eMedicine Specialties > Emergency Medicine > Pediatric

Pediatrics, Status Epilepticus

Grace M Young, MD, Associate Professor, Department of Pediatrics, University of Maryland Medical Center

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

Differential Diagnoses

Other Problems to Be Considered

Posturing
Pseudoseizures or ticks
Shivering
Tremors

Workup

Laboratory Studies

Obtain laboratory studies based on age and likely etiologies.

• Blood glucose level using immediate bedside testing (eg, Dextrostix), particularly if the child or other household members are dependent on insulin or other hypoglycemic agents
• Electrolyte levels
• Calcium and magnesium levels, particularly in neonates
• ABG levels
• Toxicology screen
• Anticonvulsant levels (if indicated by history of ingestion or existent therapy)
• WBC count: An elevated WBC count may be due to demargination, returning to reference ranges over 12-24 hours.
• Carboxyhemoglobin levels

Imaging Studies

• Stabilize all children before CT scanning or other imaging studies are performed. Obtain imaging studies based on likely etiologies.
• Cervical spine radiographs, if potential trauma
• A head CT scan is the best diagnostic imaging study, particularly if the following are suspected:
  • Hemorrhage
  • Midline shift
  • Mass lesion
• MRI is not a diagnostic tool, unless it is immediately available and the child's cardiorespiratory status is stable.

Other Tests

• Electroencephalography
  • For unremitting status epilepticus
  • Usually performed in a critical care setting

Procedures

• Lumbar puncture with opening pressure
  • For prolonged status epilepticus of unknown etiology
  • For immunocompromised patients

Treatment

Prehospital Care

• Secure the airway.
• Administer supplemental 100% oxygen.
• Infuse isotonic intravenous fluids and glucose.
• Immobilize the cervical spine in patients with possible trauma.
• Consider rectally administered diazepam (0.5 mg/kg/dose) or intramuscularly administered midazolam (0.1-0.2 mg/kg/dose; not to exceed a cumulative dose of 10 mg).²

Emergency Department Care

The principles of treatment are to terminate the seizure while resuscitating the patient, treating complications, and preventing recurrence.

• Assessment and stabilization of ABCs concurrent with management of the seizure is imperative.
  • Administer 100% oxygen by facemask, assist ventilation, and use artificial airways (eg, endotracheal intubation) as needed. Suction secretions and decompress the stomach with a nasogastric tube.
  • Immobilize the cervical spine if trauma is suspected.
  • Closely monitor vital signs, cardiorespiratory function, and oxygen saturation.
  • Perform rapid blood glucose assay (eg, Dextrostix) at bedside.
• Establish intravenous access. Use intraosseous (IO) infusion if intravenous access is not immediately available in the child younger than 6 years. Most available anticonvulsants may be administered intravenously or intraosseously.
  • Infuse isotonic intravenous fluids 20 mL/kg with glucose (eg, 200 mL dextrose 5% in normal saline [D5NS] intravenously over 1 h for a 10-kg child).
  • Consider treatment with the following agents:
    • Dextrose - 0.25-0.5 g/kg/dose (1-2 mL of 25% dextrose) intravenously for hypoglycemia; not to exceed 25 g/dose
    • Naloxone - 0.1 mg/kg/dose intravenously preferably (if needed may administer intramuscularly/subcutaneously) for narcotic overdose
    • Thiamine - 100 mg intramuscularly for possible deficiency
    • Pyridoxine - 50-100 mg intravenously/intramuscularly for possible deficiency
    • Antibiotics - If meningitis is strongly suspected, initiate treatment with antibiotics prior to cerebrospinal fluid (CSF) analysis or CNS imaging.
• Administer anticonvulsant medication. The optimal protocol for management of status epilepticus begins with a benzodiazepine. In the United States, lorazepam is the first drug of choice in patients with intravenous or intraosseous access. For patients without parenteral access, intramuscular midazolam is best. If the seizures cease, no further drugs are immediately necessary, and the etiology of status epilepticus should be investigated. If seizures continue, administer intravenous phenytoin or parenteral fosphenytoin. If these are not effective, administer intravenous phenobarbital titrated to induce barbiturate coma. Finally, consider general anesthesia with pentobarbital or midazolam.
  • The goal is prompt cessation of seizure activity. Patiently allow infused anticonvulsants to act before using additional anticonvulsants. Proceed to the next drug if seizure activity continues.
  • Lorazepam (0.05-0.1 mg/kg intravenously/IO slowly infused over 2-5 min) has rapid onset and long duration of anticonvulsant action. It is preferred over diazepam.
  • Phenytoin (18-20 mg/kg intravenously/IO) or fosphenytoin (15-20 mg/kg intravenously/IO) loading doses: These long-acting anticonvulsants usually are infused if benzodiazepines do not stop the seizures. Phenytoin and fosphenytoin are effective for most idiopathic generalized seizures and for posttraumatic, focal, or psychomotor status epilepticus. Use a slow rate of infusion (<1 mg/kg/min or <50 mg/min) to avoid hypotension or cardiac arrhythmias. A full loading dose should be delivered unless the patient is known to have a current therapeutic level.
  • Midazolam (0.1-0.2 mg/kg intramuscularly) is most effective when intravenous or intraosseous access is not immediately available. Midazolam is the only benzodiazepine that can be administered safely intramuscularly with equivalent rapid onset and moderate duration of action.
  • Phenobarbital (20-25 mg/kg intravenously/IO) is effective for febrile and neonatal status epilepticus and may be infused after lorazepam or other benzodiazepines if the child is likely to have these types of seizures. Phenobarbital's major disadvantages are that it significantly depresses mental status and causes respiratory difficulty. Obtain serum anticonvulsant levels prior to administering additional long-acting anticonvulsants such as phenytoin or fosphenytoin.
• General anesthesia
  • Pentobarbital (5-10 mg/kg intravenously/IO loading dose followed by 0.5-3 mg/kg/h) or midazolam (0.2 mg/kg intravenously/IO loading dose followed by 0.75-10 mcg/kg/min)
  • All children must be intubated and paralyzed, have continuous cardiorespiratory and EEG monitoring, and be in a pediatric critical care setting.

