From the Guidelines
Status epilepticus in pediatric patients requires immediate intervention with lorazepam 0.05 mg/kg (maximum 1 mg) intravenous (i.v.) as the first-line treatment, which can be repeated every 5 minutes (to a maximum of 4 doses) to control electrographical seizures. This approach is based on the most recent guidelines for managing pediatric patients with status epilepticus, as outlined in a 2019 study published in Nature Reviews Clinical Oncology 1. The initial assessment should include checking circulation, airway, and breathing (CAB) and providing airway protection interventions, high-flow O2, and checking blood glucose levels.
Key steps in managing status epilepticus in pediatric patients include:
- Assessing and securing the airway, breathing, and circulation
- Administering lorazepam as the first-line treatment
- Using levetiracetam 40 mg/kg (maximum 2,500 mg) i.v. bolus if seizures persist
- Considering transfer to a pediatric intensive-care unit (PICU) and adding phenobarbital i.v. at a loading dose of 10–20 mg/kg (maximum 1,000 mg) for refractory seizures
- Maintaining anticonvulsant drugs after resolution of status epilepticus, with doses such as lorazepam 0.05 mg/kg (maximum 1 mg) i.v. every 8 hours for 3 doses, levetiracetam 15 mg/kg (maximum 1,500 mg) i.v. every 12 hours, and phenobarbital 1–3 mg/kg i.v. every 12 hours.
The importance of rapid and effective treatment of status epilepticus in pediatric patients cannot be overstated, as it can prevent long-term neurological sequelae and mortality, which are significant concerns in terms of morbidity, mortality, and quality of life 1.
From the FDA Drug Label
The safety and effectiveness of lorazepam for status epilepticus have not been established in pediatric patients A randomized, double-blind, superiority-design clinical trial of lorazepam versus intravenous diazepam in 273 pediatric patients ages 3 months to 17 years failed to establish the efficacy of lorazepam for the treatment of status epilepticus. Open-label studies described in the medical literature included 273 pediatric patients; the age range was from a few hours old to 18 years of age Paradoxical excitation was observed in 10% to 30% of the pediatric patients under 8 years of age and was characterized by tremors, agitation, euphoria, logorrhea, and brief episodes of visual hallucinations.
The safety and effectiveness of lorazepam for status epilepticus have not been established in pediatric patients. In a clinical trial, lorazepam failed to establish efficacy for the treatment of status epilepticus in pediatric patients. Paradoxical excitation was observed in 10% to 30% of pediatric patients under 8 years of age. Therefore, the use of lorazepam in pediatric patients with status epilepticus is not recommended due to the lack of established safety and efficacy 2.
From the Research
Definition and Clinical Manifestations
- Status epilepticus is characterized by a prolonged, self-sustaining seizure or repeated seizures without return to baseline 3
- The clinical manifestations of status epilepticus in children range from overt generalized convulsions to more subtle behavioral manifestations, including unresponsiveness in the setting of the intensive care unit 3
- Status epilepticus is the most common neurologic emergency of childhood, with a large proportion of episodes resulting from a prolonged febrile seizure or an acute symptomatic etiology 3
Treatment Options
- The goal of treatment is the rapid termination of the seizure, to minimize the acute and chronic effects of this emergency and to allow for the prompt assessment and management of the underlying precipitant 3
- Benzodiazepines are the first-line treatment for status epilepticus, with intravenous lorazepam and intramuscular midazolam being effective options 4
- In children, buccal midazolam has emerged as a first-line non-intravenous drug with similar efficacy and safety to other intravenous or rectal benzodiazepines 4
- For established status epilepticus, intravenous antiepileptic drugs such as valproate, levetiracetam, and phenytoin are used, with valproate and levetiracetam having a more favorable tolerability profile 4, 5
- Refractory status epilepticus may require treatment with intravenous anesthetics such as midazolam, propofol, pentobarbital, and ketamine 4, 6
Importance of Prompt Treatment
- Rapid treatment and escalation of therapies to achieve early seizure control is paramount in preventing complications and providing the best patient outcomes 7
- Treatment delays and barriers to care, such as prompt seizure recognition, first-line benzodiazepine availability, and timely arrival of emergency personnel, can undermine cessation of out-of-hospital status epilepticus 7
- In-hospital, status epilepticus onset is additionally impacted by delays to first- and second-line treatment and availability of resources 7