PCCN Clinical Practice Guideline: Status Epilepticus

CONSENSUS DRAFT (July 11, 2006)

Primary Author: Dr. Sonny Dhanani

Preamble
Definition: on-going or recurrent clinical or sub-clinical seizure activity for more than 30
minutes
Status Epilepticus is a life threatening condition where prolonged seizures >30 minutes
can cause neuronal death and may result in serious neurological sequelae
Applicable in children >1 month of age
Treatment of seizure should start if no spontaneous resolution after 5 minutes or if
evidence of cardio-respiratory compromise

References
Appleton R, et al. Drug management for acute tonic-clonic convulsions including convulsive
status epilepticus in children. Cochrane Database Asyst Rev 2002; (4): CD001905.

Bleck TP. Management approaches to prolonged seizures and status epilepticus. Epilepsia 1999;
40 (Suppl ) S59-63.

Igartua J, et al. Midazolam coma for refractory status epilepticus in children. Crit Care Med
1999; 27: 1982-1985.

Lowenstein DH, et al. Status epilepticus. N Engl J Med 1998; 338: 972.

The Status Epilepticus Working Party. The treatment of convulsive status epilepticus in children.
Arch Dis Child 2000; 83: 415-419.

Walker MC. Status epilepticus in the intensive care unit. J Neurol 2003; 250(4): 401-406.
At 0 min On presentation to hospital, initiate ABCs:
A – support airway
B – 100% oxygen, assess ventilation, SpO2 monitor
C – cardiorespiratory monitor, check pulses, establish IV access

• History (AMPLE)
• Investigations – glucose, electrolytes, calcium, magnesium, blood gas,
medication levels, +/- toxin screen, +/- metabolic screen
• Cultures and antibiotics as appropriate
• Suspect and treat raised ICP as needed, CT scan when warranted
• Keep normothermic, acetaminophen/ibuprofen as appropriate

Lorazepam 0.1 mg/kg, IM/SC or

At 5 min Lorazepam 0.1 mg/kg Yes No Diazepam 0.5mg/kg PR, max
IV access?
IV/IO, max 4 mg 10mg

Lorazepam 0.1 mg/kg, IM/SC or

Lorazepam 0.1 mg/kg Consider IO if difficult Diazepam 0.5mg/kg PR, max
At 10 min IV/IO, max 4 mg IV access 10mg

• The order of Phenytoin and Phenobarbital may

At 15 min Phenytoin 20 mg/kg IV/IO, be interchanged
max 1 g, over 20 minutes, in • Phenytoin should be used in head trauma
0.9% NaCl (NS) • Phenobarbital should be used 1st if patient
already on phenytoin maintenance
• Rapid Sequence Intubation if compromised
airway at any point
• Ventilate to normal parameters
At 25 min Phenobarbital 20 mg/kg • Sedation and muscle relaxants only if
IV/IO, max 1 g, over 5-10mins necessary to ventilate or protect airway

Early referral to PICU if any of following:

At 35 min Midazolam 0.15 mg/kg IV bolus, • airway/ventilation/cardiovascular compromise
then 2 mcg/kg/min by IV infusion • seizure refractory to 2nd line medications
• seizure >30 minutes
• initiating Midazolam or Thiopental infusion

Midazolam Midazolam
increase by 2 mcg/kg/min q 5 min, If stops x 48 hrs taper by
0.15 mg/kg bolus as needed, 1 mcg/kg/min
max 24 mcg/kg/min or 20 mg/hr q 30 mins
At 90 min Thiopental 4 mg/kg IV bolus,
then 1 mg/kg/hr IV infusion
Discontinue Midazolam Infusion

Thiopental
increase by 1 mg/kg/hr q 30 min, Thiopental
If stops x 48 hrs
2 mg/kg bolus as needed, taper by 25%
max 6 mg/kg/hr q 12 hrs

Ongoing management:
• Appropriate monitoring – continuous BP monitoring, consider
arterial and central venous lines
• Neurology consult essential with refractory cases
• Continuous EEG monitoring, therapy based on electrographic
suppression of seizure activity
• Can discontinue Midazolam and Phenobarbital maintenance
once Thiopental started
• Monitor for cardiovascular compromise with
midazolam/thiopental infusion. Consider vasoconstrictor
support.
• If difficulty weaning Thiopental, then restart Midazolam infusion
during wean
• Consider Pyridoxine 100mg IV if under 18 months old
• Maintain therapeutic drug levels
• Continue baseline antiepileptics when possible