Acute seizure and status epilepticus management (< 18 years) - Curbside
Acute seizure and status epilepticus management (< 18 years)
Editors: Dan Imler, MD
Inclusion Criteria  (Any one criteria present)
  • Ongoing seizure activity
Exclusion Criteria
  • Non-epileptic movements

Consider neurology consultation

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Evidence
Total Notes: 6
Evidence

1 Risk for status epilepticus

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:

  • < 1 year at onset of seizures
  • History of status epilepticus in the past
  • Symptomatic etiology of their epilepsy


References:
  1. Incidence, cause, and short-term outcome of convulsive status epilepticus in childhood: prospective population-based study.
    Chin RF, Neville BG, Peckham C, Bedford H, Wade A, Scott RC, Scott RC,
    Lancet 2006 Jul;368(9531):222-9.
  2. The epidemiology of convulsive status epilepticus in children: a critical review.
    Raspall-Chaure M, Chin RF, Neville BG, Bedford H, Scott RC,
    Epilepsia 2007 Sep;48(9):1652-63.
  3. The risk of seizure recurrence after a first unprovoked afebrile seizure in childhood: an extended follow-up.
    Shinnar S, Berg AT, Moshe SL, O'Dell C, Alemany M, Newstein D, Kang H, Goldensohn ES, Hauser WA,
    Pediatrics 1996 Aug;98(2 Pt 1):216-25.
  4. The association between seizure clustering and convulsive status epilepticus in patients with intractable complex partial seizures.
    Haut SR, Shinnar S, Moshé SL, O'Dell C, Legatt AD,
    Epilepsia 1999 Dec;40(12):1832-4.
  5. Risk factors for status epilepticus in children with symptomatic epilepsy.
    Novak G, Maytal J, Alshansky A, Ascher C,
    Neurology 1997 Aug;49(2):533-7.
  6. Status epilepticus in children with newly diagnosed epilepsy.
    Berg AT, Shinnar S, Levy SR, Testa FM,
    Ann. Neurol. 1999 May;45(5):618-23.
  7. Status epilepticus after the initial diagnosis of epilepsy in children.
    Berg AT, Shinnar S, Testa FM, Levy SR, Frobish D, Smith SN, Beckerman B,
    Neurology 2004 Sep;63(6):1027-34.

2 Status Epilepticus

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:

  • A condition resulting from either the failure of the mechanisms responsible for seizure termination or from the initiation of mechanisms which lead to abnormally prolonged seizures (after time point t1 - 5 min); and
  • A condition that can have long-term consequences (after time point t2 - 30 min), including neuronal death, neuronal injury, and alteration of neuronal networks, depending on the type and duration of seizures

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.



References:
  1. Guidelines for epidemiologic studies on epilepsy. Commission on Epidemiology and Prognosis, International League Against Epilepsy.

    Epilepsia;34(4):592-6.
  2. A definition and classification of status epilepticus--Report of the ILAE Task Force on Classification of Status Epilepticus.
    Trinka E, Cock H, Hesdorffer D, Rossetti AO, Scheffer IE, Shinnar S, Shorvon S, Lowenstein DH,
    Epilepsia 2015 Oct;56(10):1515-23.
  3. How long do new-onset seizures in children last?
    Shinnar S, Berg AT, Moshe SL, Shinnar R,
    Ann. Neurol. 2001 May;49(5):659-64.

3 Inital evaluation

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:

  • Anti-epileptic drug levels in patients on medications (subtheraputic in 1/3 of patients)
  • Toxic metabolites in patients who are suspected of intoxication
  • Blood glucose and electrolyte levels


References:
  1. Practice parameter: diagnostic assessment of the child with status epilepticus (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society.
    Riviello JJ, Ashwal S, Hirtz D, Glauser T, Ballaban-Gil K, Kelley K, Morton LD, Phillips S, Sloan E, Shinnar S, Shinnar S, Shinnar S,
    Neurology 2006 Nov;67(9):1542-50.

4 First-line seizure treatment

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.



