Diagnostic Considerations

Always consider the possibility of infections in pediatric patients presenting with convulsive status epilepticus (CSE). Sources of infection often, but not always, are obvious (eg, otitis media, pneumonia). Treat these infections appropriately because they contribute to lowering the seizure threshold in predisposed patients.

Infections can be the precipitating factor for both CSE and nonconvulsive status epilepticus (NCSE). Patients with CNS infections and mental status changes should not be assumed to have infection-related neurologic dysfunction before EEG findings rule out NCSE.

Early initiation of broad-spectrum antibiotics and acyclovir for suspected bacterial and viral (eg., HSV) CNS infections is appropriate therapy and should not be delayed while awaiting laboratory results.

Consider catscratch, particularly in a school-aged child with a cat or kitten at home who presents with a history of unexplained mental status changes, status epilepticus (SE) of unknown etiology, prolonged seizures, or persistent fatigue. Catscratch fever is an infection acquired from cats (often from kittens) infected with Bartonella henselae via the cat flea. Although the disease may be transmitted by any close contact with a cat, scratches or bites cause 75% of cases.

Psychogenic seizures

Occasionally, nonepileptic seizures can be confused with CSE. They may occur in patients with a previous diagnosis of epilepsy.^[42]

Patients with nonepileptic seizures can reproduce an outward clinical seizure pattern as a manifestation of an unresolved psychological conflict (psychogenic seizure), or the seizure may be a manifestation of malingering, providing the patient with a clear secondary gain. Psychogenic seizures occur less commonly in younger children than in adolescents. Symptoms of true psychogenic seizures resemble conversion symptoms.

In many cases, details of the presentation can help differentiate nonepileptic seizures from GTCSE. Features suggesting nonepileptic seizures include the following:

No loss of consciousness in the presence of bilateral movements
Asynchronous, side-to-side, and out-of-phase movements
Pelvic thrusting
Inconsistency of movement patterns and waxing and waning patterns
Persistent eye closure
Crying during the seizure

On the other hand, no loss of consciousness in the presence of bilateral movements, pelvic thrusting, and asynchronous and thrashing movements can also be part of frontal lobe seizures, which may lead to SE in some cases. Only careful observation of the patient (eg, video) with simultaneous EEG (ie, EEG video monitoring) allows the physician to differentiate between sustained nonepileptic seizures and GTCSE.

Differential Diagnoses

Workup

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Pediatric Status Epilepticus. Treatment algorithms for convulsive status epilepticus.

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Table 1. Examples of Medical Treatment of Seizures and Convulsive Status Epilepticus Based on Time Elapsed Since Seizure Onset (Steps 2-4)

Table 1. Examples of Medical Treatment of Seizures and Convulsive Status Epilepticus Based on Time Elapsed Since Seizure Onset (Steps 2-4)

Step	Medication	Dose	Alternatives
Step 2 (5-10 min)	Diazepam (Valium)	5-20 mg IV slowly; not to exceed infusion rate of 2 mg/min; pediatric dose is 0.3 mg/kg	If IV line is unavailable, use rectally administered (PR) diazepam at 0.5 mg/kg (not to exceed 10 mg) or midazolam (Versed) at 0.2 mg/kg IM, IV, or intranasal
Step 2 (5-10 min)	Lorazepam* (Ativan)	2-4 mg IV slowly*; not to exceed infusion rate of 2 mg/min or 0.05 mg/kg over 2-5 min; pediatric dose is 0.05-0.1 mg/kg
Step 3 (10-30 min)	Phenytoin (Dilantin) or fosphenytoin (Cerebyx)†	Phenytoin:20 mg/kg IV over 20 min; not to exceed infusion rate of 1 mg/kg/min; do not dilute in 5% dextrose in water (D5W) Fosphenytoin: 15-20 mg/kg IV; not to exceed infusion rate of 2 mg/kg/min or 150 mg/min whichever is slower; dilute in D5W or NS	Sodium valproate 40 mg/kg IV, max 3000 mg or levetiracetam 60 mg/kg IV, max dose 4500 show equal efficacy to fosphenytoin. If unsuccessful, administer phenobarbital 10-20 mg/kg IV (not to exceed 700 mg IV); phenobarbital may be used in infants before phenytoin; be prepared to intubate patient; closely monitor hemodynamics and support blood pressure as indicated.
Step 4 (30+ min)‡	Pentobarbital anesthesia (patient already intubated)	Loading dose: 5-7 mg/kg IV; may repeat 1-mg/kg to 5-mg/kg boluses until EEG exhibits burst suppression; closely monitor hemodynamics and support blood pressure as indicated Maintenance dose: 0.5-3 mg/kg/h IV; monitor EEG to keep burst suppression pattern at 2-8 bursts/min	Midazolam* infusion loading dose: 100-300 mcg/kg IV followed by IV infusion of 1-2 mcg/kg/min; increase by 1-2 mcg/kg/min every 15 min if seizures persist (effective range 1-24 mcg/kg/min); closely monitor hemodynamics and support blood pressure as indicated; when seizures stop, continue same dose for 48 h then wean by decrements of 1-2 mcg/kg/min every 15 min Propofol* initial bolus: 2 mg/kg IV; repeat if seizures continue and follow by IV infusion of 5-10 mg/kg/h, if necessary, guided by EEG monitoring; taper dose 12 h after seizure activity stops; closely monitor hemodynamics and support blood pressure as indicated With phenobarbital-induced anesthesia, repeated boluses of 10 mg/kg are administered until cessation of ictal activity or appearance of hypotension; closely monitor hemodynamics and support blood pressure as indicated
*Not approved by the FDA for the indicated use. †Doses for fosphenytoin administered in phenytoin equivalents (PE). ‡An alternative third step preferred by some authors is midazolam administered by continuous IV infusion with a loading dose 0.1-0.3 mg/kg followed by infusion at a rate of 0.1-0.3 mg/kg/h.

