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Status Epilepticus in Children

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Status Epilepticus in Children Toni Petrillo Pediatric Critical Care Children s Healthcare of Atlanta Status epilepticus (SE) presents in a multitude of forms ... – PowerPoint PPT presentation

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Title: Status Epilepticus in Children


1
Status Epilepticus in Children
  • Toni Petrillo
  • Pediatric Critical Care
  • Childrens Healthcare of Atlanta

2
  • Status epilepticus (SE) presents in a multitude
    of forms, dependent on etiology and patient age
    (myoclonic, tonic, subtle, tonic-clonic, absence,
    complex partial etc.)
  • Generalized, tonic-clonic SE is the most common
    form of SE

3
Definition
  • Conventional definition
  • Single seizure gt 30 minutes
  • Series of seizures gt 30 minutes without full
    recovery

4
Definition
  • If appropriate therapy is delayed, SE can cause
    permanent neurologic sequelae or death
  • thus
  • any child who presents actively convulsing
    should be assumed to have SE.
  • Haafiz A. Pediatr Emerg Care 199915(2)119-29

5
  • The longer SE persists,
  • the lower is the likelihood of spontaneous
    cessation
  • the harder is it to control
  • the higher is the risk of morbidity and mortality
  • Treatment for most seizures needs to be
    instituted after gt 5 minutes of seizure activity
  • Bleck TP. Epilepsia 199940(1)S64-6

6
Causes
  • Fever
  • Medication change
  • Unknown
  • Metabolic
  • Congenital
  • Anoxic
  • Other (trauma, vascular, infection, tumor, drugs)
  • 36
  • 20
  • 9
  • 8
  • 7
  • 5
  • 15

DeLorenzo RJ. Epilepsia 199233 Suppl 4S15-25
7
Drugs which can cause seizures
  • Antibiotics
  • Penicillins
  • Isoniazid
  • Metronidazole
  • Anesthetics, narcotics
  • Halothane, enflurane
  • Cocaine, fentanyl
  • Ketamine
  • Psychopharmaceuticals
  • Antihistamines
  • Antidepressants
  • Antipsychotics
  • Phencyclidine
  • Tricyclic antidepressants

8
Mortality
  • Adults
  • Children
  • 15 to 22
  • 3 to 15
  • Reviewed in Fountain NB. Epilepsia 200041 Suppl
    2S23-30

9
Prolonged seizures
Life threatening systemic changes
Temporary systemic changes
Death
Duration of seizure
10
Respiratory
  • Hypoxia and hypercarbia
  • ß ventilation (chest rigidity from muscle
    spasm)
  • Hypermetabolism (Ý O2 consumption, Ý CO2
    production)
  • Poor handling of secretions
  • Neurogenic pulmonary edema?

11
Hypoxia
  • Hypoxia/anoxia markedly increase (triple?) the
    risk of mortality in SE
  • Seizures (without hypoxia) are much less
    dangerous than seizures and hypoxia
  • Towne AR. Epilepsia 199435(1)27-34

12
Neurogenic pulmonary edema
  • Rare complication
  • Likely occurs as consequence of marked increase
    of pulmonary vascular pressure

Johnston SC. Postictal pulmonary edema requires
pulmonary vascular pressure increases. Epilepsia
199637(5)428-32
13
Acidosis
  • Respiratory
  • Lactic
  • Impaired tissue oxygenation
  • Increased energy expenditure

14
Hemodynamics
  • Sympathetic overdrive
  • Massive catecholamine / autonomic discharge
  • Hypertension
  • Tachycardia
  • High CVP
  • Exhaustion
  • Hypotension
  • Hypoperfusion

0 min
60 min
15
Cerebral blood flow - Cerebral O2 requirement
  • Hyperdynamic phase
  • CBF meets CMRO2
  • Exhaustion phase
  • CBF drops as hypotension sets in
  • Autoregulation exhausted
  • Neuronal damage ensues

O2 requirement
Blood flow
Blood pressure
Seizure duration
16
Glucose
  • Hyperdynamic phase
  • Hyperglycemia
  • Exhaustion phase
  • Hypoglycemia develops
  • Hypoglycemia appears earlier in presence of
    hypoxia
  • Neuronal damage ensues

17
Hyperpyrexia
  • Hyperpyrexia may develop during protracted SE,
    and aggravate possible mismatch of cerebral
    metabolic requirement and substrate delivery
  • Treat hyperpyrexia aggressively
  • Antipyretics, external cooling
  • Consider intubation, relaxation, ventilation

18
Other alterations
  • Blood leukocytosis (50 of children)
  • Spinal fluid leukocytosis (15 of children)
  • Ý K
  • Ý creatine kinase
  • Myoglobinuria