Consultations

After initial emergency stabilization, consider consultation with the following specialists:

• Pediatric emergency or critical care specialist or general pediatrician
• Pediatric neurologist
• Pediatric neurosurgeon if needed

Medication

Benzodiazepines, hydantoins, and barbiturates have anticonvulsant properties. Choose a parenteral preparation with rapid onset and long duration of action with the least amount of sedation and respiratory depression. Titrate for clinical response by waiting an adequate length of time for attainment of therapeutic levels in the brain.

Benzodiazepines

By increasing the action of GABA, which is a major inhibitory neurotransmitter in the brain, may depress all levels of CNS, including limbic and reticular formation.

Lorazepam (Ativan)

Sedative hypnotic with short onset of effects and relatively long half-life.
Preferred over diazepam because of significantly longer duration of action and equivalent rapid onset of action.
Important to monitor patient's blood pressure after administering dose. Adjust prn.

Dosing

Adult

4 mg/dose IV slowly over 2-5 min; repeat in 10-15 min prn; not to exceed 8 mg/dose

Pediatric

Infants and children: 0.1 mg/kg IV slowly over 2-5 min; repeat prn in 10-15 min at 0.05 mg/kg; not to exceed 4 mg/dose
Adolescents: 0.07 mg/kg IV slowly over 2-5 min; repeat in 10-15 min prn; not to exceed 4 mg/dose

Interactions

Toxicity of benzodiazepines in CNS increases when used concurrently with alcohol, phenothiazines, barbiturates, and MAOIs

Contraindications

Documented hypersensitivity; preexisting CNS depression, hypotension, or narrow-angle glaucoma

Precautions

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution in renal or hepatic impairment, myasthenia gravis, organic brain syndrome, or Parkinson disease

Diazepam (Valium)

For treatment of seizures. Depresses all levels of CNS (eg, limbic and reticular formation), possibly by increasing GABA activity. Effective for prehospital use as PR administration. Has a long half-life but rapidly redistributes from the CNS. Requires administration of the longer-acting phenytoin or phenobarbital because of very short duration of seizure control.
Do not administer >1-2 mg/min IVP in children or > 5 mg/min in adults.

Dosing

Adult

5-10 mg IV q10-20min; not to exceed 30 mg in an 8-h period; may repeat in 2-4 h prn

Pediatric

0.2-0.5 mg/kg/dose IV/IO administered over 2-5 min; repeat q15-30min; not to exceed a total cumulative dose of 10 mg; repeat in 2-4 h prn; alternatively, 0.5 mg/kg PR, then 0.25 mg/kg in 10 min prn

Interactions

Increases CNS toxicity with coadministration of phenothiazines, barbiturates, ethanol, opiates, or MAOIs; cimetidine, disulfiram, fluoxetine, isoniazid, ketoconazole, metoprolol, propanolol, PO contraceptives, propoxyphene, and valproic acid may increase effect of benzodiazepines due to decreased metabolism

