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Status Epilepticus - Pediatric - Emergency Department/Inpatient

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Status Epilepticus - Pediatric -
Emergency Department/Inpatient
Clinical Practice Guideline
Note: Active Table of Contents – Click to follow link
Table of Contents
EXECUTIVE SUMMARY ........................................................................................................... 3
SCOPE ...................................................................................................................................... 3
METHODOLOGY ...................................................................................................................... 4
DEFINITIONS ............................................................................................................................ 5
INTRODUCTION ....................................................................................................................... 5
RECOMMENDATIONS .............................................................................................................. 5
Goals of treatment ............................................................................................................. 5
Treatment timeline ............................................................................................................. 6
Additional diagnostic measures: ........................................................................................ 9
Considerations for post-seizure management ................................................................... 9
UW HEALTH IMPLEMENTATION ............................................................................................. 9
Figure 1. Pediatric Status Epilepticus Algorithm ...............................................................11
REFERENCES .........................................................................................................................12
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2
CPG Contact for Content:
Name: Megan Peters, MD ± Pediatric Critical Care Medicine
Phone Number: (608) 263-6135
Email Address: mpeters@pediatrics.wisc.edu
CPG Contact for Changes:
Name: Philip Trapskin, PharmD, BCPS- Pharmacy, Drug Policy Program
Phone Number: (608) 265-0341
Email Address: ptrapskin@uwhealth.org
Guideline Author(s):
Megan Peters, MD ± Pediatric Critical Care Medicine
Coordinating Team Members:
David Hsu, MD ± Pediatric Neurology
James Svenson, MD ± Pediatric Emergency Medicine
Ann Allen, MD ± Pediatric Hospitalist Medicine
Teresa Darcy ± Laboratory
Meghann Voegeli, PharmD ± Pharmacy Manager
Joshua Vanderloo, PharmD ± Pharmacy, Drug Policy Program
Monica Bogenschutz, PharmD ± Pharmacy, Inpatient Services
Susan Quamme, RN ± Pediatric Intensive Care
Mary J Erschen, RN ± Pediatric Emergency Medicine
Kylie McGinn, RN ± Nursing- Pediatric Universal Care
Lori Williams, RN ± Nursing- Pediatric Universal Care
Lindsey Spencer, MS- Center for Clinical Knowledge Management (CCKM)
Committee Approvals/Dates:
Pharmacy & Therapeutics Committee (May 2016)
Release Date: May 2016 | Next Review Date: May 2018
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3
Executive Summary
Guideline Overview
This clinical practice guideline is intended to guide clinicians in the management of status epilepticus for
pediatric patients over the age of two months. Graded recommendations for medication selection, dosing,
precautions, and route of administration are provided.
Key Practice Recommendations
Goals of therapy for pediatric patients presenting in status epilepticus are as follows:
1. Stop seizure as soon as possible.
1.1. Rapidly recognize and treat reversible causes of seizure, including hypoxia, acidosis,
hypoglycemia, or electrolyte disturbance.
1.2. Choose medications in regimented fashion according to clinical pathway.
2. Anticipate need for next antiepileptic drug and administer in a timely fashion.
2.1. Administer at least 3 antiepileptic medications in the first 60 minutes of continuous seizure
activity.
3. Maintain adequate airway, breathing, and circulation throughout treatment.
3.1. Patients must be monitored by heart rate, blood pressure, and oxygen saturation.
3.2. Maintenance of adequate cardiac output and oxygen delivery throughout treatment of seizure is
vital.
Companion Documents
1. Status Epilepticus Algorithm
2. Fosphenytoin and Phenytoin ± Adult/Pediatric ± Inpatient Guideline
3. Intranasal Medication Administration ± Adult/Pediatric - Inpatient/Ambulatory Guideline
4. UW Health Pediatric Hypoglycemia Algorithm
5. Maintenance of Ketogenic Therapy ± Pediatric ± Inpatient/Ambulatory Guideline
Scope
Disease/Condition: Status epilepticus
Clinical Specialty: Pediatric Emergency Medicine, Critical Care, Hospitalists, General Care
Intended Users: Pediatric physicians (residents, fellows, and attendings), Advanced Practice
Providers, Nurses, Pharmacists, Respiratory Therapists
Objective(s): To decrease unintended variability in caregiver practice and to minimize delays in
providing care to pediatric patients in status epilepticus, by providing guidance and evidence-based
recommendations for the acute evaluation and management of status epilepticus.
