What is the management of Status Epilepticus in pediatrics?

Management of Status Epilepticus in Children

The management of pediatric status epilepticus requires a time-sensitive, stepwise approach beginning with benzodiazepines as first-line treatment, followed by levetiracetam, valproate, or phenytoin as second-line agents, and progressing to continuous infusions for refractory cases, while simultaneously addressing the underlying cause and providing appropriate supportive care. 1

Initial Assessment and Stabilization (0-5 minutes)

• Assess circulation, airway, and breathing (CAB) and provide appropriate airway protection 1
• Administer high-flow oxygen to prevent hypoxia 1
• Check blood glucose level immediately to rule out hypoglycemia 1
• Search for and treat other underlying causes, including hyponatremia, hypoxia, drug toxicity, CNS infection, stroke, or withdrawal syndromes 2

First-Line Treatment (0-5 minutes)

• Administer lorazepam 0.1 mg/kg IV (maximum 2 mg) slowly; may repeat dose after at least 1 minute (maximum of 2 doses) 1
• Alternative options if IV access is not available:
  • Midazolam intramuscularly or intranasally 3, 4
  • Diazepam rectally 3, 4
• Monitor respiratory status closely as benzodiazepines can cause respiratory depression, especially when combined with other sedative agents 1

Second-Line Treatment (5-20 minutes)

• If seizures persist after benzodiazepine administration, administer one of the following:
  • Levetiracetam 40 mg/kg IV bolus (maximum 2,500 mg) - preferred due to fewer adverse effects 1, 4
  • Valproate 20-30 mg/kg IV over 5-20 minutes - causes less hypotension than phenytoin with similar efficacy 2, 4
  • Phenytoin/Fosphenytoin 20 mg/kg IV at maximum rate of 50 mg/min - requires ECG and blood pressure monitoring due to cardiovascular risks 2
  • Phenobarbital 20 mg/kg IV over 10 minutes - consider if other options unavailable 2

Third-Line Treatment (20-40 minutes)

• For refractory status epilepticus (seizures continuing after first and second-line treatments):
  • Phenobarbital 10-20 mg/kg IV (maximum 1,000 mg) if not already given 1
  • Midazolam: IV loading dose of 0.15-0.20 mg/kg, followed by continuous infusion of 1 mg/kg per minute 2
  • Propofol: 2 mg/kg bolus, followed by 3-7 mg/kg/hour infusion (requires respiratory support) 2
  • Pentobarbital: bolus of 13 mg/kg and infusion of 2-3 mg/kg per hour (higher success rate than propofol but causes more hypotension) 2
• Initiate continuous electroencephalography (EEG) monitoring 1
• Transfer to Pediatric Intensive Care Unit (PICU) for ongoing management 1

Maintenance Therapy After Seizure Control

• For convulsive status epilepticus:
  • Lorazepam 0.05 mg/kg (maximum 1 mg) IV every 8 hours for 3 doses 1
  • Levetiracetam 30 mg/kg IV every 12 hours or increase prophylaxis dose by 10 mg/kg (to 20 mg/kg) IV every 12 hours (maximum dose of 1,500 mg) 1
  • Phenobarbital 1-3 mg/kg IV every 12 hours if used in acute management 1

Common Pitfalls and Important Considerations

• Inadequate dosing: Infra-therapeutic antiepileptic drug doses are associated with prolonged status and increased number of drugs needed 5
• Incorrect sequence of drugs: Not following established protocols leads to unfavorable outcomes 5
• Delayed treatment: The longer the duration of status epilepticus, the more difficult it is to terminate and the greater the risk of morbidity 4
• Failure to monitor: Continuous vital sign monitoring is essential, particularly respiratory status and blood pressure 2
• Neglecting the underlying cause: Always search for and treat precipitating conditions 2, 6

Prognosis

• Mortality in pediatric status epilepticus ranges from 3-10%, with morbidity approximately twice that rate 6
• Outcome depends primarily on the underlying etiology, with CNS infections carrying the highest mortality and morbidity 6
• Other prognostic factors include age, rapidity of status epilepticus onset, and adequacy of care 6