Contraindications

Documented hypersensitivity; narrow-angle glaucoma

Precautions

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution with other CNS depressants, low albumin levels, or hepatic disease (may increase toxicity); monitor for respiratory depression; may precipitate porphyria attack; monitor for respiratory depression; mild effects on blood pressure and cardiac output may be seen, which may be significant in patients with preexisting cardiac dysfunction; ataxia, irritability, and sedation are common adverse effects; patients occasionally may have psychotic reactions or suicidal ideation after use

Midazolam (Versed)

Used as alternative in termination of refractory status epilepticus. Because midazolam is water soluble, takes approximately 3 times longer than diazepam to peak EEG effects. Thus, clinician must wait 2-3 min to fully evaluate sedative effects before initiating procedure or repeating dose. DOC for child without immediate IV or IO access (available IM).

Dosing

Adult

2.5-5 mg IV once
Refractory SE: 200 mcg/kg (0.2 mg/kg) IV bolus infused over 2-5 min, followed by 45-660 mcg/kg/h (0.75-11 mcg/kg/min) continuous IV infusion

Pediatric

0.2 mg/kg IM; or 0.05-0.2 mg/kg IV/IO; may repeat q10-15min; not to exceed a cumulative dose of 10 mg; alternatively, 0.15 mg/kg IV initially, followed 1 mcg/kg/min continuous IV infusion; titrate dose until clinical seizure activity controlled

Interactions

Sedative effects may be antagonized by theophyllines; opiates and erythromycin may accentuate sedative effects of midazolam due to decreased clearance; increases CNS toxicity with coadministration of phenothiazines, barbiturates, and MAOIs; cimetidine, disulfiram, fluoxetine, isoniazid, ketoconazole, metoprolol, PO contraceptives, propanolol, and valproic acid may increase effect of benzodiazepines

Contraindications

Documented hypersensitivity; preexisting hypotension; narrow-angle glaucoma; sensitivity to propylene glycol (the diluent)

Precautions

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution in CHF, pulmonary disease, renal impairment, and hepatic failure; adverse effects include drowsiness, dizziness, nausea, vomiting, and respiratory depression

Barbiturates

These agents suppress CNS from reticular activating system (presynaptic and postsynaptic).

Phenobarbital (Barbita, Luminal)

Effective for febrile and neonatal status epilepticus. Can be administered PO. In status epilepticus, it is important to achieve therapeutic levels as quickly as possible. IV dose may require approximately 15 min to attain peak levels in the brain. If injected continuously until convulsions stop, brain concentrations may continue to rise and can exceed that required to control seizures resulting in subsequent toxicity. Important to use minimal amount required and wait for anticonvulsant effect to develop before administering a second dose.
If IM route chosen, administer into areas with little risk of encountering a nerve trunk or major artery such as one of the large muscles (eg, gluteus maximus, vastus lateralis). A permanent neurologic deficit may result from injecting into or near peripheral nerves.
Restrict IV use to conditions in which other routes are not possible, either because patient is unconscious or because prompt action is required.
IV administration should be <50 mg/min. Parental product contains 68% propylene glycol.
Ensure monitoring for hypotension, bradycardia, and arrhythmias upon administration.

Dosing

Adult

300-800 mg IV initially, followed by 120-240 mg/dose at 20-min intervals until seizures are controlled or total cumulative dose of 1-2 g is administered

Pediatric

10-20 mg/kg IV infused over 10-15 min in single or divided dose
Some patients may require 5 mg/kg/dose q15-30min until seizure is controlled or a cumulative dose of 40 mg/kg is administered

Interactions

May decrease effects of chloramphenicol, digitoxin, corticosteroids, carbamazepine, theophylline, verapamil, metronidazole, and anticoagulants (patients stabilized on anticoagulants may require dosage adjustments if added to or withdrawn from their regimen); coadministration with alcohol may produce additive CNS effects and death; chloramphenicol, valproic acid, and MAOIs may increase toxicity; rifampin may decrease effects; induction of microsomal enzymes may result in decreased effects of PO contraceptives in women (must use additional contraceptive methods to prevent unwanted pregnancy; menstrual irregularities may also occur)

Contraindications

Documented hypersensitivity; severe respiratory disease; marked impairment of liver function; severe uncontrolled pain; nephritis

Precautions

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

In prolonged therapy, evaluate hematopoietic, renal, hepatic, and other organ systems; caution in fever, hyperthyroidism, diabetes mellitus, and severe anemia since adverse reactions can occur; caution in myasthenia gravis and myxedema; paradoxical excitement and delirium can occur in infants experiencing pain; may depress mental status significantly

Hydantoins

These agents stabilize neuronal membranes and decrease seizure activity.

