Status Epilepticus in Children
OVERVIEW
Status epilepticus is considered to have occurred when a generalised tonic-clonic seizure has lasted greater than 30 minutes.
APPROACH
Goals
- Resuscitation
Terminate seizures
Clinical and Historical assessment for cause
Resuscitation
- Call for help – anaesthesia, paediatric neurologist
- Airway – open and secure airway, recovery position, high flow oxygen
- Breathing – ensure ventilation
- Circulation – ensure adequate circulation (20mL/kg crystalloid bolus), consider early antibiotic use to cover meningitis, routine bloods
- Disability
— check conscious state, interictal periods, localising signs, pupillary response, glucose level, check for full fontanelle and neck stiffness (meningitis)
— terminate seizure:
-> rectal diazepam – 0.5mg/kg
-> buccal midazolam – 0.5mg/kg
-> IV lorazepam 0.1mg/kg
-> IV midazolam 0.15mg/kg
-> PR paraldehyde 0.4mg/kg (mixed 1:1 in olive oil)
-> phenytoin 18mg/kg over 30min
-> phenobarbitone 20mg/kg IV over 20 min
-> thiopentone 4mg/kg with RSI
-> volatile anaesthesia
-> surgery - Exposure – rash to suggest infectious cause (esp. meningococcaemia), fever, poisoning (ecstasy, cocaine, saliciylates)
Other Management
- consider empiric therapy of intracranial hypertension (0.25-0.5g/kg mannitol)
- look for complications: aspiration, arrhythmias, hypertension, APO, hyperthermia, DIC, rhabdomyolysis
- maintain normoglycaemia
- restrict fluids to 60% maintenance to avoid hyponatraemia
- normalised sodium to 135-145
- gastric decompression with NGT
- normothermia
- ventilate to CO2 – 35-40
- dexamethasone 0.2mg/kg bd for cerebral oedema from SOL
- IDC
Diagnostic possibilities (COMATOSE)
- C – convulsion (primary or SOL)
- O – overdose
- M – meningitis
- A – adrenal failure
- T – trauma
- O – organ failure
- S – stroke
- E – end stage hypoxic ischaemic encephalopathy
References and Links
CCC Neurocritical Care Series
Emergencies: Brain Herniation, Eclampsia, Elevated ICP, Status Epilepticus, Status Epilepticus in Paeds
DDx: Acute Non-Traumatic Weakness, Bulbar Dysfunction, Coma, Coma-like Syndromes, Delayed Awakening, Hearing Loss in ICU, ICU acquired Weakness, Post-Op Confusion, Pseudocoma, Pupillary Abnormalities
Neurology: Anti-NMDA Encephalitis, Basilar Artery Occlusion, Central Diabetes Insipidus, Cerebral Oedema, Cerebral Venous Sinus Thrombosis, Cervical (Carotid / Vertebral) Artery Dissections, Delirium, GBS vs CIP, GBS vs MG vs MND, Guillain-Barre Syndrome, Horner’s Syndrome, Hypoxic Brain Injury, Intracerebral Haemorrhage (ICH), Myasthenia Gravis, Non-convulsive Status Epilepticus, Post-Hypoxic Myoclonus, PRES, Stroke Thrombolysis, Transverse Myelitis, Watershed Infarcts, Wernicke’s Encephalopathy
Neurosurgery: Cerebral Salt Wasting, Decompressive Craniectomy, Decompressive Craniectomy for Malignant MCA Syndrome, Intracerebral Haemorrhage (ICH)
— SCI: Anatomy and Syndromes, Acute Traumatic Spinal Cord Injury, C-Spine Assessment, C-Spine Fractures, Spinal Cord Infarction, Syndomes,
— SAH: Acute management, Coiling vs Clipping, Complications, Grading Systems, Literature Summaries, ICU Management, Monitoring, Overview, Prognostication, Vasospasm
— TBI: Assessment, Base of skull fracture, Brain Impact Apnoea, Cerebral Perfusion Pressure (CPP), DI in TBI, Elevated ICP, Limitations of CT, Lund Concept, Management, Moderate Head Injury, Monitoring, Overview, Paediatric TBI, Polyuria incl. CSW, Prognosis, Seizures, Temperature
ID in NeuroCrit. Care: Aseptic Meningitis, Bacterial Meningitis, Botulism, Cryptococcosis, Encephalitis, HSV Encephalitis, Meningococcaemia, Spinal Epidural Abscess
Equipment/Investigations: BIS Monitoring, Codman ICP Monitor, Continuous EEG, CSF Analysis, CT Head, CT Head Interpretation, EEG, Extradural ICP Monitors, External Ventricular Drain (EVD), Evoked Potentials, Jugular Bulb Oxygen Saturation, MRI Head, MRI and the Critically Ill, Train of Four (TOF), Transcranial Doppler
Pharmacology: Desmopressin, Hypertonic Saline, Levetiracetam (Keppra), Mannitol, Midazolam, Sedation in ICU, Thiopentone
MISC: Brainstem Rules of 4, Cognitive Impairment in Critically Ill, Eye Movements in Coma, Examination of the Unconscious Patient, Glasgow Coma Scale (GCS), Hiccoughs, Myopathy vs Neuropathy, Neurology Literature Summaries, NSx Literature Summaries, Occulocephalic and occulovestibular reflexes, Prognosis after Cardiac Arrest, SIADH vs Cerebral Salt Wasting, Sleep in ICU
Critical Care
Compendium
Chris is an Intensivist and ECMO specialist at The Alfred ICU, where he is Deputy Director (Education). He is a Clinical Adjunct Associate Professor at Monash University, the Lead for the Clinician Educator Incubator programme, and a CICM First Part Examiner.
He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives. He was one of the founders of the FOAM movement (Free Open-Access Medical education) has been recognised for his contributions to education with awards from ANZICS, ANZAHPE, and ACEM.
His one great achievement is being the father of three amazing children.
On Bluesky, he is @precordialthump.bsky.social and on the site that Elon has screwed up, he is @precordialthump.
| INTENSIVE | RAGE | Resuscitology | SMACC