Target Population: This guideline targets pediatric patients over 2 months of age presenting in status
epilepticus LQ�WKH�LQSDWLHQW�FDUH�DUHDV�RI�WKH�$PHULFDQ�)DPLO\�&KLOGUHQ¶V�+RVSLWDO.
Interventions and Practices Considered:
ξ Antiepileptic drug therapy
ξ Pharmacologic coma
Major Outcomes Considered:
ξ Cessation of seizure activity
ξ Maintenance and/or adequate support of hemodynamic stability and gas exchange throughout
therapy
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4
Methodology
Methods Used to Collect/Select the Evidence:
Electronic database searches (e.g., PUBMED) were conducted by the guideline author(s) and workgroup
members to collect evidence for review. Expert opinion and clinical experience were also considered
during discussions of the evidence.
Methods Used to Formulate the Recommendations:
The workgroup members agreed to adopt recommendations developed by external organizations and/or
arrived at a consensus through discussion of the literature and expert experience. All recommendations
endorsed or developed by the guideline workgroup were reviewed and approved by other stakeholders or
committees (as appropriate).
Methods Used to Assess the Quality of the Evidence/Strength of the Recommendations:
Recommendations developed by external organizations (e.g., Neurocritical Care Society (NCS))
maintained the evidence grade assigned within the original source document and were adopted for use at
UW Health.
Internally developed recommendations (labeled with UW Health), or those adopted from external sources
without an assigned evidence grade, were evaluated by the guideline workgroup using the Grading of
Recommendations Assessment, Development and Evaluation (GRADE) methodology.
Rating Scheme for the Strength of the Evidence/Recommendations:
GRADE Ranking of Evidence
High Further research is very unlikely to change our confidence in the estimate of effect.
Moderate Further research is likely to have an important impact on our confidence in the estimate of
effect and may change the estimate.
Low Further research is very likely to have an important impact on our confidence in the
estimate of effect and is likely to change the estimate.
Very Low Any estimate of effect is very uncertain.
GRADE Ratings for Recommendations For or Against Practice
Strong The net benefit of the treatment is clear, patient values and circumstances are unlikely to
affect the decision.
Weak Recommendation may be conditional upon patient values and preferences, the resources
available, or the setting in which the intervention will be implemented.
Recognition of Potential Health Care Disparities: No disparities were identified specifically for
pediatric patients in status epilepticus; however the North American Commission of the International
League Against Epilepsy attempted to identify known disparities in epilepsy care via a systematic review
of the published literature.1
Little research exists which directly evaluates the role of socioeconomic status (SES), gender,
race/ethnicity, age, education, and comorbidities in relation to outcomes following medical treatment for
people with epilepsy. The published data are not sufficient to reach conclusions regarding the
relationships between these factors; however some associations have been demonstrated. Among
patients with epilepsy, children have a higher use of neurologists, the emergency room and hospital
admissions independent of socioeconomic status or urban/rural residence. Anti-epileptic drug compliance
is also lower in Medicaid and uninsured patients, those with a lower socioeconomic status, and in patients
with poorer communication with clinicians. Further research using larger sample sizes which directly
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5
evaluates patient factors (including SES, race/ethnicity, gender, geographic locations) and their role in
clinical outcomes is needed.
