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Status Epilepticus Return to MD Home PageMartin L. Kutscher, MD; Departments of Pediatrics and Neurology, New York Medical College, Valhalla, NY.
Diagnostic Criteria Status epilepticus is defined as either:
Status epilepticus is a neurological emergency, although fortunately neurological damage from it is unusual. A study by Shinnar showed that most of the neurological impairment seen after status epilepticus can be traced to the underlying etiology, and that 98% of children presenting in status due to either idiopathic epilepsy or fever will remain normal. Treatment Preliminary considerations 1. As in any acute situation, attention should be first focused on the "A-B-C’s," i.e., Airway, Breathing, and Circulation. This includes:
2. Simultaneous with treatment, obtain a focused history and physical. Particular historical points include: previous history of seizures, medications, compliance, state of the child before the seizure, fever, trauma, and possible ingestion. During examination of the child, remember to look for possible infection and other organ system problems, particularly the neck and abdomen. Careful fundoscopic examination is important, looking for papilledema and retinal hemorrhages. 3. Initial laboratory investigations should include: Blood for SMA 6, calcium, liver function tests, and CBC. When appropriate, also obtain drug levels, arterial blood gases, and blood culture. Always run a stat fingerstick glucose on any patient with an unexplained acute alteration of neurological function. Anticonvulsant therapy Dosages for medications used in the treatment of status epilepticus are given in Table 2. Notice that recommended pediatric dosages and rates of administration tend to vary and be frequently changed, and should not exceed that of adults. As these are potentially dangerous medications, they should be used cautiously. 4. Anticonvulsant therapy usually begins with a benzodiazepam. Lorazepam (Ativan (TM)) is the preferred medication since its anti-convulsant effect lasts 4-12 hours, versus only 20 minutes for diazepam. Thus, lorazepam protects against seizures much longer than diazepam, yet it is just as effective, and is neither more dangerous or safe. Doses may be repeated every 5 minutes as needed, usually up to three doses. 5. A phenytoin preparation is usually given next. Even if seizure control has already been achieved, it will be needed to prevent seizure recurrence. If available, IV fosphenytoin (Cerebyx (TM)) should be used instead of IV phenytoin (Dilantin (TM)). In order to get phenytoin into solution, the IV phenytoin preparation requires high levels of propylene glycol (a cardiac suppressant) and a pH of 12. In contrast, fosphenytoin is a neutral phosphorylated formulation of phenytoin, and is less likely than IV phenytoin to cause cardiac suppression. In addition, phosphenytoin does not have the potential of skin sloughs at IV site infiltration. IV fosphenytoin can be given in any IV solution (unlike phenytoin which cannot be given with glucose). Although IV fosphenytoin can be given three times faster than phenytoin, its time to onset of action remains unchanged, since it requires the bodies own metabolic step before it is active. Cardiac arrythmias remain the major risk of either preparation, especially in childen with a history of cardiac disease. Phenytoin preparations may not be effective in febrile seizures presenting as status. In such a possible setting, phenobarbital would probably be used to follow up after the benzodiazepams. 6. If the seizure continues, intubation should be very strongly considered at this point. 7. If needed, phenobarbital is usually added next. As indicated in the table, we usually start with less than the full loading dosage due to the respiratory, hypotensive, and sedative effects of phenobarbital boluses. 8. If seizures persist, the patient should certainly be intubated if not already done. Patency of IV lines should be checked. 9. Further options include:
After seizure control is obtained 10. After seizure control is achieved, a complete history and physical can be finished. In addition:
Table 1. Status epilepticus: Summary of treatment (see Table 2 for dosages) 1. Take control of the "A-B-C’s," i.e., Airway, Breathing, and Circulation. Intubate when in doubt. Cardiopulmonary monitor. IV with glucose. 2. Perform a focused history and physical, including fundoscopic examination. 3. Obtain stat fingerstick glucose, blood for SMA 6, calcium, liver function tests, and CBC. When appropriate, also obtain drug levels, arterial blood gases, and blood culture. 4. Give lorazepam (Ativan) or diazepam (Valium) bolus. May repeat every 5 minutes usually up to three doses as needed. 5. Give fosphenytoin (Cerebyx) or phenytoin (Dilantin)load. See text if felt to be febrile seizure as status, or history of cardiac disease. 6. If the seizure continues, intubation should be very strongly considered at this point. 7. Give phenobarbital bolus. 8. If seizures persist, the patient should certainly be intubated if not already done. Patency of IV lines should be checked. 9. Additional options include:
10. See text for further evaluation such as CT and lumbar puncture.
Table 2: I.V. Anticonvulsants for Status Epilepticus. (Doses and Rates subject to change.)
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