Status Epilepticus on the Pediatric Ward,
by Nadeen Abujaber.
Hi.
I'm Nadeen Abujaber.
I'm a pediatric hospitalist at Boston Children's.
Today we're going to learn about recognizing and managing
status epilepticus on the pediatric floor.
So our case.
We have a patient.
He is a two-year-old with a history
of hypoxic-ischemic encephalopathy
with subsequent developmental delay
and a metabolic disorder resulting in hypoglycemia
with fasting or illness.
And for this, he gets continuous feeds via an NG tube.
He's admitted to your service for G tube placement
in the morning.
You're called by the nurse with complaints
that he's tachycardic and demonstrating
abnormal movements.
So with this call, what should you be thinking about now?
What's your differential diagnosis?
Seizure, pain, infection, abnormal electrolytes,
medication effect, and endocrinopathy.
What are the most important questions
to ask the nurse over the phone before even seeing the patient?
One, you have to make sure that the patient is stable.
And two, what are the length of time of his symptoms?
Once you're in the room, what do you do?
First thing, make sure the patient is on CVR and oxygen
sat monitor.
Your vitals on seeing the patient, temperature,
37 degrees Celsius.
A heart rate of 180.
Blood pressure, 110 over 70.
Respiratory rate 30.
O2 sat 86% on room air.
A focused physical examination shows that the patient is not
responsive to voice.
He's sweaty, his eyes are deviated
to the right bilaterally, he's drooling,
he's tachycardic but without any irregular rhythms.
He has good aeration and good respiratory effort.
His capillary refill is less than two seconds
and he has good radial and dorsalis pedis pulses
bilaterally.
And looking at him, he has tonic-clonic jerks of the body
and extremities.
So based on the vital signs and the physical exam,
what would be red flags on your initial examination?
If you see apnea, persistent hypoxia
despite oxygen delivery, or hypotension.
Now, based on your initial evaluation, what do
you think this most likely is?
Given the eye deviation, the poor response to stimuli,
and the tonic-clonic activity of his body and extremities,
this is most likely a seizure.
What are the typical ways that seizure presents?
You can see a change in vital signs,
which includes tachycardia, tachypnea or apnea,
or desaturations.
There can also be abnormal rhythmic movements, as well as
a change in mental status.
So what are your initial steps and management?
Always, your first priority is airway, breathing,
and circulation.
In this case, he has a patent airway
but is hypoxic, so he needs supplemental oxygen via a mask.
He has normal blood pressures, good perfusion,
and good pulses.
After that's been stabilized, you need to assess,
does he have IV access?
So in this case, he has a peripheral IV
in his right upper extremity.
If he did not have an IV, there are other routes,
including he has an NG tube, which can be used temporarily
until IV access is obtained.
And we often use rectal delivery of medication.
But keep in mind, because of rapid redistribution
this can increase the rate of seizure recurrence.
So now, what additional history should we
collect to better understand why he's had a seizure?
So ask about past history of seizures and management
parameters if he has a seizure history.
In this case, he has no seizure history.
Does he have fever or other infectious symptoms?
Because this can lower the seizure threshold.
In this case, negative symptoms for an infection.
Has the patient been started on any new medications
or has he missed any medications?
This is especially relevant for someone with a seizure history
and who is on anti-epileptic medications.
Also, think about if a patient is
on benzodiazepines or baclofen and is
going through withdrawal.
In this case, there were no new medications
or missed medications.
Has the patient had any vomiting, diarrhea,
discontinuation of feeds?
This helps assess for abnormal electrolytes, especially sodium
and glucose.
In this case, the nurse realizes he's
been discontinued from his feeds in preparation for being NPO,
but hasn't gotten his IV fluids yet.
So, based on your examination and the history,
what laboratory data and/or imaging should you consider?
So in this case, a D-stick, given
his history of hypoglycemia when off
feeds, and his feeds were unknowingly disconnected.
Otherwise, you should consider CBC and blood culture
if he's had an infection, a chemistry if there's
a concern for low sodium or low glucose, AED levels
if he has a seizure history.
Imaging is typically not done unless there
is a concern for head trauma or increased ICP.
And in that case, you would obtain a head CT.
But always make sure your patient
has been stabilized prior to imaging.
So what do we do next?
You're at the bedside.
The vitals are as follows.
Temperature, 38 degrees Celsius.
Heart rate, 175.
Blood pressure, 100/65.
Respiratory rate, 30.
O2 sat, 98% on 5-liter face mask.
He continues with the tonic-clonic movements and eye
deviation.
It has been five minutes.
The nurse checks a D-stick and it's 25.
The next step you should take, administer a dextrose bolus.
The recommended doses are 0.5 to 1 gram per kilo IV.
If you're giving D25, you give 2 to 4 mL per kilo.
If you're giving D10, the recommended dose
is 5 to 10 mL per kilo.
Now, he's continuing despite the dextrose bolus
with seizure activity.
If a patient has been seizing for five minutes,
you administer Ativan 0.1 milligram per kilo IV or IM,
max dose of 4 milligrams.
If there is no IV access, you can also give Diastat rectally
0.5 milligrams per kilo.
If the seizure persists for 5 to 15 minutes,
then you want to repeat the Ativan, the same dose of 0.1
milligram per kilo IV, plus Fosphenytoin 20 milligrams
PE per kilo.
If the seizure persists for 15 to 20 minutes,
then you give phenobarbital 20 milligrams per kilo IV.
And if the seizure persists for 20 to 30 minutes,
then you give Fosphenytoin 10 milligrams PE per kilo.
These are some special notes.
If the patient has a past history of seizures,
always know the seizure medication plan.
If the patient, for example, is already on Keppra,
we often will give a bolus of Keppra rather than Ativan.
Another note is, when do we consult neurology?
I think we can consult neurology as early as warranted,
but definitely if no response to medications
by 10 to 15 minutes.
Special considerations when managing seizures.
So we already addressed hypoglycemia with this patient,
but another special situation that can precipitate seizures
is hyponatremia.
And in that case, you want to give hypertonic sodium chloride
3% solution 2 to 4 mL per kilo IV in a slow push
until the seizure stops.
Then you give the remaining over 30 to 60 minutes.
And it's always important to think in the back of your mind,
when do we involve the ICU?
So definitely thinking about involving the ICU
if the patient is hemodynamically unstable, has
apnea and needing to support his respirations, if he's
having a poor response to medications
or persistent seizures, or we're needing to escalate care,
giving Fosphenytoin, for example.
So to conclude this case, the patient
received a D25 bolus and one dose of IV Ativan.
His tonic clonic movements stopped
and his vital signs normalized.
He was fatigued after this episode and slept.
His feeds were restarted and his blood glucose
were trended to ensure improvement.
And this is the conclusion of this video.
Thank you for watching.
I hope you learned about management of status
epilepticus on the floor.
Thank you.
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