Definitions2
1. Status epilepticus (SE) should be defined as 5 minutes or more of continuous clinical and/or
electrographic seizure activity or recurrent seizure activity without return to baseline mental status
between seizures. (NCS Strong recommendation, moderate quality evidence)
2. SE should be classified as convulsive (associated with rhythmic jerking movements) or
nonconvulsive (electrographic seizure activity without associated convulsive movements). (NCS
Strong recommendation, high quality evidence)
3. Refractory status epilepticus (RSE) should be defined as status that does not respond to standard
treatment regimens, which includes benzodiazepine and a second antiepileptic drug. (NCS Strong
recommendation, moderate quality evidence)
Introduction
Status epilepticus (SE) is defined as continuous seizure activity lasting beyond 5 minutes OR repeated
seizures without an interim return to baseline mental status. Status epilepticus is a medical emergency
necessitating three simultaneous actions: stabilization and continuous support of airway, breathing, and
circulation; rapid identification and management of precipitant causes; and administration of
anticonvulsant medication to halt the seizure as quickly as possible. SE is the most common neurologic
emergency in children, with an incidence of 18-23 per 100,000 children per year.3 In retrospective studies
of pediatric patients, mortality from SE ranged from 3-11%.3
While the classification of refractory status epilepticus (RSE) had once been established according to the
duration of seizure activity, now it is defined as clinical or electrographic seizure activity that continues
despite administration of adequate initial benzodiazepine and a second antiepileptic drug.2 Several
studies of pediatric patients in status epilepticus have drawn associations between delays in management
and prolonged seizure or decreased effectiveness of therapy: the longer a seizure continues the more
refractory it becomes and the more difficult it is to stop.4-8 As seizures continue, the risk for additional
morbidity and mortality is also greater. A new neurologic deficit occurred in 36% of children with RSE.9 A
meta-analysis of RSE in children found mortality to be 20%.10
These studies reinforce the need to treat SE as expeditiously as possible. Additional studies in the
pediatric literature have demonstrated that unintended variation in physician practice has led to delays in
patient care²both delays in accurate diagnosis of seizure etiology and in administration of anti-seizure
medication²as well as additional morbidity from respiratory depression from suboptimal dosing of
benzodiazepine.11-13 This guideline is intended to mitigate these issues and expedite decision-making at
the bedside.
Recommendations
Goals of treatment
1. The treatment of SE should occur rapidly and continue sequentially until clinical seizures are halted.2
(NCS Strong recommendation, high quality evidence)
2. Critical care treatment and monitoring should be started simultaneously with emergent initial therapy
and continued until further therapy is successful or futile.2 (NCS Strong recommendation, moderate
quality evidence)
3. General treatment considerations
3.1. The etiology of SE should be diagnosed and treated as soon as possible. (NCS Strong
recommendation, high quality evidence)
3.2. Benzodiazepines should be given as emergent initial therapy.2,14 (NCS Strong recommendation,
high quality evidence)
3.2.1. Lorazepam is the drug of choice for intravenous (IV) or intraosseous (IO) administration.
(NCS Strong recommendation, moderate quality evidence)
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3.2.2. Midazolam is the drug of choice for intranasal (IN) or intramuscular (IM) administration.
(UW Health Strong recommendation, moderate quality evidence)
3.2.3. Rectal diazepam can be given when there is no IV or IO access and IM or IN
administration of midazolam is contraindicated. (NCS Strong recommendation,
moderate quality evidence)
3.3. Intravenous fosphenytoin/phenytoin should be the drug of choice for urgent control AED therapy
(NCS Strong recommendation, moderate quality evidence), except in the following scenarios:
3.3.1. Patient has a history of cardiac dysrhythmia
3.3.2. Patient presents in myoclonic or absence status epilepticus
3.3.3. 3DWLHQW¶V�KRPH�DQWLHSLOHSWLF�GUXJ�UHJLPHQ�DOUHDG\�LQFOXGHV�SKHQ\WRLQ
Treatment timeline
1. Zero to 5 minutes ± Rapid assessment of pediatric patients in convulsive or nonconvulsive status
epilepticus by MD and RN
1.1. Assessment and support of airway, breathing, circulation (UW Health Strong recommendation,
low quality evidence)
1.1.1. Application of appropriate monitoring devices15:
ξ Continuous cardiac rhythm monitoring
ξ Continuous pulse oximetry
ξ Blood pressure cuff to be measured every 5 minutes
1.1.2. Application of high concentration oxygen in the setting of hypoxemia (in general, this
may include a non-UHEUHDWKHU�R[\JHQ�PDVN��VHW�WR�D�IORZ�RI�R[\JHQ�DERYH�WKH�SDWLHQW¶V�
minute ventilation. Note, however, that provision of oxygen may mask low oxygen
saturation caused by hypoventilation, and this will not be helped solely by oxygen
supplementation. Bag-mask ventilation is indicated in the situation of hypoxemia caused
by hypoventilation.
