Status Epilepticus

Status epilepticus is defined as continuous seizure

activity or recurrent seizure activity without
regaining of consciousness lasting longer than 5
.minutes
Years ago, a seizure needed to last longer than 20
.minutes to be considered status epilepticus

It is now defined as any seizure greater than 5

minutes. This makes sense because most seizures
.do not last longer than 2 minutes
The longer a seizure lasts, the less likely it will stops
on its own without medication. Very long seizures
(i.e., status epilepticus) are dangerous and even
increase the chance of death
The incidence of SE range between 5 and 60 per
100,000 population in various study. It is most
common in children younger than 5 yrs of age with
incidence in this group more than 100 per 100,000
.children
of patient presenting with SE are having their 30%
first seizure and approximately 40% of these later
develop epilepsy. Febrile satatus epilepticus is the
.most common type of SE in children
Status epilepticus carries 14% risk of new neurologic
deficit, most of this (12.5%) secondary to underlying
pathology
There are different types of status epilepticus:
.convulsive and non-convulsive

Convulsive status epilepticus requires emergency

treatment by trained medical personnel in a
.hospital setting. It can be life-threatening
Convulsive Status Epilepticus

The most common type is (generalized tonic,

clonic or tonic - clonic) seizures. But other type
do occur including nonconvulsive(complex
partial abscence), myoclonic, epilepsia partialis
.continua and neonatal status epilepticus
Convulsive status epilepticus accounts for 70% of
episodes of status epilepticus (SE) oc­curring in
.infants and children
Nonconvulsive Status Epilepticus

Manifested as confusional state, dementia,

hyperactivity with behavioral problems,
fluctuating impairment of consciousnesswith at
time unsteady sitting or walking, fluctuating
.mental state and hallucination

.
When nonconvulsive status epilepticus occurs or is
suspected, emergency medical treatment in a
hospital setting is needed. EEG testing may be
needed to confirm the diagnosis first. People with
this type of status are also at risk for convulsive
.status epilepticus, thus quick treatment is required
:Refractory Status Epilepticus

Is the status epilepticus that has failed to response

to therapy, usually at least 2 medications
(benzodiazepine and another medication)
New-onset refractory status epilepticus: it can be
caused by any of causes of status epilepticus in
patient without prior epilepsy, it also presumed to
be encephalitic or postencephalitic. Can last
several weeks or longer and often but not always
.has poor prognosis
 Morbidity and mortality

Effective treatment of status epilepticus has

reduced the mortality rate in children to
between 1% and 5%. However, status
epilepticus can be associated with significant
morbidity, including epilepsy, motor
 .disorders, and cognitive abnormalities
The underlying cause is considered to be the most
important determinant of outcome, and the
morbidity appears to be less in those with febrile
and unprovoked status epilepticus
Studies of status epilepticus in primates have
demonstrated a direct relationship between the
duration of the seizure and the development of
permanent brain injury that probably occurs as a
result of the depletion of energy substrate
In addition, children treated more aggressively and
those with shorter episodes of SE are less likely to
.develop subsequent neurological deficits or epilepsy

Similarly, resistance to first- and second-line

treatments for SE is directly related to the duration of
.seizures prior to treatment
Etiology

New onset of epilepsy of any type -1

Drugs intoxication (tricyclic antidepressant) in -2

children and drugs and alcohol abuse in

adolescnts

Drugs withdrwal or overdose in patient on AEDs -3

,.Electrolytes disturbance(hypogyc., hypocalc -4

).hyponatr., hypomagn

Acute head trauma, encephalitis, meningitis -5

Ischemic stroke & intracranial hemorrhage -6

Pyridoxin dependency -7
Inborn error of metabolism(nonketotic -8

hyperglycinemia in neonates and

mitochondrial encephalopathy with lactic

.acidosis (MELAS) in children and adolescents

HIE (e.g after cardiac arrest) -9

Encephalopathy(hypertensive, renal or -10

)hepatic

brain malformation, neurodegenerative -11

,disease, progressive myoclonic epilepsy

.storage disease
management

:Recognition and initial stabilization

Maintain A, B, C & Neurological exam

Give oxygen by cannula or mask

Cardiopulmonary monitor
Connect to pulse oximeter (o2 sat)

Establish IV access

Prepared for possible intubation

Correct any electrolytes abnormalities

:Investigation

Bed side glucose

Blood gas

Send lab(Na, Mg, Ca, Po4, CBC, Urea & creat, LFT)
:Consider when clinically indicated

Anticonvulsant drug level

Toxicology, metabolic scereen

Blood and urine culture, LP (if no contraindication)

.CT/MRI brain
Start anticonvulsant treatment after minutes of seizure activity
(consider pre-arrival seizure duration)

Initial Therapy Phase is Benzodiazepine

If no available IV/IO

IM medazolam (one dose) 0.2mg/kg

If not available

Rectal diazepam 0.2 – 0.5mg/kg maximum 20mg

If there is IV/IO

Lorazepam 0.1mg/kg/dose max 4mg/dose or

Medazolam 0.1 – 0.2mg/kg max 10mg

Both of them can be repeated once

:If both not available

Diazepam (0.15 – 0.2mg/kg/dose max

10mg/dose)

Second therapy phase: 2 options

Patient must be on cardiorespiratory

:Option 1: choose one of the following

IV fosphenytoin(20 mg PE/kg/dose) slowly over 5

-10 minutes or phenytoin (20mg/kg/dose) slowly
over 30 minutes
OR

IV valproic acid (40mg/kg, max 300mg/dose single dose)

OR

IV levetiracetam (20-60mg/kg, max 2500mg/dose,

single dose)
:Option 2

Intravenous phenobarbital 20mg/kg/dose single

dose

:Third therapy phase

Call PICU and pediatric neurology

Use the ulternative choice of second therapy
phase

If you choose option 1 in previous phase go for

option 2 now and vice versa
:Refractory status epilepticus

Request for continuous EEG

Look for clinical or subclinical seizure or non-

convulsive status epileplicus (NCSE)
Consider insertion of central venous line

Be ready for intubation

Monitor vital sign and check for arrhythmias

:Medazolam infusion

Bollus with 0.2mg/kg then start infusion at 1mic/kg/min

Increase by 2 every 10-15min PRN(with siezure) up to 24mcg/kg/min

Common side effect: hhypotention and loss of airway reflexes

If seizure persist

Barbiturate coma