PCCN Clinical Practice Guideline: Status Epilepticus CONSENSUS DRAFT (July 11, 2006) Primary Author: Dr.

Sonny Dhanani Preamble Definition: on-going or recurrent clinical or sub-clinical seizure activity for more than 30 minutes Status Epilepticus is a life threatening condition where prolonged seizures >30 minutes can cause neuronal death and may result in serious neurological sequelae Applicable in children >1 month of age Treatment of seizure should start if no spontaneous resolution after 5 minutes or if evidence of cardio-respiratory compromise References Appleton R, et al. Drug management for acute tonic-clonic convulsions including convulsive status epilepticus in children. Cochrane Database Asyst Rev 2002; (4): CD001905. Bleck TP. Management approaches to prolonged seizures and status epilepticus. Epilepsia 1999; 40 (Suppl ) S59-63. Igartua J, et al. Midazolam coma for refractory status epilepticus in children. Crit Care Med 1999; 27: 1982-1985. Lowenstein DH, et al. Status epilepticus. N Engl J Med 1998; 338: 972. The Status Epilepticus Working Party. The treatment of convulsive status epilepticus in children. Arch Dis Child 2000; 83: 415-419. Walker MC. Status epilepticus in the intensive care unit. J Neurol 2003; 250(4): 401-406.

At 0 min

On presentation to hospital, initiate ABCs: A support airway B 100% oxygen, assess ventilation, SpO2 monitor C cardiorespiratory monitor, check pulses, establish IV access

History (AMPLE) Investigations glucose, electrolytes, calcium, magnesium, blood gas, medication levels, +/- toxin screen, +/- metabolic screen Cultures and antibiotics as appropriate Suspect and treat raised ICP as needed, CT scan when warranted Keep normothermic, acetaminophen/ibuprofen as appropriate

At 5 min

Lorazepam 0.1 mg/kg IV/IO, max 4 mg

Yes

IV access?

No

Lorazepam 0.1 mg/kg, IM/SC or Diazepam 0.5mg/kg PR, max 10mg

At 10 min

Lorazepam 0.1 mg/kg IV/IO, max 4 mg

Consider IO if difficult IV access

Lorazepam 0.1 mg/kg, IM/SC or Diazepam 0.5mg/kg PR, max 10mg

At 15 min

Phenytoin 20 mg/kg IV/IO, max 1 g, over 20 minutes, in 0.9% NaCl (NS)

At 25 min

Phenobarbital 20 mg/kg IV/IO, max 1 g, over 5-10mins

The order of Phenytoin and Phenobarbital may be interchanged Phenytoin should be used in head trauma Phenobarbital should be used 1st if patient already on phenytoin maintenance Rapid Sequence Intubation if compromised airway at any point Ventilate to normal parameters Sedation and muscle relaxants only if necessary to ventilate or protect airway

At 35 min

Midazolam 0.15 mg/kg IV bolus, then 2 mcg/kg/min by IV infusion

Early referral to PICU if any of following: airway/ventilation/cardiovascular compromise seizure refractory to 2nd line medications seizure >30 minutes initiating Midazolam or Thiopental infusion

Midazolam increase by 2 mcg/kg/min q 5 min, 0.15 mg/kg bolus as needed, max 24 mcg/kg/min or 20 mg/hr

If stops x 48 hrs

Midazolam taper by 1 mcg/kg/min q 30 mins

At 90 min

Thiopental 4 mg/kg IV bolus, then 1 mg/kg/hr IV infusion Discontinue Midazolam Infusion

Thiopental increase by 1 mg/kg/hr q 30 min, 2 mg/kg bolus as needed, max 6 mg/kg/hr

If stops x 48 hrs

Thiopental taper by 25% q 12 hrs

Ongoing management: Appropriate monitoring continuous BP monitoring, consider arterial and central venous lines Neurology consult essential with refractory cases Continuous EEG monitoring, therapy based on electrographic suppression of seizure activity Can discontinue Midazolam and Phenobarbital maintenance once Thiopental started Monitor for cardiovascular compromise with midazolam/thiopental infusion. Consider vasoconstrictor support. If difficulty weaning Thiopental, then restart Midazolam infusion during wean Consider Pyridoxine 100mg IV if under 18 months old Maintain therapeutic drug levels Continue baseline antiepileptics when possible