1.2. Note time of seizure onset. Document this time in HealthLink in a progress note.
1.3. Stop any ongoing enteral feeds.
1.4. If the patient is on ketogenic therapy as part of his/her home regimen avoid using dextrose-
containing fluids.
1.5. Establishment of IV or IO access.
1.6. Assessment of POC glucose and correction of hypoglycemia (see UW Health Pediatric
Hypoglycemia Algorithm for details)
1.6.1. Peripheral access: 5 mL/kg of dextrose 10% IV solution
1.6.2. Central access: 2 mL/kg of dextrose 25% IV solution
1.6.3. If the patient is on ketogenic therapy and is hypoglycemic, use the Maintenance of
Ketogenic Therapy ± Pediatric ± Inpatient/Ambulatory Clinical Practice Guideline for
management.
1.7. Assessment of physical examination, including neurologic examination
1.8. Acquisition of laboratory samples, including, but not limited to2,16 (UW Health Weak
recommendation, low quality evidence):
ξ Serum electrolytes ± sodium, potassium, chloride, bicarbonate, calcium (total and
ionized), and magnesium
ξ Blood urea nitrogen and creatinine
ξ Complete blood count with differential
ξ Antiepileptic drug concentrations, which may include phenytoin and phenobarbital
or other antiepileptics that a patient may be on as an outpatient. Consider
discussing with Neurology what medications may require drug concentrations.
ξ If the patient is on ketogenic therapy, obtain a blood gas and a beta-
hydroxybutyrate level.
ξ Other labs that may be warranted depending on presentation include blood culture,
urine culture, assessment of hepatic function, coagulation panels, assessment of
inborn errors of metabolism, or toxicology screen.
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2. After 5-10 minutes of seizure – Emergent Therapy
2.1. The first drug administered must be benzodiazepine (NCS Strong recommendation, high quality
evidence)
2.2. Administer a maximum of two first-line treatment doses (including pre-hospital treatment).2
2.3. IV or IO access
2.3.1. The first medication, to be administered after 5 minutes of continuous seizure activity is
lorazepam 0.1 mg/kg (UW Health Strong recommendation, high quality evidence)
2.3.1.1. Maximum dose: 4 mg
2.3.1.2. To be administered over 2 minutes
2.3.2. The second medication, to be administered after 10 minutes or continuous seizure
activity is lorazepam 0.1 mg/kg (UW Health Strong recommendation, high quality
evidence)
2.3.2.1. Repeat maximum dose: 4 mg
2.3.2.2. To be administered over 2 minutes
2.4. No IV or IO access
2.4.1. Frist and second medications, to be administered at 5 and 10 minutes is midazolam.
Route of administration may depend on availability of formulation. 14
2.4.1.1. Intramuscular: midazolam 0.1 to 0.2 mg/kg, maximum dose 10 mg. (NCS
Strong recommendation, moderate quality evidence)
2.4.1.2. Buccal or intranasal: Midazolam 0.2 to 0.5 mg/kg, maximum dose 10 mg. (UW
Health Strong recommendation, high quality evidence)
2.4.1.2.1. Half of the dose of intranasally administered midazolam should
be given in each nostril via an atomizer (see Intranasal
Medication Administration ± Adult/Pediatric -
Inpatient/Ambulatory Clinical Practice Guideline for further
details); the volume drawn up should be 0.1 mL more than the
volume to be administered in order to account for dead space in
the atomizer device.
