Invictus Reviews

Pediatric Status Epilepticus: A Primer

• Mel Herbert

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Status epilepticus has been redefined from 30 minutes to just 5 minutes of continuous seizure activity, aligning better with current treatment approaches that emphasize early intervention. This includes recognizing non-convulsive status, which often presents as a prolonged postictal state with subtle eye movements or gaze deviation.

• Systematic assessment includes history of seizures, medications, shunts, trauma, potential ingestions
• Lab evaluation should include glucose, electrolytes, calcium, pregnancy testing when applicable
• Initial treatment involves two doses of benzodiazepines via IV, rectal, buccal, or intranasal routes
• Simplified dosing: midazolam/diazepam 0.2 mg/kg (max 10mg); lorazepam 0.1 mg/kg (max 4-5mg)
• Second-line agents include levetiracetam (60 mg/kg), fosphenytoin (20 PE/kg), or valproate
• For refractory status, consider ketamine, phenobarbital, or continuous infusions after intubation
• Propofol is generally avoided in children under age 3 and carries risk of propofol infusion syndrome

Season two of "The Pit" is in production with writers writing, actors acting, and producers producing. It's scheduled for release in January of next year.


Speaker 1:

Hey Invictus people, let's talk about pediatric status epilepticus. Let's take a section of one of the lectures that Eileen Claudius just laid down and I'll ask a few questions. First of all, do you know the new definition of status epilepticus? It has changed in the last few years. Do you have a systematic approach to the drug therapy? Initially of status epilepticus, hard to say In kids, a little bit different than in adults, and again also has changed over the last few years? Now, this is just a section of the full lecture because there's other things you've got to think about, like causes and work up on all that stuff. But we'll focus mainly on definitions and initial treatment here.

Speaker 1:

And then, before we start, a lot of people have been asking about the Pit. Yep, the Pit is in production right now, season two. We're writing lots of things. Production is occurring, actors are acting, writers are writing, producers are producing. It's all happening and I think you're really going to enjoy it and it is due and this is the question people have been asking to come out in January of next year. So without further ado, let's go with Eileen Claudius talking about PEDS status epilepticus.

Speaker 2:

So status is defined as more than five minutes of continuous seizure or individual seizures with a pause between but no return to the patient's neurologic baseline. So maybe a one minute seizure, four minutes of just lying there not waking up, and then another two minute seizure, would also be considered status. This is a huge change from when I was in training, because I was taught status was 30 minutes or more, but it's now five minutes, which is more in line with the way that we want to treat seizures. We don't want to wait 30 minutes to start treating status epilepticus. We want to wait five at most, and so this is kind of more in line with what we're actually doing. Clinically. Non-convulsive status can be very difficult and it can have a myriad of presentations, but I will say that what I see most frequently is a patient who had a convulsive seizure and then is just really having a prolonged postictal time. Maybe they still have some gaze deviation or some odd eye movements after the seizure, but they're really just not waking up as they should and that patient is probably still in status. It's just non-convulsive at this point. Sometimes we'll also see it in individuals that just have substantially altered mental status without another clear cause and in those cases the same medications used for clinical status can be used for subclinical status as well.

Speaker 2:

Now, my history in physical is pretty brief when I have a patient who's seizing beyond my ABCs. So I want to ask if they have a history of seizure, what medications they're on for that, as well as what other medications they're on If they have anything like a VP shunt, that might kind of throw you of throw a little bit of a curve ball into the situation. If they have a history of trauma and if they have a history of a potential ingestion and maybe the family will tell me oh yeah, they just took an overdose of a tricyclic antidepressant. But I do often just kind of pursue it a little bit further and say hey, does anyone in the house have tuberculosis? Just got started on isoniacid? What medications does this patient have access to? And then for my physical exam, I'm going to check for a fever, I'm going to make sure their blood pressure is okay, I'm going to see if I can find any focal neurologic findings, which sometimes can be hard to do when someone is seizing, but often it's relatively simple because the whole rest of the body is moving to notice if one part of the body is limp and not moving at all.

