PSE Summary

Definition

  • Seizure > 5 minutes
  • Treatment starts after 5 min
  • Risk increases with duration

Common Causes

  • Fever (< 6 years)
  • Head injury/trauma
  • Meningitis/encephalitis
  • Epilepsy
  • Hypoxia/hypoglycemia

Complications

  • Airway obstruction
  • Cardiac arrhythmias
  • Pulmonary edema
  • Hyperthermia
  • Neurological damage

Treatment Timeline

  • 0-5 min: ABC, O2, glucose
  • 5 min: 1st benzodiazepine
  • 10-15 min: 2nd benzodiazepine
  • 15-35 min: 2nd line agent
  • 20-40 min: RSI & intubation

Medications

  • Benzodiazepines: Midazolam/Lorazepam
  • 2nd line: Levetiracetam/Phenytoin
  • 3rd line: Thiopental/Propofol

Resuscitation

  • Airway management
  • High flow O2
  • IV/IO access
  • Check glucose
  • Fluid bolus if shocked

Pediatric Status Epilepticus

Medical emergency requiring prompt recognition and treatment

Overview

Convulsive status epilepticus (CSE) is defined as a seizure that continues for greater than 5 minutes. Treatment usually starts once a seizure has lasted > 5 minutes as seizures are unlikely to spontaneously terminate after this time, and the risk of a seizure becoming refractory increases with increasing seizure duration.

Medical Emergency

Status epilepticus is a neurological emergency requiring immediate intervention to prevent complications and potential neurological damage.

Causes

Common causes of convulsions in children include:

Febrile Seizures

  • Most common cause in children < 6 years
  • Associated with fever
  • Usually benign but requires evaluation

Neurological Causes

  • Head injury/trauma
  • Meningitis/encephalitis
  • Epilepsy (known or new onset)

Metabolic & Other

  • Hypoxia
  • Hypoglycemia
  • Poisoning/toxins
  • Metabolic abnormalities

Complications

Generalized convulsive (tonic clonic) status epilepticus (CSE) can be fatal, but mortality is lower in children than in adults. Neurological outcomes are age-dependent.

Immediate Complications

  • Airway obstruction
  • Hypoxia
  • Aspiration of vomit
  • Cardiac arrhythmias

Systemic Complications

  • Hypertension followed by hypotension
  • Pulmonary edema
  • Hyperthermia
  • Disseminated intravascular coagulation (DIC)
  • Myoglobinuria (rhabdomyolysis)

Neurological Outcomes

  • Neuronal injury and death
  • Cognitive impairment
  • Increased risk of future epilepsy
  • Long-term neurological deficits

Mortality Risks

Death may be due to complications of the convulsion, overmedication, cardiac arrhythmias, or the underlying disease process.

Assessment and Resuscitation

Airway

  • Ensure airway is open
  • Consider airway-opening manoeuvres
  • Use airway adjuncts if needed
  • Recovery position if breathing satisfactorily

Breathing

  • Give high flow oxygen via face mask with reservoir
  • Support ventilation with bag-valve mask if hypoventilating
  • Consider intubation and ventilation

Circulation

  • Obtain IV or IO access
  • Check blood glucose - treat if < 3 mmol/L
  • Give 20 ml/kg crystalloid bolus if signs of shock
  • Consider antibiotics if infection suspected

Disability

  • Assess mental status (AVPU)
  • Check pupillary size and reaction
  • Look for signs of raised ICP
  • Check for meningeal signs
  • Consider poisoning evidence

Treatment Protocol (APLS 2021 Guidelines)

Seizure Starts (0-5 minutes)

  • Confirm seizure clinically
  • Check ABC, provide high flow O2
  • Attach monitoring equipment
  • Check blood glucose, treat if < 3 mmol/L

After 5 minutes

  • Give first dose of benzodiazepine:
  • Midazolam 0.3-0.5 mg/kg buccal OR
  • Lorazepam 0.1 mg/kg IV/IO
  • Consider pre-hospital treatment already given
  • Maximum 2 doses of benzodiazepines

After 10-15 minutes

  • Give further dose of IV lorazepam 0.1 mg/kg
  • Reconfirm epileptic seizure
  • Prepare second line agent of choice

After 15-35 minutes

  • Give second line agent:
  • Levetiracetam 30-60 mg/kg IV (over 5 mins, max 3 g) OR
  • Phenytoin 20 mg/kg by slow IV infusion over 20 minutes OR
  • Phenobarbital 20 mg/kg by IV infusion over 5 mins
  • Call anaesthetist and PICU

After 20-40 minutes

  • Consider second or third line agent
  • Rapid sequence induction of anaesthesia:
  • Thiopental sodium 4 mg/kg IV OR
  • Propofol 1–1.5 mg/kg IV
  • Intubation and ventilation
  • EEG monitoring for ongoing seizures

Additional Considerations

  • Use ketamine and midazolam as alternatives for RSI
  • Consider single dose rocuronium if using neuromuscular blockade
  • Ongoing seizures may not be clinically apparent after intubation (require EEG)

Special Considerations

Infection Considerations

Refractory Status Epilepticus

Post-Resuscitation Care