Treating Status Epilepticus in the Pediatric ER
1Pediatrics, Kangdong Sacred Heart Hospital, Republic of Korea
Statue epilepticus(SE) can occur in children regardless of prior epilepsy history and associated morbidity and mortality can be significant. Several population-based studies report that 3 to 42 episodes of SE occur in children per 100,000 population per year and mortality rate after SE ranges from 3 to 11%.
The definition of SE has changed since its introduction by Gastaut and his colleagues in 1962, and the Task Force of International League Against Epilepsy has announced that SE is a condition of abnormally prolonged seizures or repeated seizures, treatment of which must be initiated at designated time and their long-term sequelae can be expected after another set of time from the beginning of SE. These time table may vary from different seizure semiology, especially by the degree of motor activity and impairment of consciousness.
Due to its unpredictablitity and urgency, not many well-designed randomized controlled trials (RCTs) have been conducted for the management of SE, but prompt recognition and treatment of the seizures is reported to reduce neurological sequelae, number of additional status epilepticus and to have better clinical outcomes. The guideline for status epilepticus treatment proposed by American Epilepsy Society in 2016 recommends a timeline-based algorithm for convulsive seizures, lasting a minimum of five minutes. After allowing zero to five minutes of stabilization phase for monitoring and managing vital signs with laboratory testing, benzodiazepines(BZD) should be administered in the first-line therapy phase of five to 20 minutes, which should followed by a non-benzodiazepine of the second-line therapy phase, if the BZD fails. If the seizure persists unto the third-line therapy phase (40 to 60 minutes), a different second-line antiepileptic medication or general anesthetic drug must be given to the patient. This AES guideline are evidence-based on recent medical literature on SE treatment efficacy, safety and tolerability from infant to adults and recommends specific antiepileptic drug(AED) choice and dosage for each phase.
Other seizures such as focal status with impairment of consciousness or absence status epilepticus may have different timelines for initiation of treatment and target time of controlled seizures. EEG recordings can be utilized for these non-convulsive status epilepticus patients for accurate diagnosis and assessment of the treatment efficacy. While intravenous administration of benzodiazepine is commonly recommended, alternative route such as intranasal, buccal and intramuscular benzodiazepines can also be considered especially in emergencies.
If intravenous anesthetic drugs of the third-line therapy step don’t work in cases of refractory SE or super-refractory SE, various modalities or new antiepileptic medications have been tried successfully in some cases. New drugs such as lacosamide or perampanel are available and other non-pharmacologic treatments such as vagal nerve stimulation or deep brain stimulation, ketogenic diet, hypothermia and more are recent additional options.
Evidence-based guidelines are available for proper management of status epilepticus in children with numerous alternatives. Prompt recognition and appropriate control of the seizures are critical in reducing morbidity and mortality of status epilepticus and competent understanding and practice of the guideline cannot be stressed enough.