Status epilepticus PICU DIVISION

DEFINITION Status Epilepticus (SE) “ seizures occur so frequently that over the course of 30 or more minutes, he or she has not recovered from the coma produced by one attack before the next attack supervenes SE is one of the few true emergencies in the practice of pediatric neurology US : Estimated 152.000 cases occur per year  42.000 deaths and inpatient cost of $3.8 to $7 billion per year

MODIFIED CLASSIFICATION OF SE Generalized SE Convulsive Nonconvulsive (i.e. absence or following prolonged convulsion) Focal SE Simple : without altered conciousness Complex : with altered conciousness

General convulsive SE (GCSE) consist of : continuous clonic or tonic motor activity with bilateral epileptiform discharges on the EEG As GCSE progresses, motor movements are reduced and may be characterized only by subtle twitching of the limbs, face, or trunk  called subtle GCSE Nonconvulsive SE (NCSE) consist of : continuous electrographic seizure with no motor movements May occur after prolonged GCSE

Generalized convulsive SE ( GCSE ) - Primary generalized Classification Generalized convulsive SE ( GCSE ) - Primary generalized - Tonic-clonic - Myoclonic - Clonic / Tonic Secondary generalized SE - Partial seizures with secondary generalization - Tonic seizures Non-convulsive SE ( NCSE ) - Absance status ( Petit Mal ) - Atypical absance status - Atonic - NCSE due to partially treated GCSE Partial SE - Simple partial : * Typical * Epilepsia partialis continua - Complex partial SE ( CPSE ) Neonatal SE Behera CMK, et al, MJAFI 2005;61: 174-178

incidence The incidence of SE peaks during young and old age In infants younger than 1 year, the incidence of SE may be as high as 150/100.000 Incidence is more than twofold higher in children younger than 5 years than in those older than 5 years

etiology Fever 20 – 29% Idiopathic 16 – 39% Chronical static of CNS ( remote symptomatic ) 14 – 23% Acute symptomatic 23 – 40% - CNS infection - Traumatic Brain Injury - Hypoxic-Ischaemic - Cerebrovaskular - Intoxication - Metabolic/Electrolyte Disturbances - Tumor - Acute AED withdrawal Progressive encephalopathy 2 – 6% Livingston J, Epilepsy in Children, 1996

Treatment of SE Principal goal of therapy in SE is to abort the seizure before irreversible neuronal injury occurs (after 20 min – 1 hr of continuous seizure activity) Securing airway Maintaining adequate ventilation and circulation Positioned on their sides with the head below the torso to minimize the risk of aspiration Insert oral or nasopharyngeal airway Early intubation  if oxygenation is inadequate Applied a cardiac monitor and transcutaneous O2 sat monitoring

PROTOCOL FOR THE DRUG TREATMENT OF SE IN CHILDREN <18 months, consider pyridoxine 100 mg/IV 5 min Lorazepam, dose : 0,1mg/kg, max 4 mg, PR/IV Diazepam 0,05-0,3 mg/kg 10 min 15 min Phenytoin, dose 20 mg/kg, max 1 gr The order of phenytoin and phenobarbital can be interchanged in infants younger than 18 months excepts in TBI

Persistent seizure in the face of midazolam 35 min Phenobarbital, dose 20 mg/kg, max 1 gr, 45 min Midazolam, dose 0,15 mg/kg/IV bolus followed by 2 µg/kg/min infusion then titrate to max 24 µg/kg/min Thiopentone, bolus 2-4 mg/kg followed by 2-4 mg/kg/hr infusion Titrate midazolam to seizure control by increasing by 2 µg/kg/min every 5 min and with boluses of 0,15 mg/kg as needed, if no seizure in 48 hrs, taper midazolam by 1 µg/kg/min every 15 min Persistent seizure in the face of midazolam

Based on EEG suppression of epileptiform discharges; use additional boluses of 2 mg/kg with increase in infusion rate of 1 mg/kg/hr every 30 min to 6 mg/kg/hr as needed Discontinue midazolam and phenobarbital once thiopentone infusion started Maintain phenytoin at therapeutic level Consider vasopressor support Monitor thiopentone levels If no seizures for 48 hours, taper over 12 hr in 25% decrements and reinstitute phenobarbitone while tapering

OTHER TREATMENT OF SE Nolan M, Beca J, Neurology, Oct 2004

Nolan M,Beca J, Neurology, Oct 2004

REFRACTORY STATUS EPILEPTICUS (rse) Def : characterized by seizures that persist beyond 60 min and fail to respond to first- and second-line therapy Prolonged therapy for sustained RSE may be required Although it is virtually always possible to control seizures with high-dose seizure-suppressive medication, complete remission is not always possible when these high-dose medications are withdrawn  poor outcome, especially with all children having medically intractable epilepsy and developmental deterioration Sustained RSE is most often associated with viral encephalitis or postinfectious process

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