REBEL Core Cast 9.0 – Pediatric Status Epilepticus

Posted by Marco Torres on Apr 17, 2019

Pediatric Status Epilepticus Shownotes

Definition: Seizure that has been going on for >5 minutes OR recurrent seizures without return to baseline. If the patient was seizing at home and still seizing when they get to the ED, consider it to be status.

REBEL Core Cast 9.0 – Pediatric Status Epilepticus

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Seizing Patient Algorithm:

A pediatric patient who is seizing is brought into your ED…what do you do next?

First:

A-B-C-D-E / Oxygen / Cardiac + O2 Monitor
IV Access / Fingerstick Glucose
Brief H&P from Parents / EMS
Labs to get: CBC; CMP; Mag; Phos; +Beta HCG when appropriate; Anti epileptic drug (AED) levels

Medications:

1st line:

If unable to obtain IV access, IM / Buccal / PR / IO are additional routes. Draw up two doses and have them ready to go.
IV/IO/IM Route
- Lorazepam 0.1mg/kg – max dose 4 mg
- Diazepam 0.3 mg/kg – max dose 20 mg
- Midazolam 0.2 mg/kg – max dose 10 mg

PR Route
- Diazepam 0.5 mg/kg – max dose 20 mg
Buccal Route
- Midazolam 0.3mg/kg – max dose 10mg ( Use IV formulation, open lower lip and place med then rub into cheek for absorption)

2nd line:

Levetiracetam IV 50mg/kg – max dose 2500mg
Phenytoin IV 25mg/kg

Next step:

If the patient is given the above medications and is continuing to seize, they will require sedation and intubation. Pediatric patients are better able to tolerate the acidemia from seizing so waiting a little longer for the medication to take effect may be ok.

Most ED docs are comfortable intubating with propofol and it is ok to use. There is some controversy in prolonged propofol infusion. There are reports that prolonged propofol use >48 hours has led to fatal acidosis in pediatric patients but it’s incidence is very rare.

Monitor closely post intubation, also get that EEG!

Take home points:

Remember you have the CHOP pediatric status guidelines at your fingertips online. You can offload some thinking in a stressful pinch by having these handy. We will link to them for you in the show notes
Your first two medications should be benzos. If you can’t get IV access within 5 minutes, consider buccal midazolam. You use the IV midazolam formulation, in the cheek of the child, at a dose of 0.3 mg/kg with a max dose of 10mg
If the child continues to seize, an additional medication should be added at 5 minute increments. As you give one medication, be prepping the next so there is no delay once you decide it is needed.
While there are differences of opinion on the proper procedure for intubation and sedation in the child with persistent status, the most important thing ultimately is to get the seizure to stop. Propofol is usually readily available and most ED docs are comfortable with it. It’s ok to use that, knowing that your peds colleagues may switch it out once they take control of the patient.

References / Links:

Children’s Hospital of Philadelphia: Status Epilepticus Clinical Pathway
EM Cases : Pediatric Seizures
EM Docs: Seizures in the First Year of Life