Status Epilepticus

Remember the ABC’s! ”Oxygen, suction, IV, monitors” is a good knee-jerk line to remember.
A- airway: insert a nasal trumpet if needed
B- breathing: administer oxygen via FM or bag mask ventilation; pulse ox; have
suction ready in case of emesis or significant secretions
C- circulation- IV access, ECG, and BP monitoring
- prolonged sz can cause shock-like stateàbolus NS prn
D- directed H&P, seizure hx and meds, head trauma, toxin exposure , meningitis
D- dextrose stick, check a glucose leve
De brain: look out for signs of increased ICP
  
(Cushings triad; HTN, bradycardia, irregular respirations)
  
Verify no blown pupils. May need neurosurgery
  
If neuro exam focal or h/o head trauma or bleeding d/o, consider non contrast CT

Stop the seizure:
1) Ativan – 0.1 mg/kg IV max dose 4 mg/dose. Be ready with BMV
Diazepam – 0.5 mg/kg PR. Max 5 mg/dose for <5 yo and 10 mg/dose for >5 yo
Versed 0.2 mg/kg IM
2) Wait and monitor for approx 5 min. Have someone draw p meds to be ready.
3) Repeat ATIVAN or VALIUM up to 2 more times at 5 min intervals
4) If still seizing load FOSPHENYTOIN 20 mg/kg slow over at least 20 min (1 mg
/kg/min)
Note: admin of fosphenytoin merits ECG monitoring secondarily to risk of bradycardia and arrythmias. May also cause groin pain if given too quickly
5) Wait and monitor for additional 5 -10min
6) If still seizing load FOSPHENYTOIN 10 mg/kg slow over at least 10 min (max
dose 30mg/kg total dosing)
7) If seizure continues intubate, call for an ICU bed, and load PHENOBARBITAL 20/kg slow IV push (causes resp depression, low BP) Note- if paralyzed for intubation, need cont EEG monitoring)
If seizure continues after 20 min give PHENOBARBITAL 10mg/kg, max dose 40 mg/kg (3 doses)
9) If seizure continues consider pentobarbital coma
10) Needs EEG monitoring for seizure activity of burst suppression

If unable to get IV access:

IM route: versed 0.2 mg/kg or FOSPHENYTOIN 20 mg/kg
Rectal Route: Valium 0.5 mg/kg, max dose 20 mg/dose, or Ativan 0.1 mg/kg

Management
Airway/Breathing
To intubate: ATROPINE (0.01 mg/kg), THIOPENTAL (2-5mg/kg). VECURONIUM (0.1MG/KG)
Do not give ketamine! Strongly consider lidocaine to suppress vagal response
Circulationà Fluid restrict unless patient hemodynamically unstable
The brainà call neurosurgery, get a head CT w/o contrast before LP!!!
In the meantime, you should:
1) Elevate head 30 degrees and keep midline
2) Mannitol 1 g/kg/bolus if impeding herniation (ok to repeat if serum osmalarity <320)
 - reduces the water content of the brain due to the establishment of an osmotic gradient between the brain and the intravascular compartment.
 - Mannitol is a large moleculeand will not cross the BBB.
 - Maximum effect is seen in 20 minutes and duration of action is 4 hours. Repeat doses of 0.25 to 0.5 gm/kg Q 4-6 hours are frequently used.
 - an administration set with a 0.22 micron filter must be used.
 - Adverse Effects: CHF, pulmonary edema, kidney failure
3) Consider 3% Saline 3-5 /kg over 30min-1 hr if serum osm >320
4) manage fever(which increases ICP) and prevent patient shivering ( may need NBM)
5) sedation/NMB to prevent increased ICP due to movement and agitation