status epilepticus in children toni petrillo

Status Epilepticus in Children

Toni Petrillo

Pediatric Critical Care

Children’s Healthcare of Atlanta

Status epilepticus 2

Status epilepticus (SE) presents in a multitude of forms, dependent on etiology and patient age (myoclonic, tonic, subtle, tonic-clonic, absence, complex partial etc.)

Generalized, tonic-clonic SE is the most common form of SE

Status epilepticus 3

Definition Conventional definition:

Single seizure > 30 minutes

Series of seizures > 30 minutes without full recovery

Status epilepticus 4

Definition

“If appropriate therapy is delayed, SE can cause permanent neurologic sequelae or death …”

thus

“ … any child who presents actively convulsing should be assumed to have SE.”

Haafiz A. Pediatr Emerg Care 1999;15(2):119-29

Status epilepticus 5

The longer SE persists,the lower is the likelihood of spontaneous cessationthe harder is it to controlthe higher is the risk of morbidity and mortality

Treatment for most seizures needs to be instituted after > 5 minutes of seizure activity

Bleck TP. Epilepsia 1999;40(1):S64-6

Status epilepticus 6

Causes Fever Medication change Unknown Metabolic Congenital Anoxic Other (trauma, vascular,

infection, tumor, drugs)

36%

20%

9%

8%

7%

5%

15%

DeLorenzo RJ. Epilepsia 1992;33 Suppl 4:S15-25

Status epilepticus 7

Drugs which can cause seizures Antibiotics

Penicillins Isoniazid Metronidazole

Anesthetics, narcotics Halothane, enflurane Cocaine, fentanyl Ketamine

Psychopharmaceuticals Antihistamines Antidepressants Antipsychotics Phencyclidine Tricyclic antidepressants

Status epilepticus 8

Mortality

Adults Children

15 to 22%

3 to 15%

Reviewed in: Fountain NB. Epilepsia 2000;41 Suppl 2:S23-30Reviewed in: Fountain NB. Epilepsia 2000;41 Suppl 2:S23-30

Status epilepticus 9

Prolonged seizures

Duration of seizureDuration of seizure

Life Life threateningthreatening

systemicsystemicchangeschanges

DeathDeathTemporaryTemporary

systemicsystemicchangeschanges

Status epilepticus 10

Respiratory Hypoxia and hypercarbia

- ventilation (chest rigidity from muscle spasm)- Hypermetabolism ( O2 consumption, CO2

production)- Poor handling of secretions- Neurogenic pulmonary edema?

Status epilepticus 11

Hypoxia Hypoxia/anoxia markedly increase (triple?) the

risk of mortality in SE Seizures (without hypoxia) are much less

dangerous than seizures and hypoxia

Towne AR. Epilepsia 1994;35(1):27-34

Status epilepticus 12

Neurogenic pulmonary edema

Rare complication Likely occurs as consequence of marked increase of pulmonary vascular pressure

Johnston SC. Postictal pulmonary edema requires pulmonary vascular pressure increases. Epilepsia 1996;37(5):428-32Johnston SC. Postictal pulmonary edema requires pulmonary vascular pressure increases. Epilepsia 1996;37(5):428-32

Status epilepticus 13

Acidosis Respiratory Lactic

Impaired tissue oxygenation Increased energy expenditure

Status epilepticus 14

Hemodynamics

Sympathetic overdrive Massive catecholamine /

autonomic discharge Hypertension Tachycardia High CVP

Exhaustion Hypotension Hypoperfusion

Exhaustion Hypotension Hypoperfusion

0 min0 min 60 min60 min

Status epilepticus 15

Cerebral blood flow - Cerebral O2 requirement

Blood pressure

Blood flow

O2 requirement

Seizure duration

Hyperdynamic phase CBF meets CMRO2

Exhaustion phase CBF drops as

hypotension sets in Autoregulation

exhausted Neuronal damage

ensues

Hyperdynamic phase CBF meets CMRO2

Exhaustion phase CBF drops as

hypotension sets in Autoregulation

exhausted Neuronal damage

ensues

Status epilepticus 16

GlucoseG

luco

se

Seizure duration

30 min

SE

SE + hypoxia

Hyperdynamic phase Hyperglycemia

Exhaustion phase Hypoglycemia

develops Hypoglycemia

appears earlier in presence of hypoxia

Neuronal damage ensues

Hyperdynamic phase Hyperglycemia

Exhaustion phase Hypoglycemia

develops Hypoglycemia

appears earlier in presence of hypoxia

Neuronal damage ensues

Status epilepticus 17

Hyperpyrexia Hyperpyrexia may develop during protracted SE,

and aggravate possible mismatch of cerebral metabolic requirement and substrate delivery

Treat hyperpyrexia aggressively Antipyretics, external cooling Consider intubation, relaxation, ventilation

Status epilepticus 18

Other alterations Blood leukocytosis (50% of children) Spinal fluid leukocytosis (15% of children) K+

creatine kinase Myoglobinuria

Status epilepticus 19

Oxygen, oral airway. Avoid hypoxia!

