eMedicine Specialties > Emergency Medicine > Pediatric

Pediatrics, Status Epilepticus

Author: Grace M Young, MD, Associate Professor, Department of Pediatrics, University of Maryland Medical Center
Contributor Information and Disclosures

Updated: Jul 18, 2008

Introduction

Background

Status epilepticus is defined as recurrent or continuous seizure activity lasting longer than 30 minutes in which the patient does not regain baseline mental status.1

Pathophysiology

Seizures result from rapid abnormal electrical discharges from cerebral neurons. This presents clinically as involuntary alterations of consciousness or motor activity. Consumption of oxygen, glucose, and energy substrates (eg, ATP, phosphocreatine) is significantly increased in cerebral tissue during seizures. Optimal delivery of these metabolic substrates to cerebral tissue requires adequate cardiac output and intravascular fluid volume.

Prolonged seizures are associated with cerebral hypoxia, hypoglycemia, and hypercarbia and with concurrent and progressive lactic and respiratory acidosis. When cerebral metabolic needs exceed available oxygen, glucose, and metabolic substrates (especially during status epilepticus), neuronal destruction can occur and may be irreversible. Hypoxia, hypercarbia, hyperthermia, tachycardia, hypertension, hyperglycemia, hyperkalemia, and lactic acidosis result from massive sympathetic discharge.

Frequency

United States

Seventy percent of children younger than 1 year who are subsequently diagnosed with epilepsy present with status epilepticus as the initial symptom of their illness. In children with epilepsy, 20% have status epilepticus within 5 years of diagnosis. Five percent of children with febrile seizures present with status epilepticus.

International

Rates are similar to those in the United States.

Mortality/Morbidity

In the United States, the overall mortality is 10-15%.

Sex

No sexual predilection is recognized.

Age

Status epilepticus is common at any age. Certain etiologies are more prevalent in selected age groups (see Causes).

Clinical

History

In the initial presentation of status epilepticus, a directed history suffices. Obtain a more detailed history after stabilization, including the following details:

  • The course of current seizure activity
    • Time and nature of onset of seizure activity
    • Involvement of extremities or other body parts
    • Nature of movements (eg, eye movements, flexion, extension, stiffening of extremities), including any focal movements and details of postictal neurologic deficit
    • Incontinence
    • Cyanosis (perioral or facial)
    • Duration of seizure activity prior to medical attention
    • Mental status after cessation of seizure activity
  • Fever or intercurrent illnesses
  • Prior history of seizures - If present, specify medications, anticonvulsant use, and compliance.
  • Head injury (recent and remote)
  • Central nervous system (CNS) infection or disease (eg, meningitis, neurocutaneous syndrome)
  • Intoxication or toxic exposure (see Causes for examples)
  • Other CNS abnormality (eg, ventricular-peritoneal shunt, prior CNS trauma)
  • Birth history and developmental delay (eg, anoxic encephalopathy, cerebral palsy)
  • Other medical history (eg, acquired immunodeficiency syndrome, systemic lupus erythematosus, type 1 diabetes mellitus)

Physical

Perform a rapid, directed physical and neurologic examination during status epilepticus, followed by a detailed examination when the child is stabilized.

  • Signs of sepsis or meningitis
    • Temperature more than 38.5°C; in patients younger than 2-3 months, more than 38.0°C
    • Respiratory distress
    • Cyanosis
    • Poor peripheral perfusion
    • Bulging fontanelles in infant
    • Meningismus (in children >12-18 mo)
    • Presence of petechiae or purpura, herpetic vesicles
  • Evidence of head or other CNS injury
    • Bradycardia, tachypnea, and hypertension (Cushing triad for signs of increased intracranial pressure)
    • Poor pupillary response
    • Asymmetry on neurologic examination
    • Abnormal posturing
    • Gross deformity or soft tissue injury to head
  • Hallmarks of neurocutaneous syndromes (eg, port wine stain)