Speaker 2:

And then our lab evaluation. A patient who has a seizure comes in after the seizure looking 100% fantastic. It's a kid with no medical history. They're completely back at baseline. It was a two-minute seizure. There was no trauma. They look amazing.

Speaker 2:

They probably don't need any labs other than maybe a pregnancy test if it's a female of the appropriate age. But for somebody who is still seizing, I'm going to get a pretty broad lab workup. I'm going to check their glucose urgently. I'm going to get electrolytes with calcium. Obviously pregnancy testing. Unless the patient's family has already disclosed that they are pregnant, I'll confirm it as well.

Speaker 2:

Obviously, if they are on anticonvulsants that I can get levels of, I will get levels to check where those are. If it's appropriate, things like levothyroxetam, where there is a level available. It's not going to come back for a week. It's not really going to modify what I do. I'm not sending that. But something like carbamazepine, something like phenytoin, those levels I'm going to send off Toxic logic studies. I may end up doing some neuroimaging once. I've kind of temporized the situation. If this is a prolonged seizure without any obvious cause, if it's a patient that might have meningitis or encephalitis. They're probably going to get a lumbar puncture at some point when the situation is stabilized and absolutely I want this patient on a monitor. But for first-time seizures I will get an EKG just to make sure that it really is a seizure and it isn't sort of convulsive movements due to a primary cardiac arrest.

Speaker 2:

Now in terms of medications, I generally will start with two doses of a benzo. Certainly no one's going to fault you if you give three doses of a benzo but there isn't much efficacy beyond the first two doses. Of course the side effects are still going to build up. So if you don't have an IV when the patient comes in, obviously you're going to try to start one. Certainly you can go ahead and put in an IO line.

Speaker 2:

But there are medications that can be given that are relatively effective for status cessation even without having any parenteral access. Many of the benzos can be given IM. I have to say the absorption is somewhat variable. It takes a little while and I don't tend to prefer that route. But diazepam can be given rectally and a lot of families will actually have rectal preparations pre-mixed for home use. Midazolam can be given buccally. It can also be given nasally and the dose is 0.2 milligrams per kilo. So if you do have access to those nasal atomizers, giving midazolam nasally is a really fast and efficient way to terminate status epilepticus. Once you have your IV or IO established, I tend to start with lorazepam when we're not having a shortage, which seems like it's always these days. But diazepam, lorazepam, midazolam, they're all fine. The doses are there. If the seizure is not stopping in about two to five minutes, go ahead and repeat the dose. And do remember in kids when you're doing weight-based dosing, to obviously respect the maximums, because many children will reach those maximums pretty early.

Speaker 1:

Let me just jump in here for a second because I have a simplified way of thinking about this. Think of midazolam and diazepam as the same 0.2 milligrams per kilogram repeated dose up to a max of 10 milligrams, whereas lorazepam is 0.1 milligrams, half the dose and the max dose is four or five milligrams. So it's like these two diazepam, midazolam 0.2 to 10, and lorazepam 0.1 to a four or five. Is that helpful? Hope so.

Speaker 2:

If those two doses of benzos haven't worked, then I'm going to move on to a second line medication. There was a recent study looking at levothyrocytem versus phosphenetoin versus valproate and really they were all pretty equivalent when it comes to seizure cessation as well as side effects. They stopped the seizures in patients that were still seizing at this point in about half of the cases. So certainly not perfect, but relatively equivalent. Now the landmark study looking at this used a dose of levothyroxetam of 40 milligrams per kilo. Obviously, most of us have gone to using a higher dose of 60 milligrams per kilo. That having been said, if you prefer to start with phosphenetoin, that's absolutely fine and the dose there is going to be 20 phenytoin equivalents or kind of the equivalent of 20 grams per kilo. That can be given IV or IM, which is nice. It does cause a little bit more hypotension and you certainly can repeat a small dose of 5 if that's not working in 10 minutes.

