Pediatric STATUS EPILEPTICUS: A-B-C-Drugs

Welcome back

From Philadelphia “The City of Brotherly Love” to your inbox -  a brand new Pediatric Emergency Medicine resource to educate, enlighten, and entertain! Hundreds of your colleagues have already signed up and are receiving the E-newsletter in their inbox!

The E-newsletter complements the highly successful and internationally available CHOP PEM Podcast—a great resource for anyone caring for critically ill and injured children—listen while working out, biking, driving, or trying to fall asleep.

DID YOU KNOW:

• Status Epilepticus [SE] was first described on Babylonian tablets in 600 BC

  

• Early treatment of status epilepticus is recommended — the longer the seizure, the more refractory it is to treatment

• Anti-Epileptic treatment SOON to be studied — a COMBINATION of ketamine and levetiracetam after failure of first-line benzos

• Both midazolam and diazepam nasal sprays are available for RESCUE therapy of status epilepticus in the pre-hospital setting
  

EVIDENCE-BASED ARTICLES: as discussed on the CHOP PEM Podcast on STATUS EPILEPTICUS

• First-line treatment for SE is lorazepam, right?? You may be surprised to read this! Lorazepam vs. Diazepam for Pediatric Status Epilepticus

• Med in the muscle or med in the vein - which is better? IM Midazolam vs. IV Lorazepam for Prehospital Treatment of Status Epilepticus

• After benzos, what is the next GO-TO drug to stop STATUS - Efficacy of Levetiracetam, Fosphenytoin and Valproate for Status Epilepticus

• Treatment delays and QI initiatives in SE—cutting edge ideas - Seizure Codes

CLINICAL PEARLS

• CHOP STATUS EPILEPTICUS Pathway

• CHOP ANTI-EPILEPTIC DRUGS

BREAKING NEWS: Thanks to Drs. Pam Okada, Sing-yi Feng and Craig Huang [editors of PEM Question Review book], we will now be bringing you access to PEM Board-Review questions in each newsletter. Please clink on this LINK to see info re: the MEDCHALLENGER PEM Board Review course/materials.

[Answers at bottom of E-Newsletter]

A) A 3 wo infant presents to the ED for abnormal facial twitching. During your exam, he begins to have facial and mouth twitching on the left followed by arm and leg movements, and then generalized tonic-clonic convulsions. You obtain IV access and determine that the glucose, sodium and ionized calcium levels are normal. After supporting the ABCs, which of the following is the most appropriate approach in management for this actively convulsing patient? 

1. Aggressively treat any witnessed seizure activity with anticonvulsants 

2. Administer half the normal pediatric anticonvulsant loading dose 

3. Administer phenobarbital until generalized convulsions stop; observe focal facial twitching closely 

4. Observe the patient until generalized convulsions exceed 5 minutes in duration, then treat with anticonvulsants 

5. Admit for video EEG, and determine appropriate anticonvulsant therapy once the EEG is reviewed 

B) A 7 yo boy known to have epilepsy presents to the ED with continuous tonic-clonic convulsions for about 10 minutes. He has been compliant with carbamazepine dosing. His T is 37ºC, HR 120, RR 36, BP 95/50, pOx 91% on RA, and his bedside glucose is 80 mg/dL. After the 2nd dose of lorazepam he starts to have diminished respiratory effort, and you decide to intubate him. What is the best choice of sedative in this rapid sequence intubation?  

1. Midazolam 

2. Etomidate 

3. Propofol 

4. Ketamine

5. No sedative agent is needed 

C) A 3 do infant presents in status epilepticus with persistent multifocal clonic seizures. She was the full-term product of an uncomplicated delivery, although the mother recalls some episodic, recurrent hammering type fetal movements in the days prior to delivery. Thus far, you have obtained bedside point of care testing, which reveals: Na 139, K 4.2, HCO3 22, and Glu 95. You have already given the patient 2 doses of IV lorazepam, 1 dose of IV phenobarbital, and 1 dose of IV fosphenytoin. The patient is maintaining her O2 saturation but continues to have seizure activity. Which of the following should be administered next? 

1. Topiramate 

2. Hypertonic saline 

3. Dextrose 

4. Pyridoxine 

5. Zonisamide 

LISTEN to the CHOP PEM Podcast on STATUS EPILEPTICUS featuring CHOP Neurologist Dennis Dlugos, MD [Director of the Section of Clinical Neurophysiology and the Epilepsy/Clinical Neurophysiology Fellowship. He holds the Catherine D. Brown Endowed Chair in Pediatric Epilepsy] and Children’s National PEM physician Jim Chamberlain, MD [Director, Data Analytics and Informatics]

BOARD REVIEW QUESTION: answers

A) answer = 1. Aggressively treat any witnessed seizure activity with anticonvulsants. Neonates are at high risk for seizures when compared to all other age groups. They are also more likely to have significant apnea with seizures, or to have subclinical seizures. Unlike seizures in older children, brief focal neonatal seizures can affect brain development and alter neuronal circuitry, resulting in impaired memory and learning. Neonates are more likely to have subclinical seizures for a period of time before the seizures become more clinically apparent. In addition, the differential diagnosis for neonatal seizures is broad. International expert consensus supports phenobarbital as first-line for neonatal seizure; however, phenobarbital and phenytoin are equally efficacious. If seizures persist after first-line anticonvulsant therapy, a trial of pyridoxine (vitamin B6) or folic acid pending metabolic studies should be considered. There is no role for withholding anticonvulsant therapy while a neonate is seizing, or for administering ½ the pediatric loading dose. Focal seizure activity should be as aggressively treated as generalized convulsions. While a Neurology consult and video EEG monitoring for neonatal seizures may be indicated, withholding anticonvulsants prior to EEG is not recommended.

B) answer = 5. No sedative agent is needed. The most common sedatives used in rapid sequence intubation (RSI) include ketamine, etomidate, and midazolam (or other benzodiazepines). Midazolam, like lorazepam, is a rapid- acting benzodiazepine with amnestic, anxiolytic, and anticonvulsant properties, so it is the sedative agent of choice for cardiovascularly stable patients presenting with status epilepticus if sedation is needed, but this would be duplicative of the lorazepam already given. In addition, since the patient has no awareness and is unresponsive to and unaware of external stimuli during a generalized tonic-clonic seizure, a sedative is unnecessary. Ketamine has a bronchodilating effect, making it useful for RSI of patients with severe bronchospasm requiring intubation. Etomidate is associated with myoclonus-resembling seizures. The frequency with which this occurs ranges from 10 to 80% in various reports. However, the etiology is not well-defined. Although etomidate has some anticonvulsant properties, it also appears to stimulate seizures in others. Propofol has significant myocardial depressant effects and lowers blood pressure and respiratory drive. These have made propofol an uncommon agent for use in RSI for children. Of note, lorazepam is a sedative, but does not have analgesic properties. Administration of an opioid is generally recommended as well

C) answer = 4. Pyridoxine. This infant’s presentation with multifocal clonic seizures refractory to traditional seizure medications is suggestive of an inborn error of metabolism such as pyridoxine-dependent seizures. In this clinical scenario, it is worthwhile trying an empiric dose of 100 mg IV pyridoxine to see if seizure activity terminates. While topiramate and zonisamide are excellent anti-epileptics drugs, they are not indicated in the management of status epilepticus. Dextrose would certainly be appropriate if the patient was hypoglycemic, but this patient’s glucose level is normal. Hypertonic saline would be appropriate if the patient was hyponatremic, perhaps secondary to improper formula mixing, but the patient has a normal sodium level as well.