CPS Statement: Emergency Management of Status Epilepticus

CPS Statement: Emergency Management of Status Epilepticus

The following was adapted from the Canadian Paediatric Society’s statement on “Emergency management of the paediatric patient with generalized convulsive status epilepticus.” Please see the full statement for the full recommendations from the Canadian Paediatric Society including a detailed algorithm and suggested dosages. For a more general approach, see our PedsCases podcast on Status epilepticus in children.

Background:

Generalized convulsive status epilepticus (CSE) is defined as either continuous generalized tonic-clonic seizure activity with loss of consciousness for greater than 30 minutes, or two or more discrete seizures without a return to baseline mental status. It may be caused by infection, metabolic disturbance, medication overdose or withdrawal, fever, neurologic abnormalities, or it may be idiopathic. CSE is a medical emergency and can cause lifelong disability or death if untreated. The goal of therapy is to stop seizure activity as soon as possible to limit neurological damage. Studies have shown that seizures that last greater than 5 minutes are at a high risk of progressing to CSE. Therefore, any child who arrives in the emergency department with acute tonic-clonic generalized convulsions is assumed to be in early CSE, and emergency management needs to begin promptly. These guidelines are intended for emergenciy situations where having a timely, standardized protocol is beneficial, and may be adjusted based on local expertise, or the individual child.

1) Maintenance of Adequate ABCs (and DFG):

Maintenance of airway, breathing and circulation is the top priority in any emergency situation.

Airway: Patients in CSE have a high risk of losing their airway due to clenched jaws, poorly coordinated respiration, and production of secretions and vomit. Position the child on their side and suction easily accessible secretions. After suction, place the patient on their back with a chin lift or jaw thurst to help open the airway.

Breathing: Administer 100% oxygen via a facemask.

Circulation: IV access should be obtained as soon as possible with two large-bore IVs.  If IV access is not possible, consider establishing an intraosseous line. Place the child on cardiac monitoring. You should expect to see increased heart rate and blood pressure. If a patient is bradycardic or hypotensive, they may need bag-valve mask ventilation, or intubation.

Don't Forget Glucose (DFG): Check bedside blood glucose.  If glucose is less than 2.6 mmol/L, then administer an infusion of dextrose (see complete for details).

2) Termination of the seizure and prevention of recurrence:

Pre-Hospital Treatment: Administration of abortive medications as soon as possible has been shown to improve outcomes. Options include buccal or oral lorazepam, midazolam or diazepam .

Hospital First-Line Treatment: IV Lorazepam is usually the first-line treatment, but other options include midazolam or diazepam depending on IV access. If the child is still seizing after five minutes, administer a second dose.  If the child is still seizing after a second dose, move on to second-line treatment as more than two doses can induce respiratory depression.

Hospital Second-Line Treatment: Two groups of medications (listed below) can be considered for second-line treatment depending on IV access. Start by giving one medication from one of the listed groups; if the patient is still seizing after five minutes, give a medication from the second group.

  • A) Fosphenytoin or Phenytoin - Preferred
  • B) Paraldehyde or Phenobarbital

During this time the team should obtain a brief history asking about any seizure disorders, other symptoms, fever, medication usage and allergies.  If the patient stops seizing at any time, continue to monitor and begin to investiage for etiology.

3) Diagnosis and initial therapy of life-threatening causes of CSE:

Children with a clear febrile seizure or known seizure disorder may not require an extensive work-up.  If the etiology is unclear, the work-up may include:

  • Blood - Lytes, glucose, CBC diff, blood gas, anticonvulsants (if on therapy), blood cultures (if sepsis suspected).
  • CT Head - If history of trauma, focal neurologic signs, unexplained loss of consciousness, or suspicion of increased intracranial pressure (ICP) or cerebral herniation.
  • Lumbar Puncture (LP) - If meningitis suspected and there is no suspicion of increased ICP

CT and LP should be deferred until the patient is stable, and convulsions have stopped. If sepsis is likely, IV antibiotics may be given immediately after blood cultures, without waiting for a LP. If intoxication is proven or strongly suspected, administer activated charcoal.  If the child does not regain consciousness as expected, you can use an EEG to exclude non-CSE.

4) Arrangement of appropriate referral for ongoing care, or transport to a secondary or tertiary care centre:

Patients who have had previous febrile seizures or epilepsy should be referred to a secondary or tertiary care hospital. Patients with unstable vital signs or continuing CSE should be transferred to a pediatric intensive care unit.

5) Management of Refractory Status Epilepticus:

CSE that is unresponsive to second-line treatment is considered to be refractory status epilepticus (RSE.) Patients with RSE should receive subspecialist and intensive care consultation, and should escalate therapy to include anesthetic support.  For more details on RSE, please see the full statement.

Last updated by PedsCases: January 25, 2015

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