1. Status epilepticus the paeds emerg perspective Stephen C. Porter MD MPH MSc Division Chief, Pediatric Emergency Medicine The Hospital for Sick Children Associate Professor of Paediatrics University of Toronto School of Medicine

2. Outline for today Definitions ABCDs and parallel processing The pathway for status epilepticus at The Hospital for Sick Children Scientific and artful considerations

3. Video tells the story http://www.youtube.com/watch?v=aL1cZqmk C4A&feature=related http://www.youtube.com/watch?v=aL1cZqmk C4A&feature=related

4. Definition of status epilepticus The International Classification of Epileptic Seizures defines status epilepticus as a seizure that lasts for a sufficient length of time (30 minutes or longer) or is repeated frequently enough that the individual does not regain consciousness between seizures Outcomes are worse for children with more prolonged seizures – early treatment is key

5. ABCDs for status

6. Airway and breathing

7. Circulation and access Timely IV placement Alternatives – IO – Rectal – Intranasal – Intramuscular

8. Rapid assessment and treatment For a child presenting in status epilepticus Are there signs of trauma? Does the child have a known seizure disorder? Is the serum glucose low? Is there fever? Are there abnormal chemistries? Are there focal neurologic findings?

9. Rapid assessment and treatment For a child presenting in status epilepticus Are there signs of trauma? Does the child have a known seizure disorder? Is the serum glucose low? Is there fever? Are there abnormal chemistries? Are there focal neurologic findings?

10. Rapid assessment and treatment For a child presenting in status epilepticus Are there signs of trauma? Does the child have a known seizure disorder? Is the serum glucose low? Is there fever? Are there abnormal chemistries? Are there focal neurologic findings? Are anticonvulsant levels sub-therapeutic? Obtain drug levels as indicated Is it a breakthrough seizure due to inter- current illness? Evaluate for infection

11. Rapid assessment and treatment For a child presenting in status epilepticus Are there signs of trauma? Does the child have a known seizure disorder? Is the serum glucose low? Is there fever? Are there abnormal chemistries? Are there focal neurologic findings? Hypoglycemic seizure Dextrose 0.25 – 1 g/kg

12. Rapid assessment and treatment For a child presenting in status epilepticus Are there signs of trauma? Does the child have a known seizure disorder? Is the serum glucose low? Is there fever? Are there abnormal chemistries? Are there focal neurologic findings? Source of infection, in particular meningitis Screening labs Need for LP? Empiric antibiotics after blood/urine obtained?

13. Rapid assessment and treatment For a child presenting in status epilepticus Are there signs of trauma? Does the child have a known seizure disorder? Is the serum glucose low? Is there fever? Are there abnormal chemistries? Are there focal neurologic findings? Electrolyte disturbance Uremia Hepatic failure Metabolic derangement Ingestion Serum chemistries, kidney function, ammonia

14. Rapid assessment and treatment For a child presenting in status epilepticus Are there signs of trauma? Does the child have a known seizure disorder? Is the serum glucose low? Is there fever? Are there abnormal chemistries? Are there focal neurologic findings? Mass lesion Stroke Brain abscess CT scan of head

15. Pathway of care for status epilepticus Treatment should start when a seizure continues longer than 5 minutes Continuous cardio-respiratory monitoring is essential. If IV access fails, consider other routes of delivery Fosphenytoin is generally preferred for the initial loading dose over phenytoin or phenobarbital. If a patient is on phenytoin maintenance, consider phenobarbital for the initial loading dose Most common errors – Using too low of a dose for a benzodiazepine – Delay in initiating second line treatment

17. The first 10 minutes

18. 10 minutes  30 minutes

19. Refractory status

20. Scientific and artful – intranasal meds Draw up the calculated dose of midazolam PLUS an additional 0.1mL (for priming) into a 1mL syringe Attach atomizer (MAD Device) to the 1mL syringe Prepare atomizer by slowing priming (expelling air via the atomizer) the additional 0.1mL of midazolam Position patient either sitting up at minimum of 45 degrees Administer dose by inserting atomizer into nostril loosely and aim for the center of the nasal cavity Doses with a volume greater than 0.5mL should be split between both nostrils to prevent loss of solution Depress plunger quickly

21. Scientific and artful – risk of meningitis There is an association between prolonged, focal or recurrent seizures and meningitis Nigrovic et al validated and published a clinical prediction rule stratifying risks for bacterial meningitis among children with CSF pleocytosis; seizure was the only clinical predictor A child with a simple febrile seizure who recovers to a normal mental status with a normal neurologic exam and who is otherwise well is not at risk of meningitis A child with a complex febrile seizure who recovers to a normal mental status with a normal neurologic exam and who is otherwise well is at very low risk of meningitis For a child in status epilepticus who is febrile, obtain blood cultures and treat with empiric doses of antibiotics

22. CFS by feature. Kimia A et al. Pediatrics 2010;126:62-69 ©2010 by American Academy of Pediatrics

23. Rates of CSF pleocytosis among patients with a CFS. Kimia A et al. Pediatrics 2010;126:62-69 ©2010 by American Academy of Pediatrics

24. Summary Doing the right thing for status epilepticus – Emphasis on ABCDs (bag mask skills) – Parallel processing: treat and diagnose – Correct drugs in timely manner in right sequence Benzodiazepine (times two) Second line agent (usually fosphenytoin) – System readiness to deliver a pathway of care