Status Epilepticus




DEFINITION



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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







BACKGROUND AND EPIDEMIOLOGY



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  • 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






CAUSES OF SE



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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






KEY PRINCIPLES OF SE MANAGEMENT



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  • 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





TREATMENT



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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.


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Jan 14, 2019 | Posted by in PEDIATRICS | Comments Off on Status Epilepticus
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