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10-20% of children with epilepsy will have at least one episode of status epilepticus in their lifetime with ~10% having it as their inital seizure episode. Independent risk factors inculde:
There have been multiple revisions of the definition of status epilepticus by the International League Against Epilepsy (ILAE). The current guidelines include the following statement:
Although purposely vague, it gives the emphasis that treatment for seizures should occur by the 5 min mark as studies have shown that seizures that last at least 5 min have a high risk of lasting at least 30 min and incurring neurologic compromise.
When a patient presents with a seizure the initial focus should be on resuscitation and preparation for seizure control. A majority of seizures will stop in the first 5 min without any medication. However, preparing for prolonged seizures is key to early intervention and the potential mitigation of complications.
Serum laboratory markers have low utility in most patients, however, key items that may be useful are:
Benzodiazepines are the first-line treatment for status epilepticus as they have rapid onset and good outcomes for initial control of seizures. Lorazepam and diazepam are the preferred initial benzodiazepines in the pediatric population.
Midazolam also is effective at stopping seizures; however, it has a very short half-life. If IV access cannot be obtained that it may be given through an intramuscular, intranasal, oral, buccal, or rectal route.
The literature on second line medications for status epilepticus is less conclusive and controversial. Fosphenytoin is a commonly used medication in this instance and has a good safety profile. Levetiracetam has become more commonly used however there is less data about its efficacy. Some experts believe that Fosphenytoin, Levetiracetam and Valproic acid can all safely be used in this case.
In very young patients, phenobarbitol is still the second/third line medication of choice.
Refractory seizures (> 30 min) usually require continuous infusion therapy. Midazolam is the most commonly used medication in children in this situation and has minimal cardiovascular side effects.