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Scottish Paediatric Retrieval Service (Edinburgh)

www.paedsretrieval.com

Standard Operating Procedure – Status Epilepticus

Date written: October 2010

Review date:

Related documents:

Author: Emma-Beth Wilson

Approved by:

Aims

• To outline the treatment of Status Epilepticus

• To recognize complications of patients with prolonged seizure activity

Background

• Status Epilepticus is life threatening but mortality is lower in children (4%) than in

adults (10-20%).

• Death may be due to complications of the convulsion, such as obstruction of the

airway, hypoxia, and aspiration of vomit, overmedication, and cardiac arrhythmias or

to the underlying disease process.

• Status Epilepticus is defined as a seizure lasting 30 minutes or longer or when

successive convulsions occur so frequently over a 30-minute period that the patient

does not recover consciousness between them.

• It can be further divided into convulsive or non-convulsive.

• Fever and known epilepsy are the most common causes.

• Also consider CNS infection, hyponatraemia, head injury, space occupying lesion,

blocked VP shunt, overdose, hypoxia, ischaemia, and metabolic problem.

Application

• Referring hospital team, Retrieval doctors, ANPs, nursing staff and SAS paramedics.

Policy

1. Patients appropriate for retrieval team involvement

• Patients with prolonged seizure activity unresponsive to medical therapy

• Patients with potential airway problems due to seizure activity or medications used to

stop seizure

2. Acute medical management – See flowchart

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• Administer high flow oxygen

• Assess and monitor cardio-respiratory function

• Check blood glucose (give 2ml/kg 10% dextrose if hypoglycaemic). Aim for 4-6mmols/L

• Secure IV access. If IV access difficult or taking time give rectal diazepam 0.5mg/kg

(max 10mg) or buccal midazolam 0.5mg/kg (max 10mg).

• Once IV/IO access secured give IV/IO lorazepam 0.1 mg/kg (max 4mg).

• Repeat after 10 minutes if no response

• Ensure adequate airway and ventilatory drive maintained throughout. Contact

anaesthesia if any concerns.

3. Refractory status epilepticus

• This management should take place in a Resuscitation room/ICU/Anaesthetic room

• Paraldehyde 0.4ml/kg PR (8ml/kg of prepared solution)

• If patient not on phenytoin normally: Phenytoin 18mg/kg IV/IO over 30 min (make up

with 50ml normal saline and infuse at 50mg/min with ECG monitoring

• If patient is on phenytoin: Phenobarbitone 20mg/kg IV, give over 20 minutes – watch

for hypotension

• If seizure activity still present contact anaesthetic team for consideration of

anaesthesia to terminate seizures

4. Additional measures

• Check for hyponatraemia. If Na < 135 and still seizing or Na < 130 give consider bolus

of 3ml/kg 3% saline (discuss with PICU)

• Keep temp < 37°C

• If suspicion bacterial meningitis give ceftriaxone 80mg/kg IV, if encephalitis suspected

add aciclovir

• Check ammonia in neonate

Reassess and Consider:

• Ongoing seizures? (HR, BP, pupils). Aim to terminate seizures with midazolam

infusion. Bolus 0.1mg/kg then 20mcg/kg/min.

• Discuss any further management with PICU Consultant/Neurology

• CT if suggestion raised intracranial pressure or focal lesion

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