2.5. If administering second medication, order STAT and prepare to administer a third medication.
This will give pharmacy adequate time to prepare the medication and have it available should
the seizure continue.
3. After 20 minutes of seizure, in spite of adequate therapy with benzodiazepine –
Urgent Therapy – options for third medication
3.1. IV or IO access
3.1.1. Fosphenytoin 20 PE/kg IV will be the drug and dose of choice for most patients.2 (UW
Health Strong recommendation, moderate quality evidence) (See Fosphenytoin and
Phenytoin ± Adult/Pediatric ± Inpatient Clinical Practice Guideline)
3.1.1.1. Maximum dose: 1 gram.
3.1.1.2. Maximum rate of administration will be 150 PE/minute.
3.1.1.3. Fosphenytoin prolongs cardiac ventricular repolarization/QT interval; consider
alternative therapy in patients with history of cardiac arrhythmia.
3.1.1.4. Consider alternative therapy in patients already taking phenytoin as part of
their home antiepileptic drug regimen.
3.1.1.5. Absence or myoclonic status epilepticus are relative contraindications to
treatment with fosphenytoin or phenytoin.17,18
3.1.2. Phenobarbital 20 mg/kg IV is an acceptable alternative therapy for patients who not
suited to therapy with fosphenytoin.2 (UW Health Weak recommendation, low quality
evidence)
3.1.2.1. Maximum dose: 1 gram.
3.1.2.2. Maximum rate of administration: 30 mg/min.
3.1.2.3. Is commonly selected as first drug of choice for neonatal patients in status
epilepticus.
3.1.2.4. Consider as a first drug choice for patients presenting in febrile status
epilepticus.19
3.1.2.5. Causes respiratory depression and hypotension ± be prepared to support
airway and circulation.
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3.2. No IV or IO access
3.2.1. Fosphenytoin 20 mg/kg IM.2 (UW Health Strong recommendation, moderate quality
evidence)
3.2.1.1. Maximum dose: 1 gram.
3.2.1.2. Same medication considerations apply for IM administration as for IV
administration.
3.2.2. Phenobarbital 20 mg/kg IM.2 (UW Health Weak recommendation, low quality evidence)
3.2.2.1. Maximum dose: 1 gram
3.2.2.2. Same medication considerations apply for IM administration as for IV
administration.
4. If seizures continue beyond 30 minutes in spite of administration of emergent and urgent therapies,
Pediatric Neurology should be consulted to guide additional medication selection in the setting of
refractory status epilepticus. (UW Health Weak recommendation, very low quality evidence)
5. After 30 minutes of seizure – Refractory Therapy – options for additional medications
5.1. Levetiracetam2 (UW Health Weak recommendation, low quality evidence)
5.1.1. Recommended dose is 30 to 60 mg/kg IV with maximum dose of 2.5 grams.
5.1.2. Levetiracetam is a relatively safe medication with few drug interactions.
5.2. Valproate2 (UW Health Strong recommendation, moderate quality evidence)
5.2.1. Recommended dose is 20 to 40 mg/kg IV with maximum dose of 1 gram.
5.2.2. Valproate should not be used in patients 2 years of age and younger
5.2.3. Valproate should be used with caution in patients with liver disease or metabolic
disease.
6. Providers should administer three distinct antiepileptic medications within the first 60 minutes of
continuous seizure activity. This includes the two doses of emergent benzodiazepine AND two
additional antiepileptic medications. (UW Health Weak recommendation, low quality evidence)
7. Over 60 minutes of continuous seizure activity
7.1. If the patient has not already been intubated, establish stable airway.
7.2. Continue to support circulation as needed with vasoactive infusion.
7.3. Consider repeat boluses of antiepileptic drugs.2,14 (UW Health Weak recommendation, low
quality evidence)
7.3.1. In general, more success with cessation of seizure may be found in trying a different
therapeutic agent, rather than in maximizing dose of drugs that have already been
utilized.
