedation, Long-term: neurologic and cognitive impairment/ HR, BP, RR

Question 32

What is the most common way to treat a patient in refractory or superrefractory SE, other options

Answer 32

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

Question 33

What are the absolute last resort (super refractory SE)

Answer 33

Propofol, inhaled anesthetics, and ketamine

Question 34

What is first line for second therapy in neonates for SE

Answer 34

Phenobarbital

Question 35

What are the steps for treating SE

Answer 35

1) IV Lorazepam or Diazepam; IM Midazolam
2) Repeat the benzodiazepine
3) Fosphenytoin, Leveritacetam, Valproic acid, Phenobarbital

Question 36

What is needed to treat refractory SE

Answer 36

Midazolam or Penotbarbiatal infusions (probably needs to be intubated)