Management of Pediatric Status Epilepticus in Resource-Limited Settings
This video is intended for healthcare providers in limited resource settings and aims to inform
the clinical management of status epilepticus in all children outside the neonatal period.
The learning objectives of this video include reviewing the definition of status epilepticus
and illustrating common clinical scenarios where you may encounter it, reviewing the medical
management of status epilepticus with a focus on medications available in limited resource settings.
Traditionally, brief seizures are defined as lasting less than 5 minutes, while
prolonged seizures last between 5 and 30 minutes. Status epilepticus has classically been defined
as more than 30 minutes of either continuous seizure activity or two or more sequential
seizures within 30 minutes without full recovery of consciousness between seizures.
However, the operational definition of status epilepticus is a seizure lasting more than 5 minutes
and this is the point at which we typically start administering medications.
Clinically, this means that if a patient arrives to your emergency room or clinic actively seizing,
you should assume the patient is in status epilepticus and start treatment with a seizure
rescue medication as soon as possible. If you observe the start of the seizure, you should
begin timing so you know the right time to start administering medications. It is important
to treat early for multiple reasons. First, the risk of cardiopulmonary complications
increases if the seizure goes on for a long time. Second a seizure lasting longer than
5 minutes is less likely to resolve on its own. And thirdly, as the time passes, the
medications used to stop the seizures, particularly benzodiazepines, are less effective.
Status epilepticus can present with different seizure types. Most commonly, you will see generalized
convulsive status epilepticus which can be described as a rhythmic pattern of contraction
and extension of the arms and legs, occurring while the patient is unresponsive. This can
occur in patients with known epilepsy, young children with prolonged febrile seizures, or
in patients with infection, such as cerebral malaria or meningitis. Non-convulsive status
epilepticus is another type of status epilepticus that can be hard to identify clinically.
This occurs when seizures are ongoing in a comatose patient without obvious clinical changes, like
motor movements. Sometimes, there are subtle signs such as eye blinking and face twitching,
but most of the time there are no overt signs. Focal status epilepticus, where only one part
of the body is affected, should be treated at five minutes if there is impaired consciousness
or at 10 minutes if consciousness is preserved. At the onset of seizure, start timing, while
you assess the airway, breathing, and circulation of the patient. Administer oxygen, if available.
Place the child on his or her side, loosen clothing, and do not place anything in the
mouth. Place the patient on a monitor, if available, or obtain vital signs regularly. Start obtaining
intravenous access. Obtain a finger stick blood glucose, as this is a reversible cause of seizure.
But if glucometer is not readily available, you should not wait to give a bolus of 10
percent dextrose IV at the dose of 2-5 milliliters per kilogram. You should then
consider starting a maintenance normal saline. Remember that both seizures and the medications
we use to stop seizures can cause respiratory depression. You should reassess the patient's
airway and breathing frequently and be prepared to provide respiratory support as needed.
We will now walk you through the medications we use to stop status epilepticus and when
to administer them. Our emphasis is on giving them appropriate medications within the recommended
time frame. More details about the administration guidelines will be given on the screen and
available on the algorithm PDF paired with this video. Remember, this is a neurologic emergency.
The longer the seizure goes on, the higher the risk for brain injury. Make sure you and
your team are working together and are prepared for the next step to ensure medications can
be administered quickly, if needed. The first rescue medication administered should be a
benzodiazepine, preferably by an intravenous route. At 5 minutes of continuous seizure
activity, you should first give diazepam IV at the dose of 0.3 milligrams per kilogram
with a maximum dose of 10 milligrams.
If the patient does not have IV access at this point, you can administer diazepam rectally.
But please note the different dose of 0.5 milligrams per kilogram of a maximum of 20 milligrams.
If the seizure continues for 5 minutes since the first dose of diazepam, you should
administer a second dose of diazepam at the same dosing, either intravenous or rectally,
depending on the available access. If another 5 minutes passes and the patient is still
seizing after two doses of diazepam, it is time to try a different type of medication.
Depending on availability and access, your next options are phenetoin or phenobarbital.
Loading dose of phenetoin is 20 milligrams per kilogram IV with a maximum dose of 1 gram.
Be careful infusion can rarely cause bradycardia and hypotension so the patient's
heart rate and blood pressure should be monitored closely. If seizure activity continues for
another 15 minutes, you can give a second dose of phenytoin at 10 milligrams per kilogram,
maximum 500 milligrams. If the seizure persists for another 15 minutes, reassess their respiratory
status and the next medication to administer would be phenobarbital either IV or IM at
the dose of 20 milligrams per kilogram, maximum dose of 1 gram. Now, we will go back and review
what to do if you use phenobarbital after diazepam. Phenobarbital is given at the dose
of 20 milligrams per kilogram with a maximum dose of a 1000 milligrams administered
intravenously, but can also be given intramuscularly if IV access is not available.
If the seizure persists after 15 minutes, give a loading dose of phenytoin at 20 milligrams
per kilogram IV with a maximum dose of 1 gram. Again, be careful. Infusions can rarely
cause bradycardia and hypotension, so the patient's heart rate and blood pressure should be monitored closely.
As reviewed before, you can give a second dose of phenytoin at 10 milligrams
per kilogram, maximum 500 milligrams, after 15 minutes more of continuous seizure activity.
As additional medications are used to control seizure, it is very important to continue to
monitor closely the patient's respiratory status and consider the need for a ventilator,
if available. If the convulsions continue after you've administered diazepam twice phenytoin
and phenobarbital, then the patient is in refractory status epilepticus and you should consult
a specialist to consider additional anti-epileptic agents, based on their availability. Some next
steps to consider, would be medications like sodium valproate and levetiracetam.
Medications that are available in an enteral form only can be given through a nasogastric tube. Sometimes
patients with refractory status epilepticus require a continuous infusion of benzodiazepine.
However, you should seek the guidance of a specialist when considering this treatment.
While the first priority should be stopping the seizure by using the medications just
discussed, you and your team members should also be thinking about what may have caused
this prolonged seizure and consider some of the following investigations. Laboratory testing
can help identify metabolic derangements in particular hypoglycemia and hyponatremia.
A full blood count may be suggestive of an infection. Though, you should keep in mind that the white blood
cell count may be elevated with seizure activity. A lumbar puncture, when the patient's seizure
is controlled, may be necessary to evaluate for meningitis and encephalitis. If your suspicion
for infection is high enough, you should initiate antibiotics and anti-malarial treatment.
You may also want to obtain a head CT scan if there is a history of head trauma, you suspect
stroke, or the patient remains unresponsive after clinical signs of seizure are gone.
If EEG monitoring is available, it may be helpful in determining if the patient is in non-convulsive
status epilepticus. However, even without an EEG, you should use your careful neurologic
examination to evaluate responsiveness to noxious stimuli and look for subtle signs
of non-convulsive status epilepticus, such as eye fluttering or face twitching, in an
unresponsive patient. After the resolution of status epilepticus, it is very important
to continue monitoring the patient closely. If phenytoin or phenobarbital were needed
to stop the seizure, maintenance doses of anti-seizure medicines are recommended for
the duration of the child's illness. This should be started within 12 hours after the last
rescue medication was given. More discussion about choice of anti-seizure medication for
symptomatic seizures or new epilepsy will be discussed elsewhere.
Thank you for participating in this educational video and we hope this will help you be more
prepared to take care of patients in status epilepticus.
We will now proceed to the post-test questions.