7.3.2. Fosphenytoin 5 mg PE/kg every 10 minutes until maximum dose is met (1 gram).
7.3.3. Phenobarbital 5 mg/kg IV every 10 to 20 minutes until maximum dose is met (1 gram).
7.3.4. Valproate 20 mg/kg IV every 10 to 20 minutes until maximum dose is met (1 gram).
7.4. Induce pharmacologic coma.2,14 (UW Health Weak recommendation, low quality evidence)
7.4.1. Midazolam
7.4.1.1. Loading dose 0.2 mg/kg IV
7.4.1.2. Continuous infusion 0.05-0.4 mg/kg/hr IV
7.4.2. Pentobarbital
7.4.2.1. Loading dose 5 to15 mg/kg IV
7.4.2.2. Continuous infusion 1 to 3 mg/kg/hr IV
7.4.2.2.1. If continuous pentobarbital is considered, single dedicated IV line
will be required due to numerous medication incompatibilities
with pentobarbital.
7.4.2.3. Patients receiving continuous pentobarbital should be monitored for propylene
glycol toxicity.
7.4.2.4. If the patient receives ketogenic therapy at home, avoid, if possible, the use of
pentobarbital for treatment of refractory status epilepticus, as the
carbohydrate-rich formulation will reverse ketosis.
7.4.2.5. Pentobarbital has limited compatibility in normal saline in pediatric patients
due to concentrations.
7.4.2.6. Avoidance of extravasation is critical.
7.4.3. Propofol
7.4.3.1. Loading dose 1 to 2 mg/kg IV
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9
7.4.3.2. Continuous infusion 50 to 150 mg/kg/minute IV
7.4.3.2.1. Continuous propofol infusion beyond 12 hours may require
parental consent given risk of propofol infusion syndrome in
pediatric patients receiving prolonged continuous infusions.
7.5. Discuss merits of continuous EEG monitoring with Pediatric Neurologist on call.
7.5.1. Continuous EEG may be used to demonstrate effectiveness of therapies once patient is
being placed in a pharmacologic coma.
7.5.2. Continuous EEG may also be of value in diagnosing subclinical status epilepticus for the
patient whose convulsions have stopped but mental status remains altered.
Additional diagnostic measures:
1. Lumbar puncture should be performed in any child who has fever, seizure, and meningeal signs and
symptoms.20 (UW Health Strong recommendation, moderate quality evidence)
2. Urgent EEG monitoring
2.1. Incidence of subclinical status epilepticus is 14% in adult patients who stop having convulsions
but in whom consciousness does not return. Though nonconvulsive/subclinical status epilepticus
does occur in the pediatric population, data to support routine diagnosis of subclinical status
epilepticus is less robust.16
2.2. Discuss with Pediatric Neurologist the need for urgent and/or continuous EEG for diagnosis of
subclinical status epilepticus once convulsions have been controlled with antiepileptic therapies.
2.3. Dosing of continuous infusion AEDs for RSE should be titrated to cessation of electrographic
seizures or burst suppression.2 (NCS Strong recommendation, very low quality evidence)
3. Urgent CT imaging
3.1. Neuroimaging may be pursued if there is a clinical indication or if the etiology of SE is unknown,
once the patient has stabilized and convulsions have ceased. (UW Health Weak
recommendation, very low quality evidence) Consider imaging under circumstances of:
ξ Unknown etiology of seizure
ξ Acute change in neurologic status from baseline
ξ Suspicion for trauma
ξ Focal seizure onset
ξ Pre-disposing history (age younger than 6 months, trauma, CSF shunt,
malignancy, neurocutaneous disorder)
ξ First seizure lasting longer than 30 minutes
3.2. There is insufficient evidence to support or refute routine neuroimaging.16
Considerations for post-seizure management
1. Admit those patients who meet admission criteria per PICU or inpatient admission guidelines.
2. Continue to monitor and support adequate circulation and gas exchange.
3. Follow up corrected hypoglycemia or other corrected electrolyte dyscrasias.
4. For patients who had progressed to refractory status epilepticus, allow for 24 to 48 hours of seizure-
free monitoring before antiepileptic medications are lifted.2 (NCS Weak recommendation, very low
quality evidence)
UW Health Implementation
Potential Benefits:
The anticipated benefits associated with the implementation of this Clinical Practice Guideline include the
expedited diagnosis and management of pediatric status epilepticus, with the additional benefit of
decreased morbidity (and potential mortality) that accompanies treatment delays of pediatric seizure.
