STATUS
EPILEPTICUS
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
Doses:
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.
___________________________________________________________________
