1. Status epilepticus
PICU DIVISION

2. DEFINITION Status Epilepticus (SE)
“ seizures occur so frequently that over the course of 30 or more minutes, he or she has not recovered from the coma produced by one attack before the next attack supervenes
SE is one of the few true emergencies in the practice of pediatric neurology
US :
Estimated cases occur per year  deaths and inpatient cost of $3.8 to $7 billion per year

3. MODIFIED CLASSIFICATION OF SE
Generalized SE
Convulsive
Nonconvulsive (i.e. absence or following prolonged convulsion)
Focal SE
Simple : without altered conciousness
Complex : with altered conciousness

4. General convulsive SE (GCSE) consist of :
continuous clonic or tonic motor activity with bilateral epileptiform discharges on the EEG
As GCSE progresses, motor movements are reduced and may be characterized only by subtle twitching of the limbs, face, or trunk  called subtle GCSE
Nonconvulsive SE (NCSE) consist of :
continuous electrographic seizure with no motor movements
May occur after prolonged GCSE

5. Generalized convulsive SE ( GCSE ) - Primary generalized
Classification
Generalized convulsive SE ( GCSE )
- Primary generalized
- Tonic-clonic
- Myoclonic
- Clonic / Tonic
Secondary generalized SE
- Partial seizures with secondary generalization
- Tonic seizures
Non-convulsive SE ( NCSE )
- Absance status ( Petit Mal )
- Atypical absance status
- Atonic
- NCSE due to partially treated GCSE
Partial SE
- Simple partial : * Typical
* Epilepsia partialis continua
- Complex partial SE ( CPSE )
Neonatal SE
Behera CMK, et al, MJAFI 2005;61:

6. incidence The incidence of SE peaks during young and old age
In infants younger than 1 year, the incidence of SE may be as high as 150/
Incidence is more than twofold higher in children younger than 5 years than in those older than 5 years

7. etiology Fever 20 – 29% Idiopathic 16 – 39% Chronical static of CNS
( remote symptomatic ) 14 – 23%
Acute symptomatic 23 – 40%
- CNS infection
- Traumatic Brain Injury
- Hypoxic-Ischaemic
- Cerebrovaskular
- Intoxication
- Metabolic/Electrolyte Disturbances
- Tumor
- Acute AED withdrawal
Progressive encephalopathy – 6%
Livingston J, Epilepsy in Children, 1996

8. Treatment of SE
Principal goal of therapy in SE is to abort the seizure before irreversible neuronal injury occurs (after 20 min – 1 hr of continuous seizure activity)
Securing airway
Maintaining adequate ventilation and circulation
Positioned on their sides with the head below the torso to minimize the risk of aspiration
Insert oral or nasopharyngeal airway
Early intubation  if oxygenation is inadequate
Applied a cardiac monitor and transcutaneous O2 sat monitoring

9. PROTOCOL FOR THE DRUG TREATMENT OF SE IN CHILDREN
<18 months, consider pyridoxine 100 mg/IV
5 min
Lorazepam, dose : 0,1mg/kg, max 4 mg, PR/IV
Diazepam 0,05-0,3 mg/kg
10 min
15 min
Phenytoin, dose 20 mg/kg, max 1 gr
The order of phenytoin and phenobarbital can be interchanged in infants younger than 18 months excepts in TBI

10. Persistent seizure in the face of midazolam
35 min
Phenobarbital, dose 20 mg/kg, max 1 gr,
45 min
Midazolam, dose 0,15 mg/kg/IV bolus followed by 2 µg/kg/min infusion then titrate to max 24 µg/kg/min
Thiopentone, bolus 2-4 mg/kg followed by 2-4 mg/kg/hr infusion
Titrate midazolam to seizure control by increasing by 2 µg/kg/min every 5 min and with boluses of 0,15 mg/kg as needed, if no seizure in 48 hrs, taper midazolam by 1 µg/kg/min every 15 min
Persistent seizure in the face of midazolam

11. Based on EEG suppression of epileptiform discharges; use additional boluses of
2 mg/kg with increase in infusion rate of 1 mg/kg/hr every 30 min to 6 mg/kg/hr as
needed
Discontinue midazolam and phenobarbital once thiopentone infusion started
Maintain phenytoin at therapeutic level
Consider vasopressor support
Monitor thiopentone levels
If no seizures for 48 hours, taper over 12 hr in 25% decrements and reinstitute phenobarbitone while tapering

12. OTHER TREATMENT OF SE
Nolan M, Beca J, Neurology, Oct 2004

13. Nolan M,Beca J, Neurology, Oct 2004

14. REFRACTORY STATUS EPILEPTICUS (rse)
Def : characterized by seizures that persist beyond 60 min and fail to respond to first- and second-line therapy
Prolonged therapy for sustained RSE may be required
Although it is virtually always possible to control seizures with high-dose seizure-suppressive medication, complete remission is not always possible when these high-dose medications are withdrawn  poor outcome, especially with all children having medically intractable epilepsy and developmental deterioration
Sustained RSE is most often associated with viral encephalitis or postinfectious process

15. THANK YOU