Goals of treatment:

• To stop seizures
  
  
• Treatment of complications
  
  
• Treatment of underlying etiology

Seizure control should be achieved rapidly and effectively since duration of SE is a vital determinant in the response to treatment, mortality and neurologic sequelae. Thus, SE is divided into early stage (0-30 min), established (30-60 min) and late stages (more than 60 min).

Team approach (pediatric neurologist, anaesthetist and critical care staff) along with predetermined protocol management gives best results.

There are no standard internationally/nationally accepted protocols but the following flow chart gives the practical approach to managing a child with SE.

On admission in emergency:

• Diagnose SE (continuous seizures for more than 5-10min)
  
  
• Assess Airway/Breathing/Circulation, start O2 by nasal catheter
  
  
• Position, suction, oral airway without force
  
  
• IV/IO access - dextrostix/ S. electrolytes/ ABG
  
  
• Rapid evaluation for etiology
  
  
• Monitors - pulse oximeter, ECG.
  
  
  • If dextrostix low or unavailable - Inj 10% dextrose 4ml/kg followed by
    
    
  • Inj Lorazepam - 0.1mg/kg at 2mg/min
    
                                          OR
    
    Inj Diazepam - 0.2mg/kg (max 10mg) at 5 mg/min
    
    (can be repeated twice if sz do not stop after 5 min of inj )
    
    
  • Sz continue - Inj Phenytoin 20 mg/kg (or fosphenytoin, newer derivative, less adverse effects) at 1 mg/kg/min with monitoring of BP, HR, RR ( use normal saline flush, no glucose/Ca )
    
    
  • Szs continue - consider intubation , inj Phenobarbitone 20mg/kg at not more than 100mg/min
    
    
  • Sz continue - Repeat inj phenobarb 10mg/kg
    
    
  • Most seizures stop with above treatment.
    
    
  • No control with above measures, treat as refractory SE
    
    
  • Consider intubation and artificial ventilation & EEG monitoring
    
    
  • Treatment of complications-acidosis, shock, hyperthermia.
    
    
  • IV Midazolam - Bolus 0.2 mg/kg over 10 min followed by continuous infusion at 0.1 to 2 mg/kg/hour. End point of treatment is suppression of ictal discharges or burst suppression pattern on EEG if available or cessation of clinical seizures activity. Continue infusion for at least 12 hours and then taper. Watch for Hypotension, if present treat with IV fluids & low dose dopamine.
    
                                             OR
    
    IV Diazepam infusion
    
    
  • pentobarbital coma - load with 20-30 mg/kg & then 0.2-0.5 mg/kg/min infusion. Hypotension and respiratory depression more with this than midazolam, therefore latter is preferred.
    
    
  • Other options -- Lidocaine, isofluorane etc.
    
    
  Other options if IV access not available,
  
  IO (intraosseous)- all drugs that are given IV can be given in the same doses,
  IM (intramuscular)- Fosphenytoin, midazolam
  PR(per-rectal)- diazepam(0.5-1mg/kg), lorazepam (0.1-0.4mg/kg), valproate (20mg/kg).
  
  Prognosis: Prognosis is better in children than adults especially in the absence of acute CNS insult or chronic neuroprogressive disease. Mortality and morbidity have improved greatly with optimal seizure management.
  
  Febrile and idiopathic SE have the least morbidity.

Last created on 6-11-2000
Last updated on 01-07-2006