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Author

Marvin H Braun, MD, PhD Assistant Professor of Neurology, Neuroscience Institute, Geisinger Commonwealth School of Medicine; Pediatric Neurologist, Janet Weis Children’s Hospital, Geisinger Medical Center

Marvin H Braun, MD, PhD is a member of the following medical societies: American Epilepsy Society, Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

Coauthor(s)

Frank A Maffei, MD, FAAP Professor of Pediatrics, Geisinger Commonwealth School of Medicine; Chair of Pediatrics, Division Chief, Pediatric Critical Care, Geisinger Janet Weis Children's Hospital

Frank A Maffei, MD, FAAP is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Chief Editor

Dale W Steele, MD, MS Professor of Emergency Medicine, Pediatrics, and Health Services, Policy, and Practice, Warren Alpert Medical School of Brown University; Attending Physician, Department of Pediatric Emergency Medicine, Rhode Island Hospital

Dale W Steele, MD, MS is a member of the following medical societies: American Academy of Pediatrics, American Statistical Association, Society for Medical Decision Making

Disclosure: Nothing to disclose.

Additional Contributors

Marcio Sotero de Menezes, MD Clinical Associate Professor, Department of Neurology, Division of Pediatric Neurology, Seattle Children's Hospital, University of Washington School of Medicine; Director, Pediatric Neuroscience Center and Genetic Epilepsy Clinic, Swedish Neuroscience Institute

Marcio Sotero de Menezes, MD is a member of the following medical societies: American Academy of Neurology, American Epilepsy Society

Disclosure: Received salary from Novartis for speaking and teaching; Received salary from Cyberonics for speaking and teaching; Received salary from Athena diagnostics for speaking and teaching.

Ednea Simon, MD Consulting Staff, Swedish Pediatric Neuroscience Center

Ednea Simon, MD is a member of the following medical societies: American Academy of Neurology, American Epilepsy Society, Child Neurology Society

Disclosure: Nothing to disclose.

Timothy E Corden, MD Associate Professor of Pediatrics, Co-Director, Policy Core, Injury Research Center, Medical College of Wisconsin; Associate Director, PICU, Children's Hospital of Wisconsin

Timothy E Corden, MD is a member of the following medical societies: American Academy of Pediatrics, Phi Beta Kappa, Society of Critical Care Medicine, Wisconsin Medical Society

Disclosure: Nothing to disclose.

Rajesh Ramachandrannair, MBBS, MD, FRCPC Associate Professor, Michael G DeGroote School of Medicine, McMaster University; Staff Neurologist, McMaster Children's Hospital, Canada

Disclosure: Nothing to disclose.

Acknowledgements

G Patricia Cantwell, MD, FCCM Professor of Clinical Pediatrics, Chief, Division of Pediatric Critical Care Medicine, University of Miami, Leonard M Miller School of Medicine; Medical Director, Palliative Care Team, Director, Pediatric Critical Care Transport, Holtz Children's Hospital, Jackson Memorial Medical Center; Medical Manager, FEMA, Urban Search and Rescue, South Florida, Task Force 2; Pediatric Medical Director, Tilli Kids – Pediatric Initiative, Division of Hospice Care Southeast Florida, Inc

G Patricia Cantwell, MD, FCCM is a member of the following medical societies: American Academy of Hospice and Palliative Medicine, American Academy of Pediatrics, American Heart Association, American Trauma Society, National Association of EMS Physicians, Society of Critical Care Medicine, and Wilderness Medical Society