Potential Harms:
Potential harms or potential risks that are associated with these CPG recommendations include:
ξ Medication side effects, including but not limited to:
o respiratory suppression associated with benzodiazepines and barbiturates
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10
o hypotension requiring pressor support following administration of fosphenytoin or barbiturates
o paradoxical worsening of seizures following administration of fosphenytoin
o incitement of cardiac arrhythmias following administration of fosphenytoin
o metabolic/hepatic toxicity following administration of valproic acid
ξ Ordering of labs that would not otherwise be needed
ξ Complications from intravenous or intraosseous line placement
Pertinent UW Health Policies & Procedures
1. UWHC Policy 6.10AP- Care of Patient With or at Risk For Seizure (Adult & Pediatric)
2. UWHC Policy 7.18- Admission & Discharge Criteria for Pediatric Intensive Care Unit (PICU)
Patient Resources
1. Health Facts for You# 7351- Intranasal Midazolam to Treat Seizures in the Hospital (HFFY# 7358
Spanish)
2. Health Facts For You #7212- Treatment of Prolonged Seizures and Prevention of Status Epilepticus
with Buccal Lorazepam or Midazolam
3. Health Information- Status Epilepticus
4. Health Information- Seizures
Guideline Metrics:
1. Time of onset of seizure to administration of benzodiazepine
2. Time to order Urgent therapy antiepileptic medication
3. Time to administer Urgent therapy antiepileptic medication
4. Number of patients proceeding past Emergent/first-line therapy, divided by total number of patients
presenting in status epilepticus
5. Number of patients proceeding past Urgent/second-line therapy, divided by total number of patients
presenting in status epilepticus
6. Documentation of seizure start time and duration in Health Link
7. Documentation of point-of-care glucose measurement
8. Percentage of patients with D�GLVFKDUJH�GLDJQRVLV�RI�³VHL]XUH´�ZKR�KDYH�3HGLDWULF�6WDWXV�(SLOHSWLFXV
order set ordered
Implementation Plan/Clinical Tools
1. Guideline will be posted on uConnect in a dedicated location for Clinical Practice Guidelines.
2. Release of the guideline will be advertised in the Physician/APP Briefing newsletter.
3. Content and hyperlinks within clinical tools, documents, or Health Link related to the guideline
recommendations (such as the following) will be reviewed for consistency and modified as
appropriate.
Order Panel
Seizure & PAD - Pediatric [198171]
Order Sets
ED Seizure RN Triage [751]
IP ± Seizure/Video EEG ± Pediatric ± Supplemental [4352]
Disclaimer
Clinical practice guidelines assist clinicians by providing a framework for the evaluation
and treatment of patients. This guideline outlines the preferred approach for most
SDWLHQWV��,W�LV�QRW�LQWHQGHG�WR�UHSODFH�D�FOLQLFLDQ¶V�MXGJPHQW�RU�WR�HVWDEOLVK�D�SURWRFRO�IRU�
all patients. It is understood that some patients will not fit the clinical condition
contemplated by a guideline and that a guideline will rarely establish the only
appropriate approach to a problem.
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11
Figure 1. Pediatric Status Epilepticus Algorithm
Pediatric Status Epilepticus – Emergency Department/Inpatient Algorithm
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MD/RN rapid assessment
Start recording
ABCs, oxygen, monitors, BP every 5 minutes
Establish IV access; obtain glucose, POC
Brief history and physical exam, neuro exam
1
st
MEDICATION:
lorazepam 0.1 mg/kg IV or IO (max 4 mg)
2
nd
MEDICATION:
Repeat lorazepam dose
Order STAT and prepare to administer Urgent AED
Seizure
continuing?