Fosphenytoin (Cerebyx)

Diphosphate ester salt of phenytoin that acts as water-soluble prodrug of phenytoin. Following administration, plasma esterases convert fosphenytoin to phosphate, formaldehyde, and phenytoin.
To avoid need to perform molecular weight-based adjustments when converting between fosphenytoin and phenytoin sodium doses, express dose as phenytoin sodium equivalents (PE). Although can be administered IV and IM; IV route is route of choice and should be used in emergency situations.
Concomitant administration of an IV benzodiazepine usually is necessary to control status epilepticus. Full antiepileptic effect, whether administered as fosphenytoin or parenteral phenytoin, is not immediate. Not currently recommended for acute control of status epilepticus because of its slow onset of action. Prepare drug in 100 mL of NS or D5W.

Dosing

Adult

Emergent loading dose: 15-20 mg PE/kg IV/IM at 100-150 mg PE/min
Nonemergent loading dose: 10-20 mg PE/kg IV/IM at 100 mg PE/min
Maintenance dose: 4-6 mg PE/kg/d IV/IM; infusion rate not to exceed 150 mg PE/min to minimize risk of hypotension

Pediatric

Loading dose: 15-20 mg PE/kg IV/IM
Maintenance dose: 4-7 mg PE/kg IV/IM

Interactions

Amiodarone, benzodiazepines, chloramphenicol, cimetidine, disulfiram, ethanol (acute ingestion), omeprazole, phenacemide, phenylbutazone, succinimides, fluconazole, isoniazid, metronidazole, miconazole, sulfonamides, trimethoprim, and valproic acid may increase phenytoin toxicity; may decrease toxicity when taken concurrently with barbiturates, carbamazepine, theophylline, diazoxide, ethanol (chronic ingestion), rifampin, antacids, charcoal, and sucralfate; may decrease effects of acetaminophen, corticosteroids, dicumarol, disopyramide, doxycycline, estrogens, haloperidol, amiodarone, carbamazepine, cardiac glycosides, methadone, metyrapone, mexiletine, PO contraceptives, quinidine, theophylline, valproic acid

Contraindications

Documented hypersensitivity; sinoatrial block; second- and third-degree AV block; Adams-Stokes syndrome

Precautions

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Blood dyscrasias have occurred; consequently, perform blood counts and urinalyses when therapy is begun and at monthly intervals for several months thereafter; discontinue use if rash appears (if rash is exfoliative, bullous, or purpuric, do not resume use); death from cardiac arrest has occurred after too-rapid IV administration (administer <150 mg/min or <2-3 mg/kg/min) preceded sometimes by marked QRS widening; administer cautiously to patients with acute intermittent porphyria; caution in diabetes (may raise blood sugar levels); discontinue drug if hepatic dysfunction occurs; may cause fetal hydantoin syndrome

Phenytoin (Dilantin)

May act in motor cortex where may inhibit spread of seizure activity. Activity of brain stem centers responsible for tonic phase of grand mal seizures also may be inhibited. Effective for idiopathic, posttraumatic, focal, and psychomotor status epilepticus. Individualize doses. Administer larger dose before retiring if dose cannot be divided equally.
Administer only in saline solutions (incompatible when mixed with dextrose-containing solutions).

Dosing

Adult

Loading dose: 15-20 mg/kg IV once or divided doses followed by 100-150 mg/dose q30min; infusion rate not to exceed 50 mg/min to avoid hypotension and arrhythmias

Pediatric

18-20 mg/kg IV/IO; infusion rate not to exceed 1 mg/kg/min (infuse over minimum of 20 min) to avoid hypotension and arrhythmias

Interactions

Amiodarone, benzodiazepines, chloramphenicol, cimetidine, fluconazole, isoniazid, metronidazole, miconazole, phenylbutazone, succinimides, sulfonamides, omeprazole, phenacemide, disulfiram, ethanol (acute ingestion), trimethoprim, and valproic acid may increase toxicity; effects may decrease when taken concurrently with barbiturates, diazoxide, ethanol (chronic ingestion), rifampin, antacids, charcoal, carbamazepine, theophylline, and sucralfate; may decrease effects of acetaminophen, corticosteroids, dicumarol, disopyramide, doxycycline, estrogens, haloperidol, amiodarone, carbamazepine, cardiac glycosides, quinidine, theophylline, methadone, metyrapone, mexiletine, PO contraceptives, valproic acid