Causes

  • Neonates (first month of life)
    • Birth injury (eg, anoxia, hemorrhage) and congenital abnormalities
    • Metabolic disorders (eg, hypoglycemia, hypocalcemia, hyponatremia) and inborn errors of metabolism (eg, lipidoses, amino acidurias)
    • Infection (eg, meningitis)
  • Early childhood (<6 y)
    • Birth injury
    • Febrile convulsions (3 mo to 6 y)
    • Infection
    • Metabolic disorders
    • Trauma
    • Neurocutaneous syndromes
    • Cerebral degenerative diseases
    • Tumors
    • Idiopathic
  • Children and adolescents (>6 y)
    • Birth injury
    • Trauma
    • Infection
    • Epilepsy with inadequate drug levels
    • Cerebral degenerative disease
    • Tumor
    • Toxins
    • Idiopathic
  • Toxins and medications
    • Topical anesthetics (eg, lidocaine)
    • Anticonvulsant overdose
    • Camphor
    • Hypoglycemic agents (eg, insulin, ethanol)
    • Carbon monoxide
    • Cyanide
    • Heavy metals (eg, lead)
    • Pesticides (eg, organophosphate)
    • Cocaine
    • Phencyclidine
    • Belladonna alkaloids
    • Nicotine
    • Sympathomimetics (eg, amphetamines, phenylpropanolamine [recalled from US market])
    • Tricyclic antidepressants

More on Pediatrics, Status Epilepticus

Overview: Pediatrics, Status Epilepticus
Differential Diagnoses & Workup: Pediatrics, Status Epilepticus
Treatment & Medication: Pediatrics, Status Epilepticus
Follow-up: Pediatrics, Status Epilepticus
References
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References

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  2. Brevoord JC, Joosten KF, Arts WF, van Rooij RW, de Hoog M. Status epilepticus: clinical analysis of a treatment protocol based on midazolam and phenytoin. J Child Neurol. Jun 2005;20(6):476-81. [Medline].

  3. Appleton R, Choonara I, Martland T,et al. The treatment of convulsive status epilepticus in children. The Status Epilepticus Working Party, Members of the Status Epilepticus Working Party. Arch Dis Child. Nov 2000;83(5):415-9. [Medline].

  4. Arzimanoglou A. Outcome of status epilepticus in children. Epilepsia. 2007;48 Suppl 8:91-3. [Medline].

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Further Reading

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Keywords

status epilepticus, SE, epilepsy, status epilepticus in children, seizure, febrile seizures, continuous seizure activity, hypoxia, hypercarbia, hyperthermia, tachycardia, hypertension, hyperglycemia, hyperkalemia, hypoglycemia, lactic acidosis, respiratory acidosis, epilepsy, sepsis, meningitis, respiratory distress, meningismus

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Contributor Information and Disclosures

Author

Grace M Young, MD, Associate Professor, Department of Pediatrics, University of Maryland Medical Center
Grace M Young, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Emergency Physicians
Disclosure: Nothing to disclose.

Medical Editor

Garry Wilkes, MBBS, FACEM, Director of Emergency Medicine, Bunbury Health Service, Western Australia Country Health Service; Adjunct Associate Professor, School of Exercise, Biomedical and Health Sciences, Faculty of Computing, Health and Science, Edith Cowan University; Medical Director, St John Ambulance Service
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine.com, Inc
Disclosure: Pfizer Inc Stock Investment from broker recommendation; Avanir Pharma Stock Investment from broker recommendation

Managing Editor

Wayne Wolfram, MD, MPH, Clinical Associate Professor, Departments of Pediatrics, Children's Hospital and University of Cincinnati
Wayne Wolfram, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Pediatrics, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Richard G Bachur, MD, Assistant Professor of Pediatrics, Harvard Medical School; Associate Chief and Fellowship Director, Attending Physician, Division of Emergency Medicine, Children's Hospital of Boston
Richard G Bachur, MD is a member of the following medical societies: American Academy of Pediatrics, Society for Academic Emergency Medicine, and Society for Pediatric Research
Disclosure: none None None

 
 
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