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STATUS EPILEPTICUS in children : summarized

Dr Tehreem Fatima
DEFINITION: A seizure lasting more than 30 minutes or recurrent seizures for more than 30 minutes during which the patient does not regain consciousness. However, in clinical practice, seizure lasting >5 min is taken as Status Epilepticus; therefore,  after initial resuscitation, the anti-convulsive treatment is started as soon as possible to prevent neurological damage.
DIANOSIS AND MANAGEMENT: Rapid directed Hx & PE; detailed examination after stabilization; lab studies should proceed concurrently with stabilization (choice based on age &likely etiology).
BASIC AIM: to terminate the seizure, resuscitate patient, treat complications and prevent recurrence; all should go hand in hand.
Primary assessment and resuscitation
Airway: Ensure a patent airway and put the child in the recovery position
If the airway is not patent, use an airway maneuver or airway adjunct
Airway compromise is an indication for intubation

Breathing: Assess breathing – signs of respiratory distress, respiratory rate, SpO2, breathing pattern (central, depressed)
Give high flow O2 via face mask to all children

Circulation: Assess circulation – pulse rate, BP, CRT, CVS exam

Hypertension indicates a possible cause for the convulsion, or more likely is a result of it. Malignant hypertension requires urgent management.

Establish Intravenous/Intraosseous access and request STAFF NURSE on duty to draw following samples from IV line:

Blood tests:
BSL, CBC, U&E (including Na,K,Ca,Mg),Blood Gas and Blood C&S(suspected meningitis)

Signs of shock? Manage shock (IV crystalloid @20ml/kg upto 60ml/kg + cardiac support)

Suspected meningoencephalitis? Give empirical antibiotic coverage (IV ceftriaxone+Vancomycin+Acyclovir)

Signs of raised intracranial pressure? Consider mannitol 0.25 g/kg
Give Paracetamol suppository in case of fever(febrile seizures)
Disability: Conscious level(AVPU), pupil size & reaction, Assess posture (decorticate/decerebrate), SOMI, Anterior fontanelle

Exposure: Assess for Temperature, Petechial/purpuric rash, Signs of trauma
--> As you proceed, keep the attendants ( preferably parents) counseled about what you are suspecting, and what treatment is being given to the patient !!!

Secondary assessment
Emergency treatment of the convulsion
 After ABC resuscitation and exclusion or treatment of hypoglycemia, the priority is to stop the convulsion according to the APLS algorithm.
History taking:
Duration of fitting, Recent trauma, Treatment given, Poison ingestion, History of epilepsy, Last meal, Current febrile illness, Known illnesses
Ongoing management should be continued in PICU:
-->Pass NG tube for gastric decompression, restrict fluids to 60% of maintenance, monitor UOP.
-->Attach cardiac monitor to monitor cardiac rhythm
-->Defer LP in case of cardiovascular instability/reduced conscious level. Consider CT head
-->Identify and treat metabolic causes/poisoning, Check Fundus (papilledema, retinal hemorrhages)
--> Meanwhile, keep the attendants counseled.

First-Line Drugs:
 IV Lorazepam is DOC. If unavailable, use IV Diazepam/Midazolam.
In case, no IV access established:
1-Give Buccal/Nasal Midazolam(first choice)  2-Rectal Diazepam 3. IM midazolam/diazepam
IV Diazepam:  0.3-0.4mg/kg
Buccal/Nasal Midazolam: 0.2-0.5 mg/kg (Max 5 mg)
Rectal Diazepam: 0.5mg/kg (Max 10 mg)
IV Midazolam: 0.15 mg/kg
Buccal midazolam; turn child to one side, put syringe (without needle) b/w lower gums & cheek. If resisting/secretions, give half in both nostrils (use thick preparation)
Repeat again after 5 min, if seizure uncontrolled

After 5 min if still uncontrolled:
Second-Line Drug:
IV Phenytoin: Loading Dose:- 15-20mg/kg(in 20 cc N/S @ 1m/kg/min)--- give under continuous ECG & BP monitoring—add in maintenance dose
If still uncontrolled after 10 min of loading:
Third-Line Drugs:
IV Leveteracitam: (If Liver disease/Metabolic disease/coagulopathy/ on chemotherapy) -20-30 mg/kg @ 5 mg/kg/min infusion—add in maintenance dose

If seizure still uncontrolled:
Give maintenance dose of inj Phenytoin.
ADMIT and SHIFT the patient to PICU and start Midazolam infusion if fits are still not controlled:
Inj Midazolam-0.2 mg /kg bolus then infusion @ 1 μg/kg/min, increasing 1
μg/kg/min, every 5- 10 min, till seizures stop, up to a maximum of 30 μg/kg/min, start tapering 24 h after seizure stops @ 1 μg/kg/min, every 3 h. However strict monitoring for respiratory depression should be there

If PICU admission delayed or ventilation facility not available then use:
1. Inj Levetiracetam or inj Valproate if not used earlier
2. Paraldehyde (If available)-0.4 mL/kg per rectal; 50:50 solution in olive oil or N/S

 If seizures still persist on midazolam infusion, consider RSI of anesthesia (seek help from Anesthetist) :
Inj Thiopental: Loading Dose: 4mg/kg bolus followed by 3-5 mg /kg /hr infusion rate (up to 8 mg/kg/hour) to achieve Burst suppression. Start tapering after 24 h seizure free period
Inj Propofol: using 0.5 %, 1% or 2% injection :(age: 1mo- 17 yr) initial: 2.5-4 mg/kg at a rate of 20-40 mg every 10 seconds  until response ; followed by infusion @ 9-15 mg/kg/hr.

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