Consider bag-valve mask ventilation. Consider intubation

IV/IO access. Treat hypotension, but NOT hypertension

AA

BB

CC

Status epilepticus 20

Treatment Arterial blood gas?

All children in SE have acidosis. It often resolves rapidly with termination of SE

Intubate? It may be difficult to intubate the actively seizing child Stop or slow seizures first, give O2, consider BVM

ventilation If using paralytic agent to intubate, assume that SE

continues

Status epilepticus 21

Initial investigations

Labs Na, Ca, Mg, PO4 , glucose CBC Liver function tests, ammonia Anticonvulsant level Toxicology

Status epilepticus 22

Initial investigations Lumbar puncture

Always defer LP in unstable patient, but never delay antibiotic/antiviral rx if indicated

CT scan Indicated for focal seizures or deficit, history of trauma

or bleeding d/o

Status epilepticus 23

Treatment Give glucose (2-4 ml/kg D25%, infants 5 ml/kg D10%),

unless normo- or hyperglycemic

Hyperglycemia has no negative effect in SE (as long as significant hyperosmolality is being avoided)

Status epilepticus 24

Treatment Hyponatremia:

Give 5 cc/kg of 3% (hypertonic saline)

Hypocalcemia: Give 20-25 mg/kg of Calcium Chloride

Status epilepticus 25

Treatment The longer you wait with anticonvulsant, the more

anticonvulsant you will need to stop SE Most common mistake is ineffective dose

Status epilepticus 26

Anticonvulsants Rapid acting

plus

Long acting

Status epilepticus 27

Anticonvulsants - Rapid acting Benzodiazepines

Lorazepam 0.1 mg/kg i.v. over 1-2 minutes Diazepam 0.2 mg/kg i.v. over 1-2 minutes

If SE persists, repeat every 5-10 minutes

Status epilepticus 28

Benzodiazepines

Diazepam High lipid solubility Thus very rapid onset Redistributes rapidly Thus rapid loss of

anticonvulsant effect Adverse effects are

persistent: Hypotension Respir depression

Lorazepam Low lipid solubility Action delayed 2 minutes Anticonvulsant effect 6-12 hrs Less respiratory depression than

diazepam

Midazolam May be given i.m.

Status epilepticus 29

Anticonvulsants - Long acting Phenytoin

20 mg/kg i.v. over 20 min

pH 12

Extravasation causes severe tissue injury

Onset 10-30 min May cause hypotension,

dysrhythmia Cheap

Fosphenytoin 20 mg PE/kg i.v. over 5-7

min PE = phenytoin equivalent

pH 8.6

Extravasation well tolerated Onset 5-10 min May cause hypotension

Expensive

Status epilepticus 30

Anticonvulsants - Long acting Phenobarbital

20 mg/k g i.v. over 10 - 15 min Onset 15-30 min May cause hypotension, respiratory depression

Status epilepticus 31

Initial choice of long acting anticonvulsants in SE

Is patient an infant?Is patient already receiving phenytoin?

Is patient an infant?Is patient already receiving phenytoin?

YesNo

At high risk for extravasation ?(small vein, difficult access etc.)?

Phenobarbital

YesYesNoNo

Phenytoin Fosphenytoin

Status epilepticus 32

If SE persists

Midazolam infusion 1 - 10 mcg/kg/min after bolus 0.15 mg/kg

Pentobarbital infusion 1-3 mg/kg/hr after bolus 10 mg/kg

Status epilepticus 33

Non - convulsive status epilepticus

How do you tell that patient’s seizures have stopped?

Status epilepticus 34

Non - convulsive SE ? Neurologic signs after termination of SE are

common: Pupillary changes Abnormal tone Babinski Posturing Clonus May be asymmetrical

Status epilepticus 35

Non - convulsive SE ?

Up to 20% of children with SE have non - convulsive SE after tonic - clonic SE

Status epilepticus 36

Non - convulsive SE ?

If child does not begin to respond to painful stimuli within 20 - 30 minutes after tonic - clonic SE, suspect non - convulsive SE Urgent EEG

Status epilepticus 37

References Haafiz A, Kissoon N. Status epilepticus: current concepts. Pediatr Emerg

Care 1999;15(2):119-29. Bleck TP. Management approaches to prolonged seizures and status

epilepticus. Epilepsia 1999;40(1):S64-6. Orlowski JP, Rothner DA. Diagnosis and treatment of status epilepticus. In:

Fuhrman BP, Zimmerman JJ, editors. Pediatric Critical Care. St. Louis: Mosby; 1998. p. 625-35.