Speaker 2:

Valproate I've used a lot less. It certainly does work. There are a fair number of side effects and a few contraindications. We tend to avoid it in the younger children although that is controversial metabolic patients as well. So what I usually do is I generally will start with my two doses of a benzo. If that doesn't work, I'll start with 60 milligrams per kilo of levothyroxetam IV, and if that doesn't work, I will load the patients on 20 phenytoin equivalents of phosphenytoin per kilo IV. Now, if that still doesn't work and your patient is still seizing, this is when I really start to get a little bit worried. Now I will say concurrently, I'm checking my labs and making sure there's nothing like hyponatremia that I need to be fixing, checking my temperature, all those other underlying reasons for a seizure, but if I haven't found one, my next step is usually going to be to load on something like phenobarbital at 20 milligrams per kilo. The problem with phenobarbital is you do get some respiratory depression and hypotension, so it may be required to intubate after giving that medication, which is probably okay, as you'll see when we get to the next slide. Usually, though, before trying phenobarbital, I will try ketamine.

Speaker 2:

It is a little bit controversial in status epilepticus, and whether you give a specific bolus dose or you give more of a small bolus and then a drip or multiple small boluses really depends on your center and your policy. There's not a clear winner. When you look overall at the literature, I personally will usually give a one milligram per kilo dose, and I'll give it slowly, just like I would in sedation, over 30 to 60 seconds, just as kind of a Hail Mary, before giving a medication that's probably going to cause me to have to really worry about that patient's airway. Now, at this point we are probably a little bit over 30 minutes into this seizure, and so I think that intubating if you have not stopped the seizure with all of those measures, even if the patient is still breathing, is definitely acceptable at this point. And if you've gotten to this point and the patient is still seizing, you're going to have to turn to your refractory status medications, all of which really do kind of force your hand to intubate as well. So at this point you can start a benzodiazepine drip with midazolam, you can start a pentobarbital drip or you can start propofol.

Speaker 2:

Propofol is kind of one of those things that you sort of know when you start it, that somebody is going to yell at you when you try to transfer that patient to the PICU. We tend to use a little bit less propofol in kids than we do in adults. It tends not to be recommended in children under the age of three years, and certainly if a patient is on a high dose propofol drip for a long period of time, they can get propofol infusion syndrome, where they get very acidotic, they get rhabdo electrolyte abnormalities and there is a high fatality rate For a short duration while you're trying to get refractory status under control. I don't think that it is unreasonable, particularly in a slightly older child, but there are other options as well, and propofol tends not to be the prioritized option. On the other hand, if I had an adult patient that had a relatively stable blood pressure, I think propofol would be a great option at this point in terms of treatment of refractory status.

Speaker 3:

Anytime I think about how do you get tested on status?

Speaker 1:

Oh, and for those of you that don't know, that is Matt Delaney. Matt is a faculty here at MRAP and at Invictus who has come on to do the heavy lifting here. So you're going to see a lot of Matt, If you haven't already. You've probably heard him a lot on the MRAP show and other stuff as well. But back to your emphasis there, Matt.

Speaker 3:

It's hard to keep all the drugs in mind, but the way that I've seen this pop up on the test a lot of the time, it's not that you have to pick. Should we use levotiracetam versus phosphonatoin? They really want to know that we recognize this idea that if someone is still seizing, we need to give adequate doses of the medication and then move to that second line, that third line agent. I think that's a big pearl that she just dropped. Also, that propofol, while we may reach for that really commonly in adults, probably is not that Hail Mary that we would throw for the pediatric patient. We're looking at third line agents.

Speaker 1:

All right, we're going to leave it there. There's much more to this lecture, which will be on the full Invictus show, which should be coming in the not too distant future, and just want to give you a sense of what we're doing, what we'll work on, how this is going to be different adding the emphasis doing all that stuff and and how this is going to be different adding the emphasis doing all that stuff and we'll talk to you soon here on the Invictus Free podcast. Herbert out.