status epilepticus in children toni petrillo pediatric critical care children’s healthcare of...
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Status Epilepticus in Children
Toni Petrillo
Pediatric Critical Care
Children’s Healthcare of Atlanta
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Status epilepticus 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
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Status epilepticus 3
Definition Conventional definition:
Single seizure > 30 minutes
Series of seizures > 30 minutes without full recovery
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Status epilepticus 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 1999;15(2):119-29
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Status epilepticus 5
The longer SE persists,the lower is the likelihood of spontaneous cessationthe harder is it to controlthe higher is the risk of morbidity and mortality
Treatment for most seizures needs to be instituted after > 5 minutes of seizure activity
Bleck TP. Epilepsia 1999;40(1):S64-6
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Status epilepticus 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 1992;33 Suppl 4:S15-25
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Status epilepticus 7
Drugs which can cause seizures Antibiotics
Penicillins Isoniazid Metronidazole
Anesthetics, narcotics Halothane, enflurane Cocaine, fentanyl Ketamine
Psychopharmaceuticals Antihistamines Antidepressants Antipsychotics Phencyclidine Tricyclic antidepressants
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Status epilepticus 8
Mortality
Adults Children
15 to 22%
3 to 15%
Reviewed in: Fountain NB. Epilepsia 2000;41 Suppl 2:S23-30Reviewed in: Fountain NB. Epilepsia 2000;41 Suppl 2:S23-30
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Status epilepticus 9
Prolonged seizures
Duration of seizureDuration of seizure
Life Life threateningthreatening
systemicsystemicchangeschanges
DeathDeathTemporaryTemporary
systemicsystemicchangeschanges
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Status epilepticus 10
Respiratory Hypoxia and hypercarbia
- ventilation (chest rigidity from muscle spasm)- Hypermetabolism ( O2 consumption, CO2
production)- Poor handling of secretions- Neurogenic pulmonary edema?
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Status epilepticus 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 1994;35(1):27-34
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Status epilepticus 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 1996;37(5):428-32Johnston SC. Postictal pulmonary edema requires pulmonary vascular pressure increases. Epilepsia 1996;37(5):428-32
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Status epilepticus 13
Acidosis Respiratory Lactic
Impaired tissue oxygenation Increased energy expenditure
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Status epilepticus 14
Hemodynamics
Sympathetic overdrive Massive catecholamine /
autonomic discharge Hypertension Tachycardia High CVP
Exhaustion Hypotension Hypoperfusion
Exhaustion Hypotension Hypoperfusion
0 min0 min 60 min60 min
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Status epilepticus 15
Cerebral blood flow - Cerebral O2 requirement
Blood pressure
Blood flow
O2 requirement
Seizure duration
Hyperdynamic phase CBF meets CMRO2
Exhaustion phase CBF drops as
hypotension sets in Autoregulation
exhausted Neuronal damage
ensues
Hyperdynamic phase CBF meets CMRO2
Exhaustion phase CBF drops as
hypotension sets in Autoregulation
exhausted Neuronal damage
ensues
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Status epilepticus 16
GlucoseG
luco
se
Seizure duration
30 min
SE
SE + hypoxia
Hyperdynamic phase Hyperglycemia
Exhaustion phase Hypoglycemia
develops Hypoglycemia
appears earlier in presence of hypoxia
Neuronal damage ensues
Hyperdynamic phase Hyperglycemia
Exhaustion phase Hypoglycemia
develops Hypoglycemia
appears earlier in presence of hypoxia
Neuronal damage ensues
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Status epilepticus 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
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Status epilepticus 18
Other alterations Blood leukocytosis (50% of children) Spinal fluid leukocytosis (15% of children) K+
creatine kinase Myoglobinuria
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Status epilepticus 19
Oxygen, oral airway. Avoid hypoxia!
Consider bag-valve mask ventilation. Consider intubation
IV/IO access. Treat hypotension, but NOT hypertension
AA
BB
CC
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Status epilepticus 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
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Status epilepticus 21
Initial investigations
Labs Na, Ca, Mg, PO4 , glucose CBC Liver function tests, ammonia Anticonvulsant level Toxicology
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Status epilepticus 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
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Status epilepticus 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)
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Status epilepticus 24
Treatment Hyponatremia:
Give 5 cc/kg of 3% (hypertonic saline)
Hypocalcemia: Give 20-25 mg/kg of Calcium Chloride
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Status epilepticus 25
Treatment The longer you wait with anticonvulsant, the more
anticonvulsant you will need to stop SE Most common mistake is ineffective dose
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Status epilepticus 26
Anticonvulsants Rapid acting
plus
Long acting
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Status epilepticus 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
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Status epilepticus 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.
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Status epilepticus 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
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Status epilepticus 30
Anticonvulsants - Long acting Phenobarbital
20 mg/k g i.v. over 10 - 15 min Onset 15-30 min May cause hypotension, respiratory depression
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Status epilepticus 31
Initial choice of long acting anticonvulsants in SE
Is patient an infant?Is patient already receiving phenytoin?
Is patient an infant?Is patient already receiving phenytoin?
YesNo
At high risk for extravasation ?(small vein, difficult access etc.)?
Phenobarbital
YesYesNoNo
Phenytoin Fosphenytoin
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Status epilepticus 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
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Status epilepticus 33
Non - convulsive status epilepticus
How do you tell that patient’s seizures have stopped?
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Status epilepticus 34
Non - convulsive SE ? Neurologic signs after termination of SE are
common: Pupillary changes Abnormal tone Babinski Posturing Clonus May be asymmetrical
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Status epilepticus 35
Non - convulsive SE ?
Up to 20% of children with SE have non - convulsive SE after tonic - clonic SE
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Status epilepticus 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
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Status epilepticus 37
References Haafiz A, Kissoon N. Status epilepticus: current concepts. Pediatr Emerg
Care 1999;15(2):119-29. Bleck TP. Management approaches to prolonged seizures and status
epilepticus. Epilepsia 1999;40(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.