3. “Status
epilepticus is a medical
emergency that requires an organized
and skillful approach to minimize the
associated mortality and morbidity”
4. Status epilepticus (SE)
presents in a multitude
of forms, dependent on etiology and patient
age (myoclonic, tonic, subtle, tonic-clonic,
absence, complex partial etc.)
Generalized, tonic-clonic SE is the most
common form of SE.
6. Definition:….
“If appropriate therapy is delayed, SE can
cause permanent neurologic sequelae or
death …”
thus
“ … any child who presents actively convulsing
should be assumed to have SE.”
Haafiz A. Pediatr Emerg Care 1999;15(2):119-29
7. The longer SE persists,
the lower is the likelihood of spontaneous
cessation
the harder is it to control
the higher is the risk of morbidity and mortality
Treatment for most seizures needs to be
instituted after > 5 minutes of seizure activity
Bleck TP. Epilepsia 1999;40(1):S64-6
8. But
This is
not practical operational definition.
Longer periods with uncontrolled seizure
activity, more likely to develop a RSE
syndrome.
More practical guidelines needed to draw that
arbitrary ‘line in sand’, beyond which
substantial risk of developing clinical SE exists.
11. Pathophysiology
GLUTAMATE = the major excitatory AA
neurotransmitter in brain
Any factor increases Glutamate activity can lead to
seizures
NMDA(N-methyl-D-aspartic acid) is an AA derivative
which acts as a specific agonist at the NMDA receptor
mimicking the action of glutamate
GABA = main inhibitory neurotransmitter, ; GABA
antagonists can cause SE
12. Drugs which can cause seizures
Antibiotics
Penicillins
Isoniazid
Metronidazole
Anesthetics, narcotics
Halothane, enflurane
Cocaine, fentanyl
Ketamine
Psychopharmaceuticals
Antihistamines
Antidepressants
Antipsychotics
Phencyclidine
Tricyclic antidepressants
List of drugs
16. Hypoxia
Hypoxia/anoxia markedly increase the risk of
mortality in SE
Seizures (without hypoxia) are much less dangerous
than seizures and hypoxia
Towne AR. Epilepsia 1994;35(1):27-34
17. Neurogenic pulmonary edema
Rare
complication
Likely occurs as
consequence of marked
increase of pulmonary
vascular pressure
Johnston SC. Postictal pulmonary edema requires pulmonary vascular pressure
increases. Epilepsia 1996;37(5):428-32
23. Hyperpyrexia
Hyperpyrexia may develop during protracted
SE, and aggravate possible mismatch of
cerebral metabolic requirement and substrate
delivery
Treat hyperpyrexia aggressively
Antipyretics, external cooling
24. Other alterations
Blood leukocytosis
(50% of children)
Spinal fluid leukocytosis (15% of children)
K+
creatine kinase
Myoglobinuria
27. Common Sense:0-5 minutes
Stabilize the patient-
A
Oxygen, oral airway. Avoid hypoxia!
B
Consider bag-valve mask ventilation. Consider
intubation
C
IV/IO access. Treat hypotension, but NOT
hypertension
28. (0-5 minutes)…
Arterial blood gas?
All children in SE have acidosis. It often resolves rapidly with
termination of SE
Intubate?
It may be difficult to intubate the actively seizing child
Stop or slow seizures first, give O2, consider BVM ventilation
If using paralytic agent to intubate, assume that SE continues
29. 0-5 minutes….
Give glucose (2-4 ml/kg D25%, infants 5 ml/kg D10%), unless
normo- or hyperglycemic
Hyperglycemia has no negative effect in SE
(as long as significant hyperosmolality is being avoided)
Adoloscent-Thiamin
100 mg IV first
31. Work-Up (when stable)
Lumbar puncture
CT scan/MRI scan
Always defer LP in unstable patient, but never delay
antibiotic/antiviral rx if indicated
Indicated for focal seizures or deficit, history of trauma or
bleeding d/o
EEG
34. Anticonvulsants - Rapid acting
Benzodiazepines
Lorazepam 0.05- 0.1 mg/kg i.v.(rectal dose same) upto 4-6
mg over 1-2 minutes
or
Diazepam 0.2- 0.5 mg/kg i.v. upto 6-10mg over 1-2 minutes
Diazepam 0.5 mg/kg rectally
Midazolam 0.15-0.3 mg/kg IV ; nasal or Buccal (0.5 mg/kg)
is used if no IV line
If SE persists, repeat every 5-10 minutes
35. Benzodiazepines
Lorazepam
Low lipid solubility
Action delayed 2 minutes
Anticonvulsant effect 6-12 hrs
Less respiratory depression than
diazepam
Midazolam
for brief seizures
May be given i.m.