References:
  1. Status epilepticus.
    Hanhan UA, Fiallos MR, Orlowski JP,
    Pediatr. Clin. North Am. 2001 Jun;48(3):683-94.
  2. Guidelines for the evaluation and management of status epilepticus.
    Brophy GM, Bell R, Claassen J, Alldredge B, Bleck TP, Glauser T, Laroche SM, Riviello JJ, Shutter L, Sperling MR, Treiman DM, Vespa PM, Vespa PM,
    Neurocrit Care 2012 Aug;17(1):3-23.
  3. Lorazepam vs diazepam for pediatric status epilepticus: a randomized clinical trial.
    Chamberlain JM, Okada P, Holsti M, Mahajan P, Brown KM, Vance C, Gonzalez V, Lichenstein R, Stanley R, Brousseau DC, Grubenhoff J, Zemek R, Johnson DW, Clemons TE, Baren J, Baren J,
    JAMA;311(16):1652-60.
  4. Drug management for acute tonic-clonic convulsions including convulsive status epilepticus in children.
    Appleton R, Macleod S, Martland T,
    Cochrane Database Syst Rev 2008 Jul(3):CD001905.
  5. Lorazepam versus diazepam in the acute treatment of epileptic seizures and status epilepticus.
    Appleton R, Sweeney A, Choonara I, Robson J, Molyneux E,
    Dev Med Child Neurol 1995 Aug;37(8):682-8.
  6. The influence of diazepam or lorazepam on the frequency of endotracheal intubation in childhood status epilepticus.
    Chiulli DA, Terndrup TE, Kanter RK,
    J Emerg Med;9(1-2):13-7.
  7. Comparative audit of intravenous lorazepam and diazepam in the emergency treatment of convulsive status epilepticus in children.
    Qureshi A, Wassmer E, Davies P, Berry K, Whitehouse WP,
    Seizure 2002 Apr;11(3):141-4.

5 Second-line medications

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.



References:
  1. Evidence-Based Guideline: Treatment of Convulsive Status Epilepticus in Children and Adults: Report of the Guideline Committee of the American Epilepsy Society.
    Glauser T, Shinnar S, Gloss D, Alldredge B, Arya R, Bainbridge J, Bare M, Bleck T, Dodson WE, Garrity L, Jagoda A, Lowenstein D, Pellock J, Riviello J, Sloan E, Treiman DM,
    Epilepsy Curr;16(1):48-61.
  2. Intravenous valproate in pediatric epilepsy patients with refractory status epilepticus.
    Uberall MA, Trollmann R, Wunsiedler U, Wenzel D,
    Neurology 2000 Jun;54(11):2188-9.
  3. Treatment of refractory status epilepticus: literature review and a proposed protocol.
    Abend NS, Dlugos DJ,
    Pediatr. Neurol. 2008 Jun;38(6):377-90.
  4. Levetiracetam in children with refractory status epilepticus.
    Gallentine WB, Hunnicutt AS, Husain AM,
    Epilepsy Behav 2009 Jan;14(1):215-8.
  5. Effectiveness of intravenous levetiracetam as an adjunctive treatment in pediatric refractory status epilepticus.
    Kim JS, Lee JH, Ryu HW, Lim BC, Hwang H, Chae JH, Choi J, Kim KJ, Hwang YS, Kim H,
    Pediatr Emerg Care 2014 Aug;30(8):525-8.
  6. Guidelines for the evaluation and management of status epilepticus.
    Brophy GM, Bell R, Claassen J, Alldredge B, Bleck TP, Glauser T, Laroche SM, Riviello JJ, Shutter L, Sperling MR, Treiman DM, Vespa PM, Vespa PM,
    Neurocrit Care 2012 Aug;17(1):3-23.

6 Refractory seizures

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.



References:
  1. Refractory Status Epilepticus in Children: Intention to Treat With Continuous Infusions of Midazolam and Pentobarbital.
    Tasker RC, Goodkin HP, Sánchez Fernández I, Chapman KE, Abend NS, Arya R, Brenton JN, Carpenter JL, Gaillard WD, Glauser TA, Goldstein J, Helseth AR, Jackson MC, Kapur K, Mikati MA, Peariso K, Wainwright MS, Wilfong AA, Williams K, Loddenkemper T, Loddenkemper T,
    Pediatr Crit Care Med 2016 Oct;17(10):968-975.
  2. Guidelines for the evaluation and management of status epilepticus.
    Brophy GM, Bell R, Claassen J, Alldredge B, Bleck TP, Glauser T, Laroche SM, Riviello JJ, Shutter L, Sperling MR, Treiman DM, Vespa PM, Vespa PM,
    Neurocrit Care 2012 Aug;17(1):3-23.
  3. Midazolam in the treatment of status epilepticus in children.
    Rivera R, Segnini M, Baltodano A, Pérez V,
    Crit. Care Med. 1993 Jul;21(7):991-4.
  4. Midazolam coma for refractory status epilepticus in children.
    Igartua J, Silver P, Maytal J, Sagy M,
    Crit. Care Med. 1999 Sep;27(9):1982-5.
  5. Use of midazolam in the treatment of refractory status epilepticus.
    Hanley DF, Kross JF,
    Clin Ther;20(6):1093-105.
  6. Midazolam as a first-line agent for status epilepticus in children.
    Yoshikawa H, Yamazaki S, Abe T, Oda Y,
    Brain Dev. 2000 Jun;22(4):239-42.
  7. Intravenous midazolam in convulsive status epilepticus in children with pharmacoresistant epilepsy.
    Papavasiliou AS, Kotsalis C, Paraskevoulakos E, Karagounis P, Rizou C, Bazigou H,
    Epilepsy Behav 2009 Apr;14(4):661-4.