1. Management

2. Goals of emergency management for status epilepticus Ensure adequate brain oxygenation and cardiorespiratory function Terminate clinical and electrical activity as rapidly as possible Prevent seizure recurrence Identify precipitating factors such as hypoglycemia, electrolyte imbalance, lowered drug levels, infection and fever Correct metabolic imbalance Prevent systemic complications Further evaluate and treat etiology of status epilepticus

3. In practice, treatment should start within, and certainly 10 minutes of continuous generalized tonic-clonic seizure activity

4. Protocol ABC principle of resuscitation – Oral airway – High flow O2 (100% O2 by nasal cannula or nonrebreathing mask), intubate if necessary – Continuous ECG monitoring and pulse oximetry – IV 5% dextrose in 0.3% saline or PNSS – In the absence of dehydration or shock, fluids may be given at 75% of maintenance level or at 100 mk/m2

5. Blood glucose by stick testing – If hypoglycemic, give 2-4 mg/kg of 25% glucose solution by bolus injection

6. Drug therapy – IV diazepam 0.3 mg/kg or lorazepam 0.1 mg/kg – If IV access failed, recatl diazepam 0.5 mg/kg – 2 nd dose hould be given in children who do not respond after 10 mins and with recurrence of convulsions – If following the 1 st dose of rectal diazepam an IV access is still not established, rectal paraldehyde 0.4 mg/kg

7. If seizures persist – Verify that the convulsion is a genuine epileptic seizure – Confirm that no treatable cause like hyperglycemia is overlooked – If IV access is still not possible, interosseous needle should be inserted

8. Phenobarbital Loading dose of 20 mg/kg by slow IV bolus If seizures are controlled before full loading dose is given, remaining dose may be given 1- 2h after by either slow IV or IM May produce respiratory depression and arrest – elective intubation

9. Phenytoin 20 mg/kg (made up of 0.9% saline at a maximum concentration of 10 mg in 1 mL, infused at no more than 1 mg/kg/min) Preferred drug Less respiratory and CNS depression

10. Children on maintenance oral phenytoin and compliant, IV phenobarbital over 10 min should be given

11. Other management – Diazepam or midazolam infusion – Barbiturate coma – General anesthesia

12. If after 20 mins after phenobarbital and phenytoin infusion, patient remains in convulsive status epilepticus, consider rapid sequence induction of anesthesia by experienced anesthesia personnel using thiopental or propofol Ideally, EEG should be done Children <3 years old with prior history of CSE should be treated with IV pyridoxine

13. Diazepam, loeazepam, or valproate – best drug for treatment of nonconvulsive status Valproate – administered by NGT or rectally; effective in absence status epilepticus Common medical complications: – CHF – Hypertension – Hypotension – Pulmonary edema – Pneumonia – Oliguria

14. Treatment guideline for an acute tonic-clonic convulsion including established convulsive status epilepticus. et al. Arch Dis Child 2000;83:415-419 ©2000 by BMJ Publishing Group Ltd and Royal College of Paediatrics and Child Health

15. CURRENT GUIDELINES FOR TREATMENT OF CONVULSIVE STATUS EPILEPTICUS BY COUNTRY Japan: “Research Committee on Clinical Evidence of Medical Treatment for Status Epilepticus in Childhood has a proposed guideline for the treatment of CSE in childhood. Initial management of seizures should be attempted mainly with i.v. diazepam, the second-line treatment involves i.v. midazolam followed by i.v. phenytoin if seizures persist, and the third-line treatment requires barbiturate coma” France: “as intravenous lorazepam not available, clonazepam, rectal diazepam or buccal midazolam as the best choice for initial therapy of CSE in infants and young children. Intravenous phenytoin / fosphenytoin and phenobarbital are the second-line drugs. Of the third line AEDs, high-dose midazolam infusion rather than thiopental to minimize serious side effects from barbiturate anesthesia” The Role of Intravenous Valproate in Convulsive Status Epilepticus in the Future. Shang-Yeong Kwan, Acta Neurol Taiwan 2010;19:78-81