to treat refractory SE
Diazepam
High lipid solubility
Thus very rapid onset
Redistributes rapidly
Thus rapid loss of
anticonvulsant effect
Adverse effects are
persistent:
Hypotension
Resp. depression
36. Anticonvulsants :15-35 minutes
(If seizures persists)
Phenytoin
15-20 mg/kg i.v. over 15-20
min
pH 12
Extravasation causes severe
tissue injury
Onset 10-30 min
May cause
hypotension, dysrhythmia
Cheap
Fosphenytoin
15-20 mg PE/kg i.v./i.m. over 57 min PE = phenytoin equivalent
Fosphenytoin 150 mg is equal to 100
mg phenytoin
pH 8.6
Extravasation well tolerated
Onset 5-10 min
May cause hypotension
Expensive
37. Anticonvulsants :(15-35 minutes)
Phenobarbital
15-20
mg/kg (neonate 20-30 mg/kg)i.v.
over 15-20 min
Onset 15-30 min
May cause hypotension, respiratory
depression
38. Initial choice of long acting
anticonvulsants in SE
Is patient an infant?
Is patient already receiving phenytoin?
No
At high risk for extravasation ?
(small vein, difficult access etc.)?
No
Phenytoin
Yes
Fosphenytoin
Yes
Phenobarbital
39. If SE persists (45 minutes)
Phenobarbital if Phenytoin used
Additional phenytoin or FP 5 mg/kg (Nelson 10 mg/kg
increment) max upto 30 mg ,
Additional phenobarbital 5 mg/kg/dose every 15–30
min (max total dose of 30 mg/kg)
be prepared to support respirations
Consider IV valproate, especially for partial status
epilepticus
40. Seizures Persists (60 minutes)
Consider
Diazepam infusion, pentobarbital
(Barbiturate coma), midazolam, paraldehyde
or general anesthesia infusion in PICU
Midazolam 0.2 mg/kg bolus & 20-400
mcg/kg/hr infusion
Propofol 1-2 mg/kg then 2-10 mg/kg/hr
infusion
Avoid paralytics
41. Still Seizures Persists….
Induction of Barbiturate coma for 48 hrs
IV loading thiopental 2–4 mg/kg till a burst
suppression EEG pattern till 48 hrs
check phenobarbital level to be normal.
Paraldehyde :loading 150–200 mg/kg IV for 15–20
min, then 20 mg/kg/hr in a 5% concentration in a
glass bottle freshly prepared
42. Still Seizures Persists….
General anesthesia: if barbiturate coma is not
option.
halothane and Isoflurane.
Acts by reversing cerebral anoxia and metabolic
abnormalities, allowing the previously
administered anticonvulsants to exert their
effect.
43. Possible new drugs for Status
Lidocaine - some positive trials
Valproate - IV form available
10-15 mg/kg IV.
Gabapentin / Vigabatrin / Lamotrigine
Felbamate - blocks NMDA receptors
Ketamine - blocks NMDA receptors
Use of AED after status episode is controversial especially
idiopathic or febrile seizure.
44. Non - convulsive status epilepticus?
NCSE
is a term used to denote a range
of conditions in which electrographic
seizure activity is prolonged and results
in non convulsive clinical symptoms.
45. Non - convulsive SE ?
Up to 20 % of children with SE have non convulsive SE after tonic - clonic SE
46. Non - convulsive SE ?
If child does
not begin to respond to painful
stimuli within 20 - 30 minutes after tonic clonic SE, suspect non - convulsive SE
Urgent EEG
47. Summary
Status Epilepticus is >5 min of seizures or two seizures
without return to consciousness
Status Epilepticus is common
Delay in therapy makes SE harder to rest
Mortality and morbidity is increased in prolonged SE
BZD, Pheny/Pheno, Call for PICU
Status Epilepticus needs a DIAGNOSIS
48. Take-Home points
Better outcome if seizure stopped earlier, so no need to
wait
Always ABC D FIRST
Lorazepam - best 1st line Rx
Fosphenytoin - surpasses Phenytoin for SE, and can be
given IM in difficult situation
Propofol - advantages over barbiturates for resistant SE,
low toxicity , quick action, and fast recovery upon
discontinuation