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Managing Pediatric Seizure and Status Epilepticus in the ED

The choice of benzodiazepine agent depends on whether an intravenous access is present. Both in pre-hospital and in hospital settings, midazolam is the first choice if IM or IN route is chosen. If an intravenous line is present, lorazepam 0.1 mg/kg is an appropriate alternative and may be slightly preferred to midazolam for its longer duration of action. However, due to depot effect and slower onset of action, lorazepam is less desirable than midazolam when administrated as IM or IN. It is important to note that benzodiazepine doses can be repeated every two to four minutes as needed, but when multiple doses of a benzodiazepine are used, respiratory depression should be anticipated, and it…

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 Pediatric Small Talk – Pediatric Status Epilepticus: The Chess Game of the ED

Seizures are a common presentation to the emergency department. While most seizures are self-terminating, a small subset of patients may present in status epilepticus which is a seizure lasting longer than 5 minutes or multiple seizures without return to baseline. Fortunately, for EM physicians, the care of status has become algorithmic and there are multiple available flowcharts (e.g. https://www.chop.edu/clinical-pathway/status-epilepticus-clinical-pathway) for the escalation of anticonvulsant therapy. However just like chess grandmasters, we are more than just an algorithm and by thinking moves ahead as opposed to reacting and reading an algorithm we can improve the care for children presenting in status epilepticus.

Articles of Interest

EBM: Seizure Management in the Emergency Department

Lorazepam 0.1mg/kg IV, or fixed dose of 4mg, If no IV/IO access then midazolam 0.2 mg/kg or 10mg IM/buccal/IN or 20mg rectally can be used.

Status Epilepticus | The MCG Pediatric Podcast

Status Epilepticus is one of the most common pediatric neurologic emergencies and requires prompt, targeted treatment to reduce patient morbidity and mortality. On this podcast, Pediatric Critical Care Physician, Dr. Renuka Mehta, Pediatric Resident Physician, Dr. Yvonne Ibe, and medical student, Emily Austin will discuss management for status epilepticus and rapid interventions that can be potentially lifesaving—because in seizure management, time is brain.

A podcast on the management of status epilepticus

Status epilepticus can be very stressful in the Pediatric Emergency Department. This episode of PEM Currents: The Pediatric Emergency Medicine Podcast focuses on management, and will guide you through the treatment process, starting with benzodiazepines, followed by a discussion of the recent evidence for second line therapy between fosphenytoin, levetiracetam, and valproate.

Emergency management of the paediatric patient with convulsive status epilepticus

Benzodiazepines are the first-line drugs of choice. Because rapid intervention is critically important, if no IV access is available, benzodiazepines should be given by an alternate route while IV access is being obtained.

Emergent Treatment of Status Epilepticus in Children

Although the treatment of pediatric SE has been examined in a number of trials, the current NCS guidelines are based primarily on expert opinion. Historically, IV lorazepam has been the preferred benzodiazepine for primary treatment of SE, despite the lack of FDA approval for this specific indication. Recent data support the use of diazepam and midazolam, in addition to lorazepam, for cessation of seizures in pediatric SE. Older anticonvulsants, such as phenytoin and fosphenytoin, have fallen somewhat out of favor owing to ADRs, but they maintain a place in therapy as secondary agents.

Guideline for the management of convulsive status epilepticus in infants and children

The recommen­ded first-line therapy includes a fast-acting benzodiazepine followed by a longer-acting antiepileptic. In cases of refractory status epilepticus, further treatment will depend on the setting. When pediatric intensive care is not available, phenobarbital or paraldehyde might be used. When pediatric intensive care is available, midazolam, barbiturates, and pro­pofol are options.

Management of Pediatric Seizures

Seizures account for about 1% of all ED visits for children younger than 18, and at least 5% of pediatric patients will experience a seizure by the time they are 16 years old. Treating the condition in the ED poses myriad challenges.

