Paediatric Status Epilepticus

Paediatric status epilepticus shares many facets with adult status epilepticus, and therefore much of the material from the adult page is replicated here.

Resources

Convulsive seizures lasting ≥5mins are deemed status epilepticus
Status is the most common childhood medical neurological emergency, with an incidence of approximately 20 per 100,000 per year in the developed world

In short, any cause of seizures
Some patients may develop new-onset refractory status epilepticus ( NORSE ) without a history of prior seizures

This is associated with high mortality (∽20%) and is often due to unknown causes (50%) or autoimmune disease (36%)

Category	Examples
Cardiovascular	Stroke Eclampsia Ischaemic or hypertensive encephalopathy
Infectious	Meningo-encephalitis Intra-cerebral abscesses Febrile convulision (6m - 5yrs)
Intra-cranial/trauma	Intra-cerebral bleed TBI Neurosurgical intervention Blocked VP shunt
Autoimmune	Cerebral vasculitis Autoimmune encephalitis
Metabolic	Hypo- K⁺, Na⁺, Mg²⁺, Ca²⁺ Hypoglycaemia Uraemia Hyperammonaemia Drug overdose or withdrawal Inborn error of metabolism
Iatrogenic	Sympathomimetics TCAs Olanzapine High-dose TXA Beta-lactams Prochlorperazine
Neoplastic	SOL
Congenital	Poorly controlled epilepsy Cerebral palsy

Prompt treatment is vital, as neuronal GABA receptors undergo altered localisation during seizures making treatment harder and harder the longer the seizure goes on
Naturally one will perform management and investigatory steps somewhat simultaneously, but the latter is ensconced in a separate section below for clarity

If seizure not self-terminating within a few minutes

ABCDE approach
Treat obvious causative factors:

Hypoglycaemia - 2ml/kg 10% IV dextrose with a target blood glucose of 4-8mmol/L
Hyponatraemia - 3ml/kg 2.7% NaCl if Na⁺ <130mmol/L

Use the patient's own management plan if they have one
If not, administer the benzodiazepine du jour:

Lorazepam 0.1mg/kg IV
Midazolam 0.5mg/kg buccally
Diazepam 0.5mg/kg rectally

If seizure not terminated after five minutes

Give a second dose of benzodiazepine
Or give PR paraldehyde 0.4mg/kg 50:50 in olive oil if no IV or IO access
Start readying second line agents

If seizure still not terminated after a further five minutes

Give a second line agent (multiple trials do not demonstrate different efficacy between them):

Levetiracetam 40mg/kg IV (up to 3g)
Phenytoin 20mg/kg (up to 2g) IV unless already on phenytoin
Phenobarbital 20mg/kg IV over 5mins

Administer regular doses of chosen anticonvulsant(s) thereafter (see BNFC for dosing guidelines)
Call the friendly neighbourhood anaesthetists or intensivist

If seizure still not terminated i.e. refractory status epilepticus

Induce general anaesthesia e.g. propofol 1.5 - 4mg/kg IV or thiopentone 3 - 5mg/kg IV
If the team are not ready, can administer alternative second line agent whilst preparing for RSI
Although NMBA should be used for intubation, they shouldn't be continued thereafter

Additional management

IV ceftriaxone 80mg/kg for suspected meningitis ± aciclovir & macrolide is suspected encephalitis

A failure to investigate and treat the underlying cause will contribute to refractory seizures
Some of these tests can be performed alongside management above; some will have to wait until a modicum of clinical stability is established

Blood tests

VBG or ABG
FBC | Urea and creatinine | LFTs | Clotting inc. fibrinogen
Electrolytes including magnesium, calcium and ammonia
Glucose
Toxicology screen
Anti-epileptic drug levels
Blood cultures

Neurological investigations

Neuroimaging e.g. CT brain, MRI head if focal neurology, trauma, suspected VP shunt issue, suspected SOL or new seizure
Lumbar puncture - may see pleocytosis as a consequence of status epilepticus
EEG
The opinion of a neurologist and/or neurophysiologist