Treatment of Pediatric Status Epilepticus

Abstract

Status epilepticus is characterized by a prolonged, self-sustaining seizure or repeated seizures without return to baseline. The clinical manifestations of status epilepticus in children and adults range from overt generalized convulsions to more subtle behavioral manifestations, including unresponsiveness in the setting of the intensive care unit. Status epilepticus is the most common neurologic emergency of childhood. A large proportion of these episodes are the result of a prolonged febrile seizure or an acute symptomatic etiology. Fortunately, status epilepticus occurs without consequence for many children, but for others, it is correlated with long-term neurologic dysfunction or death. Treatment of status epilepticus should commence promptly upon its recognition, using predefined treatment protocols. The goal of treatment is the rapid termination of the seizure, to minimize the acute and chronic effects of this emergency and to allow for the prompt assessment and management of the underlying precipitant. Currently, the drug class of first choice in the in-hospital and out-of-hospital treatment of status epilepticus is the benzodiazepines, which may need to be quickly followed by a next-line agent, as the efficacy of the benzodiazepines is negatively correlated with seizure duration. Traditionally, these next-line agents have included phenobarbital and phenytoin, but emerging evidence supports the use of intravenous formulations of other antiepileptic drugs. If the first two agents fail, high-dose intravenous midazolam or anesthetic therapy should be rapidly initiated. This paper reviews the current treatment options and strategies for pediatric patients with status epilepticus.

Etiology, clinical course and response to the treatment of status epilepticus in children: A 16-year single-center experience based on 602 episodes of status epilepticus

“…28 Recently published protocol for SuperRefSE treatment 2 showed how challengeable is the treatment of this particular SE type. Since the most beneficial treatment algorithm for both children and adults is not known, 28 the data from this manuscript might be helpful in making better SE treatment approach in similar circumstances as in our hospital.…”

Long‐term outcomes of status epilepticus: A critical assessment

“…The first line usually consists of benzodiazepines, often followed by intravenous nonbenzodiazepine antiseizure medications (ASMs). If SE continues and becomes refractory, guidelines recommend transfer to the intensive care unit and additional anesthetic treatment, ideally within 30 or 40 minutes after SE onset 1, 2, 25. The most common drugs at this treatment stage are continuous infusions of midazolam, infusions of pentobarbital/thiopental, or intermittent phenobarbital doses 1.…”

“…The most common drugs at this treatment stage are continuous infusions of midazolam, infusions of pentobarbital/thiopental, or intermittent phenobarbital doses 1. Main adverse events may include respiratory depression and hypotension, and thus mechanical ventilation and blood pressure management are often needed 25. Currently, class I evidence supports the use of benzodiazepines as first‐line treatments, and a major randomized controlled trial is in progress in an attempt to obtain data supporting choices of second‐line treatment (Established Status Epilepticus Treatment Trial).…”

Refractory status epilepticus in children with and without prior epilepsy or status epilepticus

“…Both adults [13][14][15][16][17] and children [17][18][19][20] receive antiepileptic drugs (AEDs) later than recommended by most SE guidelines. [21][22][23] Most episodes of pediatric SE occur in children with no history of seizures. 1,19 However, there are no data on whether having a history of seizures or SE results in more timely treatment-including initial abortive medication and escalation of therapies-and better outcomes.…”