Status Epilepticus

Status Epilepticus is a time-sensitive emergency, since untreated seizures lead to more seizures and delayed treatment contributes to morbidity and mortality.¹ Providing sufficient evidence- based treatment early is essential to improve patient outcomes. If your patient is actively seizing, refer to TREKK and EIIC’s Status Epilepticus Algorithm.

• Seizures lasting longer than 5 minutes or multiple seizures without full recovery of consciousness between seizures warrant treatment as status epilepticus.
• To determine the underlying cause and manage concurrently, consider the following investigations, depending on the clinical situation:
  • Electrolytes, glucose, urea, creatinine, CBC, blood/urine cultures, blood gas, LFTs and/or drug screen.
  • Anti-convulsant levels if patient on treatment (e.g., phenytoin, carbamazepine, phenobarbital, valproic acid).
  • Head CT if history of trauma, signs of increased intracranial pressure, and/or focal neurological signs.
  • Lumbar puncture (LP) if suspicion for meningitis AND no focal neurologic findings on exam or contraindications to LP on imaging. Initiation of antimicrobials should NOT be delayed if LP is not possible.

• Fever, severe infection (meningitis, encephalitis), anoxic injury, hypo/hyperglycemia, hypo/hypernatremia, hypo/hypercalcemia, traumatic brain injury, anti-epileptic drug non- adherence/withdrawal/overdose, toxic exposure,  structural brain abnormality, hypoxic-ischemic encephalopathy, progressive neurodegenerative disorder, stroke, underlying  genetic condition.

PHASE 0 (GOAL 0-5 MINUTES)

• Maintain airway (suction secretions, position, jaw thrust), breathing (100% oxygen via non-rebreather mask +/- assisted ventilation), and circulation (monitor, IV access, isotonic fluid bolus if inadequate perfusion).

PHASE 1 (GOAL 5-15 MINUTES)

PREHOSPITAL²

• DO NOT wait to check blood glucose before initiating treatment or placing an IV/IO.
• Give Midazolam 0.2 mg/kg/dose IM/intranasal (MAX 10 mg/dose)
  • Consider standardized Midazolam dose: 5 mg/dose for 13-40 kg; 10 mg/dose for >40 kg via IM/intranasal route.
• Check blood glucose:
  • If blood glucose <3.3 mmol/L (<60 mg/dL): Treat with D25W 2 mL/kg/dose IV (MAX 100 mL/dose) OR D10W 5 mL/kg/dose IV (MAX 250 mL/dose).
  • If ≥3.3 mmol/L (≥60 mg/dL): Give second dose of Midazolam 0.2 mg/kg/dose IM/intranasal (MAX cumulative dose of 10 mg in prehospital setting; if max dose given, consult Medical Director/Base Hospital for next step).

EMERGENCY DEPARTMENT³

• Give a benzodiazepine (if two doses not already given prior to ED arrival):
  • IV/IO Access:
    • Lorazepam 0.1 mg/kg/dose IV/IO (MAX 4 mg/dose) OR
    • Midazolam 0.1 mg/kg/dose IV/IO (MAX 10 mg/dose)
  • No IV/IO Access:
    • Midazolam 0.2 mg/kg/dose IM/intranasal (MAX 10 mg/dose)
    • Consider standardized Midazolam dose: 5 mg/dose for 13-40 kg; 10 mg/dose for >40 kg via IM/intranasal route.
• Check blood glucose and respond as per Prehospital section above (if not already done prior to ED arrival).
• Give a second benzodiazepine dose for ongoing seizures 5 minutes after the first dose.
• If IV/IO access becomes available, switch to IV/IO route.

PHASE 2 (GOAL 15-50 MINUTES)

• Levetiracetam, Phenytoin/Fosphenytoin and Valproic acid are equally efficacious for status epilepticus.⁴ If available, Levetiracetam is preferred given rapid administration, favourable side effect profile, and fewer drug interactions.

PHASE 3 (GOAL 50 MINUTES ONWARDS)

• If two second-line therapies fail, discuss further management with Pediatric Referral Site.
• Anticipate the need/prepare for definitive airway support due to the risk of apnea.
• Third-line therapy consists of continuous IV infusion of Midazolam, Pentobarbital, Propofol OR Ketamine.⁵

MONITORING

• Monitor heart rhythm, pulse oximetry, and blood pressure.
• Anticipate apnea and/or hypotension with the use of multiple medications.
• Neurology consult, continuous electroencephalogram (EEG) monitoring +/- video should be initiated (at Pediatric Referral Site) as soon as feasible for patients on continuous infusion or those with persistent altered mental status, need for pharmacological paralysis, and/or paroxysmal events suspected to be seizures.⁶

CRITERIA FOR ADMISSION/TRANSFER TO PEDIATRIC REFERRAL SITE

• Patients with refractory seizures or who are not awake and responsive within 4-6 hours of ED arrival should be admitted/ transferred for further evaluation and/or monitoring.