Inclusion Criteria
ξ Age > 2 months
ξ Seizures lasting > 5 minutes
ξ Recurrent seizures without return to baseline
mental status
GOALS:
ξ Stop seizure as soon as possible
ξ Anticipate need for next medication
ξ Administer three different medications < 60
minutes if seizures continue
ξ Maintain continuous support of ABCs
3
rd
MEDICATION: Urgent AED
fosphenytoin 20 PE/kg IV (max 1 g)
UNLESS cardiac arrhythmia or home medications include fosphenytoin
**See Medication Considerations**
Yes
5 min
10 min
20 min
Seizure
continuing?
4
th
MEDICATION:
phenobarbital 20 mg/kg IV (max 1 g)
Yes
5
th
MEDICATION:
levetiracetam 30-60 mg/kg IV (max 2.5 g)
OR
valproate 20-40 mg/kg IV (max 1 g)
30-60 min
**MEDICATION CONSIDERATIONS**
Choice of antiepileptic drug administered in the acute
setting is at discretion of ordering provider and may
be informed by patient’s age, home AED regimen, or
comorbid conditions
1
st
choice for Urgent therapy: Fosphenytoin
O Prolongs QT interval, careful of arrhythmia
Phenobarbital
O Commonly used as Urgent Therapy in infants or in
pediatric patients in febrile status epilepticus
O Risk of hypotension, respiratory depression
Levetiracetam
O Minimal drug interactions
O Not great at breaking status epilepticus but good for
maintenance therapy. May see maximum benefits 1-2
days following initiation of therapy.
Valproate
O Do not use in patients < 2 years old
O Caution in patients with liver/metabolic disorder
No IV/IO access?
1
ST
and 2
nd
MEDICATION:
Midazolam 0.2-0.5 mg/kg IN/buccal (max: 10 mg)
OR Midazolam 0.1-0.2 mg/kg IM (max: 10 mg)
3
rd
MEDICATION:
Fosphenytoin 20 mg/kg IM (max: 1 g)
Other options:
Diazepam 0.5 mg/kg PR (max: 20 mg)
Phenobarbital 20 mg/kg IM (max: 1 g)
Clinical or electrical seizures continue at 60 minutes?
Consider repeat bolus of Urgent or Refractory Therapy AEDs
AND
Induce Pharmacologic Coma
Start with: Midazolam 0.2 mg/kg IV load, 0.05-0.4 mg/kg/hr CI
Next: Pentobarbital 5-15 mg/kg IV load, 1-3 mg/kg/hr CI
Then: Propofol 1-2 mg/kg IV load, 50-150 mcg/kg/min CI
0-5 min
STAT: Glucose, POC
SERUM: CBC with differential, electrolytes, BUN/
Creatinine, AED levels
Outside guideline scope.
Resume standard of care.
No
BP: blood pressure; AED: anti-epileptic drug
Last reviewed: 05/2016
Pediatric Status Epilepticus Clinical Practice Guideline
Questions or comments? Email mpeters@pediatrics.wisc.edu
Outside guideline scope.
Resume standard of care.
No
Establish stable airway and support circulation
Consult Pediatric Neurology
Consider continuous EEG monitor to evaluate for:
1) non-convulsive SE if patient remains altered following cessation
of convulsive SE
2) effectiveness of therapy if placing patient in pharmacologic coma
Consider neurosurgical consultation if presentation warrants
Discuss with Pediatric Neurology and order continuous EEG
if not already in place
Continue to support oxygenation, ventilation, circulation
Allow 24-48 hrs in burst suppression or free of seizures
before lifting pharmacologic coma.
Copyright © 201� University of Wisconsin Hospital s and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 05/2016CCKM@uwhealth.org

12
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Copyright © 201� University of Wisconsin Hospital s and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 05/2016CCKM@uwhealth.org