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DEFINITION

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Status epilepticus (SE) is defined as 5 minutes or more of (1) continuous clinical and/or electrographic seizure activity or (2) recurrent seizure activity without recovery (returning to baseline) between seizures.1

  • May be convulsive (with motor features) or nonconvulsive (electrographic seizures only)

  • SE progresses in phases

    • Early SE (5–30 minutes), established SE (>30 minutes), and refractory SE

    • Refractory status epilepticus

      • Clinical or electrographic seizures that persist after an adequate dose of an initial benzodiazepine and a second appropriate antiseizure medication

      • Associated with poor outcome, with mortality up to 30%, related to young age, etiology, and multifocal or generalized EEG abnormalities

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BACKGROUND AND EPIDEMIOLOGY

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  • Epidemiology and morbidity of SE

    • Incidence of first-time SE is approximately 18 to 23 per 100,000 children per year2

    • Fifty percent of children with new-onset convulsive SE are neurologically healthy

    • One-year recurrence risk is 16% with 3% mortality, which is lower than adults

    • Risk for mortality and long-term morbidity related to primary cause of the seizure

  • Factors associated with increased morbidity in SE

    • Time to the first dose of benzodiazepine in children with SE is often delayed or the drug not given until arrival at a hospital3

    • Delay in administration of the first anticonvulsant is associated with longer SE duration4

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CAUSES OF SE

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Prolonged febrile seizures and seizure due to remote neurologic injury account for 50% of SE cases in children.

  • Other common causes in order of frequency include

    • Acute new neurologic injury

      • Central nervous system (CNS) infection; cardiac arrest, stroke; traumatic brain injury; drug or toxin

    • Acute exacerbation of underlying epilepsy

      • Missed anticonvulsant or subtherapeutic levels

      • Intercurrent illness

    • Progressive neurologic disorder

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KEY PRINCIPLES OF SE MANAGEMENT

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  • After 5 to 10 minutes, most seizures will not stop unless treated with an anticonvulsant

  • Early, sequential administration of adequate doses of anticonvulsants is essential5

  • Treatment should be given in the field prior to arrival in the ICU

  • Identify and treat precipitating cause

  • Manage systemic complications

  • All units should have a management pathway and agreed on time frame for treatment6

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TREATMENT

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Incipient SE 0 to 5 minutes of seizure onset

  • Stabilize airway, breathing, and circulation

  • Obtain fingerstick glucose in first-line labs

  • Obtain IV access and administer IV benzodiazepine if seizure lasts 5 minutes

    • If IV access is not possible, administer benzodiazepine via intramuscular, intranasal, rectal, or buccal route (see Table 42-1)

    • Do not delay treatment in order to obtain IV access

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Early (5–30 min) and established (>30 min) SE (Figure 42-1)

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FIGURE 42-1

Summary of approach to management of pediatric status epilepticus and refractory status epilepticus.

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Table Graphic Jump Location
TABLE 42-1

Anticonvulsant Medications

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