Non-IV Management of Pediatric Status Epilepticus

Overall, the evidence in support of the use of intranasal midazolam over rectal diazepam is limited and of poor quality, composed primarily of small, unblinded studies conducted in dissimilar populations with poor methodology. However, the evidence at least supports the premise that intranasal midazolam is safe and effective. It is reasonable, in light of this evidence, to use intranasal midazolam as an alternative to rectal diazepam in children with seizure activity...

Pediatric Seizures

Lorazepam (Ativan) is the preferred agent given its long half-life. Other agents may be used in the event that the patient does not have intravenous access or if lorazepam is not immediately available. Midazolam (Versed) may be administered via intramuscular, intranasal, buccal, or rectal routes, but is not a preferred intravenous agent given its short half-life.

Pediatric Status Epilepticus

Status epilepticus (SE) is a medical emergency requiring immediate, targeted treatment to help reduce patient morbidity and mortality. SE can be convulsive or non-convulsive, with convulsive status epilepticus (CSE) being the most common neurologic medical emergency in childhood. Prognosis is dependent on management of the underlying condition and on prompt treatment of seizures.

Pediatric Status Epilepticus Management

Benzodiazepines are the “emergent” medications of choice; lorazepam for intravenous administration, midazolam for intramuscular or intranasal administration, and diazepam for rectal administration. Repeat dosing may be provided in 5–10 minutes if needed

REBEL Core Cast 9.0 – Pediatric Status Epilepticus

Your first two medications should be benzos. If you can’t get IV access within 5 minutes, consider buccal midazolam. You use the IV midazolam formulation, in the cheek of the child, at a dose of 0.3 mg/kg with a max dose of 10mg. If the child continues to seize, an additional medication should be added at 5 minute increments. As you give one medication, be prepping the next so there is no delay once you decide it is needed. While there are differences of opinion on the proper procedure for intubation and sedation in the child with persistent status, the most important thing ultimately is to get the seizure to stop. Propofol is usually readily available and most ED docs are comfortable with it. It’s ok to use that, knowing that your peds colleagues may switch it out once they take control of the patient.

Status Epilepticus in Children

Airway – open and secure airway, recovery position, high flow oxygen.

Super Refractory Status Epilepticus

Does not respond to first and second-line antiepileptic treatment Persists at least 24 hours after the onset of anaesthesia, either without interruption despite appropriate treatment with anaesthesia, recurring while on appropriate anaesthetic treatment, or recurring after withdrawal of anaesthesia and requiring anaesthetic reintroduction.

Resources

PedsCases

This PedsCases Note provides a one-page infographic on status epilepticus. It summarizes types and common etiologies, along with what to look for on history and physicla exam for presentations of status epilepticus. The Note also gives an overview on investigations and management strategies. It was created by Katharine Jensen, a medical student at the University of Alberta, with help from Dr. Natarie Liu, a neurologist and epileptologist at the University of Alberta.

Status Epilepticus Clinical Pathway

Status epilepticus is a relatively common medical presentation, with 18-41 per 100,000 children presenting to emergency rooms each year. The American Epilepsy Society made recommendations in 2016 for treatment of prolonged seizures, which includes level A evidence of administration of benzodiazepines for seizure cessation in the first 20 minutes of seizure activity. Benzodiazepines are y-aminobutyric acid (GABA) receptor agonists, designed to increase inhibitory CNS activity to subsequently diminish seizure activity. The importance of early benzodiazepine administration is predicated on the idea that GABA receptors are rapidly phosphorylated and dephosphorylated during seizures which internalizes those receptors, making them unavailable for use as the seizure progresses

LearnPICU

Deficits in GABA with downregulation of GABA receptors. Consider pyridoxine in unusually refractory cases in young children <3 years old (required for metabolism and synthesis of GABA and deficiency can rarely lead to refractory seizures)

Status Epilepticus Pediatric Packages (PedsPacs)

Status Epilepticus is a time-sensitive emergency, since untreated seizures lead to more seizures and delayed treatment contributes to morbidity and mortality. 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.