CONSIDERATIONS FOR DISCHARGE HOME

• Discharge home may be considered in patients who have returned to baseline post seizure management in discussion with Pediatric Referral Site, taking into account parental comfort.
• Counsel parents/guardians on what to do if a seizure recurs at home using this resource (Eng/Esp) or this resource (Eng/Fr).

Thank you to the following content experts who led the development of the Status Epilepticus Bottom Line Recommendations:

Katherine Muir, MD, Children’s Hospital of Eastern Ontario (CHEO)

Sarah Buttle MD, Children’s Hospital of Eastern Ontario (CHEO)

Dubravka A. Diksic, MDCM, FRCPC; Pediatric Emergency Physician, Assistant Professor, Department of Pediatrics, Pediatric  Emergency Medicine, Montreal Children’s Hospital 

Thank you to the TREKK Editorial Committee, editor Dr. Sarah Reid (CHEO), who provided editorial support and expertise in  the development of this resource. Thank you as well to Mateja Carevic, TREKK Project Coordinator (University of Manitoba) who coordinated the development process.

(as cited in the Status Epilepticus Bottom Line Recommendations):

1. McKenzie KC, Hahn CD, Friedman JN; Canadian Paediatric Society, Acute Care Committee. Paediatr Child Health. 2021; 26(1): 50-57.
2. Shah MI, Macias CG, Dayan PS, Weik TS, Brown KM, Fuchs SM, Fallat ME, Wright JL, Lang ES. An evidencebased  guideline for pediatric prehospital seizure management using GRADE methodology. Prehospital Emergency Care. 2014;  18(1):15-24.
3. McTague A, Martland T, Appleton R. Drug Management for Acute Tonic-Clonic Convulsions Including Convulsive Status  Epilepticus in Children. Cochrane Database of Systematic Reviews. 2018; Issue 1, Article No.: CD001905
4. Chamberlain JM, Kapur J, Shinnar S, Elm J, Holsti M, Babcock L, Rogers A, Barsan W, Cloyd J, Lowenstein D, Bleck TP,  Conwit R, Melzner C, Cock H, Fountain NB, Underwood E, Connor JT, Silbergleit R. Efficacy of levetiracetam, fosphenytoin, and valproate for established status epilepticus by age group (ESETT): a doubleblind, response-adaptive,  randomized controlled trial. Lancet. 2020; 395(10231): 1217-1224.
5. Vossler DG, Bainbridge JL, Boggs JG, Novotny EJ, Loddenkemper T, Faught E, Amengual-Gual M, Fischer SN, Gloss DS,  Olson DM, Towne AR, Naritoku D, Welty TE. Treatment of Refractory Convulsive Status Epilepticus: A Comprehensive  Review by the American Epilepsy Society Treatments Committee. Epilepsy Curr. 2020 Sep;20(5):245-264. doi:  10.1177/1535759720928269. Epub 2020 Aug 21. PMID: 32822230; PMCID: PMC7576920.
6. Herman ST, Abend NS, Bleck TP, Chapman KE, Drislane FW, Emerson RG, Gerard EE, Hahn CD, Husain AM, Kaplan PW,  LaRoche SM, Nuwer MR, Quigg M, Riviello JJ, Schmitt SE, Simmons LA, Tsuchida TN, Hirsch LJ; Critical Care Continuous EEG Task Force of the American Clinical Neurophysiology Society. Consensus statement on continuous EEG in critically ill  adults and children, part I: indications. J Clin Neurophysiol. 2015 Apr;32(2):87-95. doi: 10.1097/WNP.0000000000000166. PMID: 25626778; PMCID: PMC4435533.

For a complete list of the evidence that informed the creation of the Status Epilepticus Bottom Line Recommendations see the Evidence Repository here.

The purpose of this document is to provide healthcare professionals with key facts and recommendations for the diagnosis and treatment of community acquired pneumonia in children in the emergency department. The TREKK Network is not liable for any damages, claims, liabilities, costs or obligations arising from the use of this document including loss or damages arising from any claims made by a third party. THIS DOCUMENT IS SUBJECT TO FULL DISCLAIMER HERE: trekk.ca/terms-of-use