Status Epilepticus

Definition & Etiology - Seizure Storm Starters

• SE Definition: Continuous seizure activity for ≥5 minutes, OR ≥2 discrete seizures without full recovery of consciousness between episodes.
• Classification:
  • Convulsive (CSE) vs. Non-Convulsive (NCSE)
  • Refractory SE (RSE); Super-Refractory SE (SRSE)
• Common Pediatric Etiologies (📌 FIMETT):
  • Febrile SE (prolonged)
  • Infections (CNS: meningitis, encephalitis)
  • Metabolic (hypoglycemia, hyponatremia, hypocalcemia)
  • Epilepsy (subtherapeutic AEDs, acute illness)
  • Trauma (head injury)
  • Toxins (e.g., isoniazid, organophosphates)

⭐ The most common identifiable cause of SE in children is prolonged febrile seizures.

Pathophysiology & Clinical Features - Brain's Electrical Riot

• Pathophysiology: Seizure termination fails (↓ GABAergic inhibition via GABA-A receptor internalization) & excitation persists (↑ NMDA receptor activity/trafficking).
• Systemic Effects: Hyperthermia, lactic acidosis, rhabdomyolysis, hypoglycemia (early) / hyperglycemia (late), arrhythmias, BP changes.
• Clinical Features:
  • CSE (Convulsive Status Epilepticus): Overt tonic-clonic, tonic, clonic, or myoclonic seizures.
  • NCSE (Non-Convulsive Status Epilepticus): Subtle; altered mental status, confusion, lethargy, staring, automatisms, nystagmus. High suspicion needed; confirm with EEG.

⭐ After approximately 30 minutes of SE, GABA-A receptors decrease on the neuronal surface, making benzodiazepines less effective.

Initial Management (0-20 min) - Rapid Rescue Race

'Time is Brain'! Staged protocol.

• Stabilization (0-5 min):
  • ABCs. Oxygen. IV access.
  • Glucose check: if <60 mg/dL, give IV Dextrose (2-4 ml/kg D10W / 1-2 ml/kg D25W).
• Initial Therapy (5-20 min) - 1st Line BZDs:
  • IV Lorazepam: 0.1 mg/kg (max 4mg), repeat once.

    ⭐ IV Lorazepam: preferred 1st-line; longer CNS action vs Diazepam.

  • No IV: IM Midazolam 0.2 mg/kg (max 10mg).
  • Others: IV Diazepam (0.15-0.2 mg/kg, max 10mg); Buccal Midazolam; Rectal Diazepam.
• Labs: POC glucose, electrolytes, Ca, Mg, ABG, CBC, LFT, RFT, AED levels.

Second & Third Line Management - Backup Battle Plan

• Second Therapy Phase (20-40 min): If seizures persist post-2 Benzodiazepine doses.

  ⭐ Fosphenytoin is preferred over phenytoin for IV administration due to lower risk of local tissue injury and cardiovascular side effects.

• Third Therapy Phase (40-60 min) - Refractory SE (RSE): If seizures persist after adequate second-line agent. Requires PICU admission and continuous EEG.
  • Options: Continuous Midazolam infusion, Propofol, or Pentobarbital coma. ⚠️ Phenytoin: cardiac monitoring needed. Phenobarbital: risk of respiratory depression.

RSE, SRSE & Prognosis - Stubborn Seizure Saga

• Refractory SE (RSE): Seizure persistence despite adequate initial Benzodiazepine (BZD) AND a second-line Anti-Epileptic Drug (AED).
• Super-Refractory SE (SRSE): SE lasting ≥24 hours after anesthetic therapy initiation, or recurring on anesthetic withdrawal.
• Management (RSE/SRSE): Continuous EEG monitoring. Consider: Ketamine, Lidocaine, Magnesium, Pyridoxine (infants), Immunotherapy, Ketogenic diet, Hypothermia.
• Complications: Neuronal injury, cerebral edema, epilepsy, cognitive impairment. Systemic: aspiration, respiratory failure, arrhythmias.
• Prognosis: Worse with anoxic injury/CNS infection, longer SE duration, age extremes, poor initial treatment response.

⭐ Mortality in pediatric SE can be up to 3-5%, with higher rates in RSE/SRSE and specific etiologies like anoxia or CNS infections.

High‑Yield Points - ⚡ Biggest Takeaways

• Status Epilepticus (SE): Seizure lasting > 5 minutes or recurrent seizures without full recovery between episodes.
• Prioritize ABCDE (Airway, Breathing, Circulation, Disability, Exposure); check blood glucose immediately.
• First-line therapy: IV Lorazepam is preferred; IV Diazepam or IM/buccal/intranasal Midazolam are alternatives.
• Second-line agents: IV Phenytoin/Fosphenytoin, Valproate, or Levetiracetam if seizures persist post-benzodiazepines.
• Refractory SE: Requires ICU admission, continuous EEG monitoring, and agents like Midazolam infusion or Propofol.
• Always investigate and treat the underlying cause (e.g., infection, metabolic, hypoxia, trauma).
• Key complications include hypoxia, hyperthermia, acidosis, rhabdomyolysis, and potential neuronal damage if prolonged.