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

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  May be convulsive (with motor features) or nonconvulsive (electrographic seizures only)

  
  
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  SE progresses in phases

  
  
  
  
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    Early SE (5–30 minutes), established SE (>30 minutes), and refractory SE

    
    
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    Refractory status epilepticus

    
    
    
    
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      Clinical or electrographic seizures that persist after an adequate dose of an initial benzodiazepine and a second appropriate antiseizure medication

      
      
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      Associated with poor outcome, with mortality up to 30%, related to young age, etiology, and multifocal or generalized EEG abnormalities

    
    

  
  

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  Epidemiology and morbidity of SE

  
  
  
  
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    Incidence of first-time SE is approximately 18 to 23 per 100,000 children per year²

    
    
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    Fifty percent of children with new-onset convulsive SE are neurologically healthy

    
    
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    One-year recurrence risk is 16% with 3% mortality, which is lower than adults

    
    
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    Risk for mortality and long-term morbidity related to primary cause of the seizure

  
  
  
  
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  Factors associated with increased morbidity in SE

  
  
  
  
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    Time to the first dose of benzodiazepine in children with SE is often delayed or the drug not given until arrival at a hospital³

    
    
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    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.

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  Other common causes in order of frequency include

  
  
  
  
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    Acute new neurologic injury

    
    
    
    
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      Central nervous system (CNS) infection; cardiac arrest, stroke; traumatic brain injury; drug or toxin

    
    
    
    
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    Acute exacerbation of underlying epilepsy

    
    
    
    
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      Missed anticonvulsant or subtherapeutic levels

      
      
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      Intercurrent illness

    
    
    
    
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    Progressive neurologic disorder

  
  

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  After 5 to 10 minutes, most seizures will not stop unless treated with an anticonvulsant

  
  
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  Early, sequential administration of adequate doses of anticonvulsants is essential⁵

  
  
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  Treatment should be given in the field prior to arrival in the ICU

  
  
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  Identify and treat precipitating cause

  
  
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  Manage systemic complications

  
  
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  All units should have a management pathway and agreed on time frame for treatment⁶

Incipient SE 0 to 5 minutes of seizure onset

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  Stabilize airway, breathing, and circulation

  
  
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  Obtain fingerstick glucose in first-line labs

  
  
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  Obtain IV access and administer IV benzodiazepine if seizure lasts 5 minutes

  
  
  
  
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    If IV access is not possible, administer benzodiazepine via intramuscular, intranasal, rectal, or buccal route (see Table 42-1)

    
    
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    Do not delay treatment in order to obtain IV access

  
  

Early (5–30 min) and established (>30 min) SE (Figure 42-1)