Neurology
You are called to the waiting room to see an 8 year old girl with known epilepsy who has started having a generalised tonic clonic seizure which is ongoing after 5 minutes. You obtain intravenous access and administer lorazepam. There is no improvement after 10 minutes and a second dose of lorazepam is given. There is no response to the second dose after a further 10 minutes. What treatment is now indicated?
Answer:
APLS algorithm:- After 10-15 minutes
- Give further dose of IV lorazepam 0.1 mg/kg
- Reconfirm epileptic seizure and 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 with ECG monitoring OR
- Phenobarbital 20 mg/kg by IV infusion over 5 mins
- Call anaesthetist and PICU
- Give second line agent
Paediatric Status Epilepticus
Neurology
Last Updated: 14th April 2023
Definition of convulsive status epilepticus (CSE) is a seizure that continues for greater than 5 min,
so treatment usually starts once seizure has lasted > 5 min. After 5 min seizures are unlikely
to spontaneously terminate and the risk of a seizure becoming refractory increases with increasing seizure duration.
Causes
Common causes of convulsions in children:
- Fever (< 6 years)
- Head injury/trauma
- Meningitis/encephalitis
- Epilepsy
- Hypoxia
- Hypoglycaemia
- Poisoning
- Metabolic abnormalities
Complications
Generalised convulsive (tonic clonic) status epilepticus (CSE) can be fatal, but mortality is lower in children than in adults. Death may be due to complications of the convulsion, such as obstruction of the airway, hypoxia and aspiration of vomit, to overmedication, to cardiac arrhythmias or to the underlying disease process. Neurological outcomes are age-dependent.
Complications of prolonged seizures include:
- Cardiac arrhythmias
- Hypertension
- Pulmonary oedema
- Hyperthermia
- Disseminated intravascular coagulation (DIC)
- Myoglobinuria
- Adverse neurological outcomes
Assessment and resuscitation
- Airway
- Ensure the airway is open - consider airway-opening manoeuvres or airway adjuncts
- If the child is breathing satisfactorily, the recovery position should be adopted to minimise risk of aspiration of vomit
- Breathing
- Give high flow oxygen through a face mask with a reservoir
- If child is hypoventilating, respiration should be supported with oxygen via a bag-valve mask device and consideration given to intubation and ventilation
- Circulation
- Obtain intravenous or intraosseous access
- Check blood glucose and treat for hypoglycaemia (< 3 mmol/L) if required
- Give a 20 ml/kg rapid fluid bolus of crystalloid to any patient with signs of shock and reassess need for repeated boluses
- Give an antibiotic such as cefotaxime or ceftriaxone if a diagnosis of septicaemia or meningitis is being considered (preferably after blood has been taken for culture); also consider early administration of aciclovir if herpes encephalitis cannot be excluded quickly
- Disability
- Assess mental status/conscious level (AVPU) and pupillary size and reaction
- Decorticate or decerebrate posturing in a previously normal child should suggest raised ICP
- Look for neck stiffness, rash or tense fontanelle which suggests meningitis
- Fever is suggestive evidence of an infectious cause or poisoning with ecstasy, cocaine or salicylates
- Consider the evidence for poisoning; history or characteristic smell
Treating convulsive status epilepticus in children as per APLS (new 2021 guidelines)
- Seizure starts
- Confirm clinically
- Check ABC, high flow O2, attach monitoring
- Check blood glucose, treat if < 3 mmol/L
- After 5 minutes
- Give 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, max 2 doses
- Give dose of benzodiazepine
- After 10-15 minutes
- Give further dose of IV lorazepam 0.1 mg/kg
- Reconfirm epileptic seizure and 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 with ECG monitoring OR
- Phenobarbital 20 mg/kg by IV infusion over 5 mins
- Call anaesthetist and PICU
- Give second line agent
- After 20-40 minutes
- Consider second or third line agent
- If preparation for deeper anaesthesia with intubation and ventilation complete, proceed to next step OR
- Administer further alternative second-line drug (levetiracetam, phenytoin, phenobarbital)
- Give third line agent
- Rapid sequence induction of anaesthesia:
- thiopental sodium 4 mg/kg IV OR propofol 1–1.5 mg/kg IV
- (with single dose recuronium if using NMB)
- ketamine and midazolam are alternatives
- Intubation and ventilation; monitoring neurological signs
- Ongoing seizures are not always easy to identify (EEG)
- Rapid sequence induction of anaesthesia:
- Consider second or third line agent
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- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
