Status epilepticus (SE) is defined as 5 minutes or more of (1) continuous clinical and/or electrographic seizure activity or (2) recurrent seizure activity without recovery (returning to baseline) between seizures.1
May be convulsive (with motor features) or nonconvulsive (electrographic seizures only)
SE progresses in phases
Early SE (5–30 minutes), established SE (>30 minutes), and refractory SE
Refractory status epilepticus
Clinical or electrographic seizures that persist after an adequate dose of an initial benzodiazepine and a second appropriate antiseizure medication
Associated with poor outcome, with mortality up to 30%, related to young age, etiology, and multifocal or generalized EEG abnormalities
Epidemiology and morbidity of SE
Incidence of first-time SE is approximately 18 to 23 per 100,000 children per year2
Fifty percent of children with new-onset convulsive SE are neurologically healthy
One-year recurrence risk is 16% with 3% mortality, which is lower than adults
Risk for mortality and long-term morbidity related to primary cause of the seizure
Factors associated with increased morbidity in SE
Time to the first dose of benzodiazepine in children with SE is often delayed or the drug not given until arrival at a hospital3
Delay in administration of the first anticonvulsant is associated with longer SE duration4
Prolonged febrile seizures and seizure due to remote neurologic injury account for 50% of SE cases in children.
Other common causes in order of frequency include
Acute new neurologic injury
Central nervous system (CNS) infection; cardiac arrest, stroke; traumatic brain injury; drug or toxin
Acute exacerbation of underlying epilepsy
Missed anticonvulsant or subtherapeutic levels
Intercurrent illness
Progressive neurologic disorder
After 5 to 10 minutes, most seizures will not stop unless treated with an anticonvulsant
Early, sequential administration of adequate doses of anticonvulsants is essential5
Treatment should be given in the field prior to arrival in the ICU
Identify and treat precipitating cause
Manage systemic complications
All units should have a management pathway and agreed on time frame for treatment6
Incipient SE 0 to 5 minutes of seizure onset
Stabilize airway, breathing, and circulation
Obtain fingerstick glucose in first-line labs
Obtain IV access and administer IV benzodiazepine if seizure lasts 5 minutes
If IV access is not possible, administer benzodiazepine via intramuscular, intranasal, rectal, or buccal route (see Table 42-1)
Do not delay treatment in order to obtain IV access
Early (5–30 min) and established (>30 min) SE (Figure 42-1)
FIGURE 42-1
Summary of approach to management of pediatric status epilepticus and refractory status epilepticus.