Status Epilepticus (Case 47)

Chapter 89 Status Epilepticus (Case 47)



Matthew J. Kapklein, MD, MPH




Case


A 6-year-old boy presents to your hospital’s emergency department after collapsing at school and beginning to have tonic-clonic movements. On arrival to the emergency department 30 minutes later, he is noted to be unresponsive, with rhythmic, jerking movements of all extremities. He is tachycardic and hypertensive, and his respirations are irregular.




Differential Diagnosis




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Speaking Intelligently


Although many children are able to maintain adequate oxygen saturation during status epilepticus, I always assume they are hypoventilating. Management of airway, breathing, and circulation (ABCs) comes first. The decision of when to stabilize the airway will be determined by three patient factors: (1) current status, (2) anticipated response to interventions, (3) actual response. For example, a patient who fails to respond to intravenous phenytoin, phenobarbital, and lorazepam and is receiving an infusion of midazolam before traveling to the computed tomography (CT) scanner may well require endotracheal intubation simply because of the anticipated additional respiratory depressive effects of the infusion. If you intubate, remember that a paralytic agent will eliminate your ability to monitor the neurologic examination for a period of time, so I try to avoid them or use a short-acting paralytic. Stopping the seizures themselves is largely a matter of selecting supportive therapies (i.e., different classes of antiepileptic drugs) until control is obtained. I generally start with benzodiazepines and if control is not obtained will load with a medication like phenytoin (fosphenytoin) or phenobarbital. In addition, one needs to think of and look for specific treatable causes (e.g., hyponatremia, hypoglycemia, subdural hematoma). If you are considering the possibility of a treatable infection, it is a good idea to give antibiotics early, even if you are planning a lumbar puncture (which may be delayed by clinical instability, seizures, or the need for imaging). Status epilepticus is associated with increased insensible fluid losses (excessive motor activity, hyperthermia, tachycardia, metabolic demand), so generous hydration with hemodynamic support as needed is a must.



Patient Care



Clinical Thinking



• Does this patient need a secure airway?

• The longer the patient seizes, the more dangerous it becomes to the brain. Use agents with the most rapid onset first. The rectal, intranasal, or intramuscular route may be your first choice if the patient does not yet have an IV or intraosseous (IO) line.

• Start by looking for specific diagnoses that are rapidly detectable and treatable, such as hyponatremia, hypocalcemia, hypoglycemia, hypoxemia, dysrhythmia, meningitis, some toxins, bleeds, or tumors.


History



• Does the child have an underlying seizure disorder?

• If febrile, is this a simple febrile seizure or a CNS infection? Fevers also lower seizure thresholds in children with epilepsy.

• Trauma can either be the causative agent of seizures or occur as a direct result (e.g., the child who collapses and hits her head).

• How was the child behaving before the seizure?

• Where was the child found? Did the child have access to medications or other poisons?


Physical Examination



• Vital signs: Most actively seizing children are tachycardic and hypertensive, with irregular and/or ineffective respirations.

• As always, start with the ABCs.

• Look for stigmata of an underlying neurodevelopmental disorder (e.g., microcephaly, contractures, dysmorphic features).

• Remember toxidromes: Some require specific therapies.

• Pupil examination can be helpful—unequal pupils may suggest an etiology requiring rapid surgical intervention.


Tests for Consideration



• Bedside glucose: Hypoglycemia may be a treatable cause $45

• Electrolytes: Hyponatremia, hypocalcemia, and hypomagnesemia are all treatable causes of seizures $115

• Arterial blood gas levels: Degree of acidemia may affect decision to intubate $45

• Drug levels: For those patients known to be on antiepileptic medications $60

• Lumbar puncture: Important but can wait until no longer seizing $135


Imaging Considerations


→ Head CT: To rule out mass lesions $1000


→ Electroencephalogram (EEG): To determine type of underlying seizure disorder (after it stops) or see if your patient may still be seizing without your knowledge (i.e., nonconvulsive status epilepticus) $225


→ Magnetic resonance imaging (MRI): To delineate small structural abnormalities $1800

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Jul 18, 2016 | Posted by in PEDIATRICS | Comments Off on Status Epilepticus (Case 47)

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