19
A
  • Oxygen, oral airway. Avoid hypoxia!
  • Consider bag-valve mask ventilation. Consider
    intubation
  • IV/IO access. Treat hypotension, but NOT
    hypertension

B
C
20
Treatment
  • Arterial blood gas?
  • All children in SE have acidosis. It often
    resolves rapidly with termination of SE
  • Intubate?
  • It may be difficult to intubate the actively
    seizing child
  • Stop or slow seizures first, give O2, consider
    BVM ventilation
  • If using paralytic agent to intubate, assume that
    SE continues

21
Initial investigations
  • Labs
  • Na, Ca, Mg, PO4 , glucose
  • CBC
  • Liver function tests, ammonia
  • Anticonvulsant level
  • Toxicology

22
Initial investigations
  • Lumbar puncture
  • Always defer LP in unstable patient, but never
    delay antibiotic/antiviral rx if indicated
  • CT scan
  • Indicated for focal seizures or deficit, history
    of trauma or bleeding d/o

23
Treatment
  • Give glucose (2-4 ml/kg D25, infants 5 ml/kg
    D10), unless normo- or hyperglycemic
  • Hyperglycemia has no negative effect in SE
  • (as long as significant hyperosmolality is being
    avoided)

24
Treatment
  • Hyponatremia
  • Give 5 cc/kg of 3 (hypertonic saline)
  • Hypocalcemia
  • Give 20-25 mg/kg of Calcium Chloride

25
Treatment
  • The longer you wait with anticonvulsant, the more
    anticonvulsant you will need to stop SE
  • Most common mistake is ineffective dose

26
Anticonvulsants
  • Rapid acting
  • plus
  • Long acting

27
Anticonvulsants - Rapid acting
  • Benzodiazepines
  • Lorazepam 0.1 mg/kg i.v. over 1-2 minutes
  • Diazepam 0.2 mg/kg i.v. over 1-2 minutes
  • If SE persists, repeat every 5-10 minutes

28
Benzodiazepines
  • Diazepam
  • High lipid solubility
  • Thus very rapid onset
  • Redistributes rapidly
  • Thus rapid loss of anticonvulsant effect
  • Adverse effects are persistent
  • Hypotension
  • Respir depression
  • Lorazepam
  • Low lipid solubility
  • Action delayed 2 minutes
  • Anticonvulsant effect 6-12 hrs
  • Less respiratory depression than diazepam
  • Midazolam
  • May be given i.m.

29
Anticonvulsants - Long acting
  • Phenytoin
  • 20 mg/kg i.v. over 20 min
  • pH 12
  • Extravasation causes severe tissue injury
  • Onset 10-30 min
  • May cause hypotension, dysrhythmia
  • Cheap
  • Fosphenytoin
  • 20 mg PE/kg i.v. over 5-7 min PE phenytoin
    equivalent
  • pH 8.6
  • Extravasation well tolerated
  • Onset 5-10 min
  • May cause hypotension
  • Expensive

30
Anticonvulsants - Long acting
  • Phenobarbital
  • 20 mg/k g i.v. over 10 - 15 min
  • Onset 15-30 min
  • May cause hypotension, respiratory depression

31
Initial choice of long acting anticonvulsants in
SE
Is patient an infant? Is patient already
receiving phenytoin?
Yes
No
At high risk for extravasation ? (small vein,
difficult access etc.)?
Phenobarbital
Yes
No
Phenytoin
Fosphenytoin
32
If SE persists
  • Midazolam infusion 1 - 10 mcg/kg/min after bolus
    0.15 mg/kg
  • Pentobarbital infusion 1-3 mg/kg/hr after bolus
    10 mg/kg

33
Non - convulsive status epilepticus
  • How do you tell that patients seizures have
    stopped?

34
Non - convulsive SE ?
  • Neurologic signs after termination of SE are
    common
  • Pupillary changes
  • Abnormal tone
  • Babinski
  • Posturing
  • Clonus
  • May be asymmetrical

35
Non - convulsive SE ?
  • Up to 20 of children with SE have non -
    convulsive SE after tonic - clonic SE

36
Non - convulsive SE ?
  • If child does not begin to respond to painful
    stimuli within 20 - 30 minutes after tonic -
    clonic SE, suspect non - convulsive SE
  • Urgent EEG

37
References
  • Haafiz A, Kissoon N. Status epilepticus current
    concepts. Pediatr Emerg Care 199915(2)119-29.
  • Bleck TP. Management approaches to prolonged
    seizures and status epilepticus. Epilepsia
    199940(1)S64-6.
  • Orlowski JP, Rothner DA. Diagnosis and treatment
    of status epilepticus. In Fuhrman BP, Zimmerman
    JJ, editors. Pediatric Critical Care. St. Louis
    Mosby 1998. p. 625-35.
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