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PICU DIVISION
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 152.000 cases occur per year 42.000 deaths and inpatient cost
of $3.8 to $7 billion per year

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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

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 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

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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
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Behera CMK, et al, MJAFI 2005;61: 174-178
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 150/100.000
Incidence is more than twofold higher in children
younger than 5 years than in those older than 5
years

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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 2 6%

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Livingston J, Epilepsy in Children, 1996
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 O 2 sat

monitoring
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<18 months,
consider
pyridoxine 100
mg/IV

The order of phenytoin

and phenobarbital can
be interchanged in
infants younger than 18
months excepts in TBI
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Titrate midazolam to
seizure control by
increasing by 2 g/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
g/kg/min every 15 min

Persistent seizure in the

face of midazolam

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 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

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OTHER TREATMENT OF SE

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Nolan M, Beca J, Neurology, Oct 2004

Nolan M,Beca J, Neurology, Oct 2004
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
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 DISCONTINUING THERAPY
When the acute encephalopathy or encephalitis is
over and seizures have stopped, anticonvulsant
therapy should be discontinued.
There is no evidence that continuous

anticonvulsant therapy prevents the

development of epilepsy in such cases.

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 TRANSPORT TO AN APPROPRIATE
FACILITY
Further care and investigation at a hospital are
almost necessary.
First brief seizure, prolonged seizure
Unstable vital sign or continuing status epilepticus
require transport to a pediatric intensive care unit.

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