eMedicine Specialties > Emergency Medicine > Pediatric
Pediatrics, Status Epilepticus: Treatment & Medication
Updated: Jul 18, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
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.
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
Toxicity of benzodiazepines in CNS increases when used concurrently with alcohol, phenothiazines, barbiturates, and MAOIs
Documented hypersensitivity; preexisting CNS depression, hypotension, or narrow-angle glaucoma
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.
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
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
Documented hypersensitivity; narrow-angle glaucoma
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).
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
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
Documented hypersensitivity; preexisting hypotension; narrow-angle glaucoma; sensitivity to propylene glycol (the diluent)
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.
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
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)
Documented hypersensitivity; severe respiratory disease; marked impairment of liver function; severe uncontrolled pain; nephritis
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.
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
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
Documented hypersensitivity; sinoatrial block; second- and third-degree AV block; Adams-Stokes syndrome
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).
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
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
Documented hypersensitivity; sinoatrial block; second- and third-degree AV block; sinus bradycardia; Adams-Stokes syndrome
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.
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
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
Documented hypersensitivity; hypovolemic shock; CHF; hepatic impairment
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)
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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Further Reading
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
