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Status Epilepticus Appendix (Algorithm)

Status Epilepticus Appendix (Algorithm) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, Neurology, Related


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| 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 Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 05/2016CCKM@uwhealth.org