Status Epilepticus In Children

Convulsive status epilepticus is continuous convulsive seizure activity lasting 5 minutes or longer, or recurrent seizures without recovery of consciousness between episodes.

Five minutes is the operational treatment threshold because spontaneous termination becomes progressively less likely beyond this point.

Causes include epilepsy with missed medication, febrile illness, CNS infection, cerebral malaria, hypoglycaemia, electrolyte disturbance, toxic ingestion, trauma and structural intracranial disease.

Persistent generalized tonic and clonic movements are typical, but prolonged status may become increasingly subtle.

Features include:

• Sustained impaired consciousness
• Tonic or clonic movements
• Eye deviation
• Facial or distal limb twitching
• Cyanosis or hypoxaemia
• Excess secretions
• Hyperthermia
• Metabolic acidosis
• Aspiration
• Respiratory depression

Persistent coma after apparent motor seizure cessation may represent non convulsive status epilepticus.

Status epilepticus is a clinical diagnosis during active convulsions. Do not delay treatment for investigation.

Immediately assess glucose, oxygen saturation, temperature and cardiorespiratory status.

Once resuscitation is underway, consider:

• FBC
• Sodium, potassium, calcium and magnesium
• Renal function
• Blood gas
• Malaria testing where appropriate
• Toxicology
• Anticonvulsant concentrations where relevant
• Lumbar puncture when CNS infection is suspected and safe
• CT or MRI for focal signs, trauma, raised intracranial pressure or unexplained persistent unconsciousness
• EEG where ongoing non convulsive seizure activity is suspected

Treat airway, breathing and circulation simultaneously.

Correct hypoglycaemia immediately.

Establish IV or IO access.

First line

Give a benzodiazepine:

• Diazepam 0.3 mg/kg IV slowly, or 0.5 mg/kg rectally

• Lorazepam 0.1 mg/kg IV, maximum 4 mg

• Buccal or intranasal midazolam where IV access is unavailable

A second benzodiazepine dose may be given after approximately 5 minutes if seizures continue.

Established status

Give one appropriate second line agent promptly:

• Levetiracetam 60 mg/kg IV, maximum 4.5 g

• Phenytoin 20 mg/kg IV, maximum rate 1 mg/kg/min, with ECG and blood pressure monitoring

• Sodium valproate 20 to 40 mg/kg IV, subject to contraindications

• Phenobarbital 20 mg/kg IV, especially where other agents are unavailable or clinically inappropriate

Refractory status epilepticus

Persistent seizure activity despite a benzodiazepine and appropriate second line therapy requires:

• Senior paediatric review immediately
• Anaesthetic involvement
• PICU transfer
• Intubation and ventilation where required
• Continuous IV anaesthetic anticonvulsant therapy according to critical care protocol
• EEG monitoring where available
• Aggressive treatment of the underlying cause