Convulsions - Status Epilepticus
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In an emergency go to Management Algorithm
For guidelines on neonatal seizure management see Newborn Services Guideline for seizures
Definition of Status Epilepticus
Recurrent seizures without complete recovery of consciousness between attacks, or continuous seizure activity for more than 30 minutes. This may occur with or without impairment of consciousness.
Includes generalized convulsive seizures, nonconvulsive seizures (absence status, complex partial status) and continuous focal motor seizure activity.
Nonconvulsive or partial motor status is not associated with the same severity of sequelae or urgency of treatment as generalized convulsive status, but if sustained may still result in permanent damage. Further consultation with the neurology consultant on call should be obtained for these patients before progressing down the treatment algorithm
|Most seizures in childhood stop within 5 minutes.
Supportive care is the mainstay of treatment in this time
Treatment should start if the seizure has not spontaneously terminated after 5 minutes. Seizures of longer duration are more difficult to terminate and may be associated with neurological sequelae.
Assessment & Management
Concurrent assessment and management should occur if seizure activity is continuing.
Key features include:
|Airway|| Airway compromise
- Secretions and trismus are common
- Complete airway obstruction is very rare
Airway positioning - eg jaw thrust
Avoid blind suctioning
|Breathing||Peri-oral cyanosis common
|Circulation||Tachycardia and poor peripheral perfusion
Shock uncommon (if present consider sepsis as underlying cause)
Ensure appropriate monitoring, including BP
Check blood glucose
APLS Medication List - Drugs in Status Epilepticus
from APLS 5th Edition Course manual
Takes effect within minutes but shorter duration of effect than lorazepam. Can depress respiration, particularly if repeated dosing. Is usually short-lived and is usually easily managed with bag-mask-valve ventilatory support. IM midazolam more effective than buccal or intra-nasal routes. Intra-nasal route requires mucosal atomiser device for optimal delivery. Buccal midazolam is twice as effective as rectal diazepam, but both drugs produce the same level and degree of respiratory depression.
Rapid onset, duration less than 1 hour. Well absorbed rectally. Widely used but may now be superseded by the more effective midazolam or lorazepam where available.
|Lorazepam||IV/IO||0.1 mg/kg||Max 4 mg.
Dilute with saline or water to at least twice the 'neat' volume and give over 2 minutes.
Consider using 0.05mg/kg if prior benzodiazepines or likely to have impaired respiratory drive.
Equally or more effective than midazolam and diazepam, possibly less respiratory depression. Longer duration of action (12-24 hours)
|Phenytoin||IV/IO||20 mg/kg||Max 1g.
Give over 20 minutes, made up in 0.9% sodium chloride solution to a maximum concentration of 10mg in 1 ml. Can cause dysrhythmias and hypotension, therefore monitor ECG and BP. Little depressant effect on respiration.
|Phenobarbitone||IV/IO||20 mg/kg||Max 1g.
Give over 20 minutes. Ensure airway support available, often causes respiratory depression. Monitor blood pressure.
|Paraldehyde||PR||0.4 ml/kg||Max 10 ml.
Make up as 50:50 solution in olive oil or 0.9% sodium chloride (avoid Arachis oil because children with peanut allergy may react to it). Can cause rectal irritation. Avoid IM use as causes severe pain and may lead to sterile abscess formation. Paraldehyde causes little respiratory depression. Avoid in liver disease. Takes 10-15 minutes to act, sustained for 2-4 hours. Don't leave paraldehyde standing in a plastic syringe for longer than a few minutes.
Paraldehyde is formulated for Intramuscular use. However due to the risks of severe muscle necrosis, the most common method of use is to administer rectally. For rectal administration, the intramuscular preparation has to be diluted with oil.
- May be effective in terminating status when IV access is not available.
- Dose: 0.4ml/kg, q 2-4 hours as required
- Method: Dilute 1:2 in olive oil
- Action may be delayed up to 2-4 hours.
- Metabolic acidosis is a possible complication in infants.
Notes on Paraldehyde
- Can be administered from plastic syringes if used quickly.
- Recommended administration in 20ml syringe attached to 10F feeding tube, inserted 10cm rectally. Hold buttock cheeks together for 2-3min (PR paraldehyde is a powerful GI stimulant). Insoluble at room temperature in solutions above 7.8% (1 in 12). Warm ampoules if crystals appear. Do not take from a vial that is discoloured or has been open for a while. Paraldehyde degrades to acetate and acetaldehyde on contact with air, and these may be fatal.
Valproate can be given intravenously in convulsive status epilepticus.
- Dose = 40 mg/kg IV sodium valproate given over 10 minutes (diluted to a maximum concentration of 50mg/ml with 0.9% sodium chloride or 5% glucose)
Peak levels are reached within 30 minutes, with an effective half-life of approximately 12 hours. A continuous intravenous infusion can also be considered if the initial dose was effective. There are also reports of the effective use of intravenous valproate in nonconvulsive status.
- Dose = 40mg/kg IV levetiracetam (maximum 3g) given over 5 minutes. Dilute 1:1 to give concentration of 50mg/1ml with sodium chloride 0.9% or 5% glucose to a minimum of 10ml.
Evidence for use of IV Levetiracetam in status epilepticus is increasing.
Information for Families
The New Zealand Paediatric Neurology Clinical Network have produced some information sheets for families on epilepsy, seizures and medication.
ALSG. Advanced Paediatric Life Support: The Practical Approach, Australia and New Zealand, 5th Edition. October 2012, BMJ Books.
Novorol CL, Chin RFM, Scott RC. Outcome of convulsive status epilepticus: a review. Arch Dis Child 2007;92:948-51.
Appleton R, Macleod S, Martland T. Drug management for acute tonic-clonic convulsions including convulsive status epilepticus in children. Cochrane Database of Systematic Reviews 2008(3).
Lewena S, Pennington V, Acworth J, Thornton S, Ngo P, Mcintyre S, et al. Emergency Management of pediatric convulsive status epilepticus. Pediatric emergency care 2009;25(2):83-7.
McMullan J, Sasson C, Pancioli A, Silbergleit R. Midazolam versus diazepam for the treatment of status epilepticus in children and young adults: a meta-analysis. Acad Emerg Med. 2010 Jun;17(6):575-82
Guardrails paediatric guidelines - accessed 2 July 2014 at http://adhbintranet/medsafety/Guardrails.htm
Did you find this information helpful?
- Date last published: 06 April 2017
- Document type: Clinical Guideline
- Services responsible: Children’s Emergency Department, Paediatric Intensive Care Unit, Paediatric Neurology
- Intended users: Emergency Department, Intensive Care and Clinical Wards
- Author(s): Claire Spooner, Heidi Baker, Mike Shepherd, John Beca
- Editor: Greg Williams
- Review frequency: 2 years
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