Contraindications

Documented hypersensitivity; sinoatrial block; second- and third-degree AV block; sinus bradycardia; Adams-Stokes syndrome

Precautions

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Perform blood counts and urinalyses when therapy is begun and at monthly intervals for several months thereafter to monitor for blood dyscrasias; discontinue use if a rash appears (do not resume use if rash is exfoliative, bullous, or purpuric); rapid IV infusion (administer <50 mg/min or <1 mg/kg/min) may result in death from cardiac arrest, marked by QRS widening; caution in acute intermittent porphyria and diabetes (may elevate blood sugar levels; discontinue use if hepatic dysfunction occurs; may cause fetal hydantoin syndrome

General anesthetics

All children must be intubated and paralyzed and must have continuous cardiorespiratory and EEG monitoring in a pediatric critical care unit. Pentobarbital may be required when seizures persist despite appropriate administration of other antiseizure agents.

Pentobarbital (Nembutal)

Short-acting barbiturate with sedative, hypnotic, and anticonvulsant properties. Can produce all levels of CNS mood alteration. Acts primarily on cerebral cortex and reticular formation through decreased neuronal synaptic activity.

Dosing

Adult

Loading dose: 5-10 mg/kg IV infused slowly over 1-2 h
Maintenance: 1 mg/kg/h IV and increase to 2-3 mg/kg/h until EEG inactivity attained

Pediatric

Loading dose: 5-10 mg/kg IV/IO infused slowly over 1-2 h; follow with 0.5-3 mg/kg/h continuous IV infusion; maintain burst suppression on EEG

Interactions

Concomitant use with alcohol may produce additive CNS effects and death; chloramphenicol may inhibit metabolism; may enhance chloramphenicol metabolism; MAOIs may enhance sedative effects of barbiturates; valproic acid appears to decrease barbiturate metabolism, increasing toxicity; barbiturates can decrease effects of anticoagulants (patients may require dosage adjustments if barbiturates added to or withdrawn from regimen); decreased contraceptive effect may occur due to induction of microsomal enzymes (alternate form of birth control is suggested); barbiturates may decrease corticosteroid and digitoxin effects through induction of hepatic microsomal enzymes, which increase metabolism; barbiturates decrease theophylline levels, and may decrease effects; may decrease verapamil bioavailability

Contraindications

Documented hypersensitivity; hypovolemic shock; CHF; hepatic impairment

Precautions

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Patient may become tolerant to hypnotic effects; caution in hypovolemic shock, respiratory dysfunction, renal dysfunction, CHF, previous addiction to sedative hypnotics; IV preparations contain 20-40% propylene glycol and up to 10% alcohol (administration of high doses of propylene glycol to infants may be associated with metabolic acidosis)

Follow-up

Further Inpatient Care

• Most children with an episode of status epilepticus should be admitted for inpatient observation, evaluation, and treatment.
• Any child with persistent altered mental status (despite cessation of seizure activity) or with prolonged status epilepticus should be admitted to a pediatric critical care unit.

Inpatient & Outpatient Medications

• A child who has a single generalized tonic-clonic seizure for the first time often does not receive long-term anticonvulsant therapy. Consult a pediatric neurologist.

Transfer

• Transfer is prudent unless the hospital facility has a pediatric critical care unit and staff familiar with the risks and complications of status epilepticus in children.

Deterrence/Prevention

• Patients should avoid exposure to specific causes.

Complications

• Anoxic brain damage
• Aspiration
• Head trauma
• Minor soft tissue trauma
• Joint dislocation: Posterior shoulder dislocation is a classic complication and is difficult to diagnose in the unconscious patient.
• Complications as a result of the underlying cause

Prognosis

• Outcome depends on the underlying cause.

Patient Education

• Patients should follow instructions from the pediatric neurologist.
• Patients should maintain compliance with anticonvulsant therapy.
• For excellent patient education resources, visit eMedicine's Brain and Nervous System Center. Also, see eMedicine's patient education article Epilepsy.

Miscellaneous

Medicolegal Pitfalls

• Failure to stabilize and treat ABCs
• Failure to diagnose meningitis
• Failure to diagnose CNS tumor
• Failure to diagnose CNS trauma, hemorrhage, or injury
• Failure or delay in diagnosing posterior shoulder dislocation, particularly in the intubated, sedated patient

Special Concerns

• Anticonvulsant medications are generally teratogenic drugs.

References

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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

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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