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Status Epilepticus

Though rarely life-threatening, status epilepticus requires prompt attention in a setting with full access to emergency and intensive care. Status occurs in children with acute CNS infection, as febrile seizures in an otherwise healthy child, as a sign of progressive neurologic disease, in a child with known epilepsy with inadequate blood levels and/or additional illness, metabolic causes (e.g., low glucose, hyponatremia, low calcium), structural causes such as a tumor or stroke, and toxins (e.g., alcohol). The following guidelines may help guide management until the patient can be safely transferred to an appropriate emergency facility for evaluation and additional treatment. This protocol is an example; each facility will have their own algorithm. For one example, see ED status epilepticus protocol (Primary Children's Medical Center, SLC, UT) (PDF Document 30 KB).
Upon presentation by a patient with seizure activity:
  • 0-5 minutes -
    • Confirm the diagnosis;
    • Maintain airway by head positioning or oropharyngeal airway;
    • Administer nasal or blow-by oxygen;
    • Suction as needed;
    • Obtain and monitor vital signs, use pulse oximetry and cardiac monitoriing as indicated;
    • If the seizure has not abated within 4-5 minutes, establish an intravenous line; and
    • Obtain blood for laboratory determinations (glucose, serum chemistries, toxicology screen, culture, or anti-epileptic drug (AED) levels) as applicable.
  • 6-9 minutes -
    • If hypoglycemic (or if rapid reagent strip for glucose testing is not available), administer 2 ml/kg of D25W or 5ml/kg D10W;
    • In an infant with no known seizure disorder, give pyridoxine 100mg IV; and
    • Monitor oxygenation with pulse oximetry.
  • 10-20 minutes -
    • Administer lorazepam, 0.1 mg/kg (up to 4 mg) at 2 mg/min IV, or diazepam 0.2 mg/kg (up to 10mg) at 5 mg/min IV; and
    • Repeat diazepam in 5 minutes if seizure persists.
    • If IV access cannot be established, give diazepam 0.5 mg/kg PR. IM therapy is not recommended.
    • Many facilities are using intranasal or buccal midazolam instead of lorazepam or diazapam. See [Walker: 2006] and [Wolfe: 2006].
  • 21-60 minutes -
    • If seizure persists, load with fosphenytoin (preferred for children) IV at 15-20 mg/kg (in phenytoin equivalents) at 150 mg PE/min or 3mg PE/kg/min.
    • If phenytoin is used, the dose is 15-20 mg/kg at 1 mg/kg/min IV while monitoring ECG and blood pressure. Infusion should be slowed if dysrhythmia or QT interval widening develops.
    • If seizure persists for 15 minutes after using phenytoin, additional doses of fosphenytoin/phenytoin may be given at 5mg/kg (up to 30 mg/kg total).
    • If seizures persist, give phenobarbital 20mg/kg IV at 100 mg/min. With the use of phenobarbital following benzodiazepines, the risk of respiratory depression is increased, and the likely need for intubation increases and should be anticipated. [Chin: 2004] If phenobarbital fails to stop the seizure, other measures such as general anesthesia, are usually necessary. For a discussion, see [Abend: 2008].

Resources

Practice Guidelines

Riviello JJ Jr, Ashwal S, Hirtz D, Glauser T, Ballaban-Gil K, Kelley K, Morton LD, Phillips S, Sloan E, Shinnar S.
Practice parameter: diagnostic assessment of the child with status epilepticus (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society.
Neurology. 2006;67(9):1542-50. PubMed abstract

Helpful Articles

Wolfe TR, Macfarlane TC.
Intranasal midazolam therapy for pediatric status epilepticus.
Am J Emerg Med. 2006;24(3):343-6. PubMed abstract

Hirsch, LJ and Arif, H.
Status epilepticus.
Continuum. 2007;13(4):121-151.

Neville BG, Chin RF, Scott RC.
Childhood convulsive status epilepticus: epidemiology, management and outcome.
Acta Neurol Scand Suppl. 2007;186:21-4. PubMed abstract

Walker DM, Teach SJ.
Update on the acute management of status epilepticus in children.
Curr Opin Pediatr. 2006;18(3):239-44. PubMed abstract

Appleton R, Macleod S, Martland T.
Drug management for acute tonic-clonic convulsions including convulsive status epilepticus in children.
Cochrane Database Syst Rev. 2008(3):CD001905. PubMed abstract

Raspall-Chaure M, Chin RF, Neville BG, Bedford H, Scott RC.
The epidemiology of convulsive status epilepticus in children: a critical review.
Epilepsia. 2007;48(9):1652-63. PubMed abstract

Lewena S, Pennington V, Acworth J, Thornton S, Ngo P, McIntyre S, Krieser D, Neutze J, Speldewinde D.
Emergency management of pediatric convulsive status epilepticus: a multicenter study of 542 patients.
Pediatr Emerg Care. 2009;25(2):83-7. PubMed abstract

Authors

Compiled and edited by: Lynne M Kerr, MD, PhD - 6/2011
Content Last Updated: 6/2011

Page Bibliography

Abend NS, Dlugos DJ.
Treatment of refractory status epilepticus: literature review and a proposed protocol.
Pediatr Neurol. 2008;38(6):377-90. PubMed abstract

Chin RF, Verhulst L, Neville BG, Peters MJ, Scott RC.
Inappropriate emergency management of status epilepticus in children contributes to need for intensive care.
J Neurol Neurosurg Psychiatry. 2004;75(11):1584-8. PubMed abstract / Full Text

Walker DM, Teach SJ.
Update on the acute management of status epilepticus in children.
Curr Opin Pediatr. 2006;18(3):239-44. PubMed abstract

Wolfe TR, Macfarlane TC.
Intranasal midazolam therapy for pediatric status epilepticus.
Am J Emerg Med. 2006;24(3):343-6. PubMed abstract