Epileptic status in children

Epileptic status is a convulsive seizure that lasts for 30 minutes in children, or a series of seizures that follow one after another with such frequency that the patient does not have time to regain consciousness between them.

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Risk factors for epileptic status in children

Acute processes:

• electrolyte disturbances, for example Na +, Ca2 +, glucose;
• stroke, anoxic / hypoxic brain damage;
• CNS infections, such as meningitis, encephalitis;
• drug intoxication / overdose;
• sepsis;
• acute renal failure.

Chronic processes:

• history of epilepsy, poorly controlled treatment, or recent changes in anticonvulsants;
• a brain tumor or other intracranial bulk lesions.

How does epileptic status manifest in children?

Often epileptic status in children is a signal of epilepsy's debut, but it happens that convulsive seizures first arise at later stages of its development. In newborns, seizures occur with an incomplete loss of consciousness and its preservation by external stimuli.

The generalized status epilepticus can be manifested by tonic-clonic, tonic, clonic, myoclonic cramps. With epileptic status without seizures, patients in the EEG are recorded with a pyclonic stupor and slow waves reflecting the state of epileptic twilight of consciousness (small prolonged epilepsy). Partial status epilepticus can be elementary, somatotrophic or dysphagic. For a complex partial epileptic status (temporal-lobe epilepsy or a prolonged epileptic stupor), persistent preservation of epileptic twilight of consciousness is characteristic.

With the generalized epileptic status, the basic property of an epileptic fit is violated - the capacity for self-recovery. The number of seizures with epileptic status can reach several tens or hundreds a day. Developing respiratory disorders, hemodynamics deficiency, progressing disorders of brain metabolism, deepening coma, up to a lethal outcome.

How to recognize the status epilepticus in children?

The epileptic status is diagnosed with the duration of the convulsive attack above the threshold values: from 5-10 minutes to more than 1 hour. During epileptic status, EEG changes reflect the phenomena of hypoxia and edema of the brain. After arresting the epileptic status in children, it is possible to increase paroxysmal activity on the EEG, which does not indicate a worsening of the condition - during this period, the ability of neurons to regenerate electric potentials is observed.

Emergency care for epileptic status

A child with an epileptic seizure is not recommended to hold tight, as this can lead to injuries. The patient is placed on a flat surface, and a pillow or a folded blanket is placed under the head. To prevent biting of the tongue, lips and cheeks, if possible, put something soft between the teeth. It is necessary to prevent language Westernization. The head is turned to the side and gives the body the Trendelenburg position.

In the case of spontaneous breathing following repeated seizures (and after intravenous injection of anticonvulsants), oxygen therapy is carried out with 50-100% humidified O ₂. With neurologic depression, breathing requires intubation of the trachea and mechanical ventilation. Suction of the contents of the oropharynx and respiratory tract is performed.

It is necessary to provide access to the vein and begin infusion therapy after cramping seizures. Depending on the age, it is recommended to enter a 20% or 40% solution of glucose. Specially limit the amount of fluid administered with epileptic status should only be with overload. The patient should periodically change the position of the body. Due to the delay in the release of urine, a permanent catheter is inserted into the bladder.

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Coping with status epilepticus

• Respiratory tracts - breathing - blood circulation ... 100% O2. Check blood sugar and treat hypoglycemia.
• Stop convulsions intravenously by administering lorazepam (0.1 mg / kg) or diazepam (0.1 mg / kg) as first-choice therapy.
• If the convulsions do not stop within 10 minutes, the second choice therapy will be:
  • phenytoin 15 to 17 mg / kg by slow intravenous infusion (rate <50 mg / min), or phosphenytoin 22.5 mg / kg (equivalent to 15 mg / kg phenytoin) at a rate of up to 225 mg / min (equivalent to 150 mg / min phenytoin) .
• Intubate and ventilate to maintain RaO2 and PaCO2 in the normal range.
• Volumetric replacement therapy to maintain adequate systemic BP, cerebral perfusion pressure.
• Inotropes may also be required, especially if general anesthesia is required to control seizures.

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Further treatment of epileptic status

Search and treat the cause of seizures.

• epilepsy in anamnesis ± recent changes in antipsychotic drug therapy;
• discontinuation of alcohol intake, drug overdose;
• infection of the central nervous system, intracranial pathology, for example stroke, subarachnoid hemorrhage.

With refractory epileptic status, if convulsions can not be controlled after 30 minutes of second-choice therapy, initiate anesthesia with propofol (under EEG control).

Make sure that the levels of long-acting anticonvulsants are in the therapeutic range.

Think about the therapy of the third choice: for example, phenobarbitone 20 mg / kg infusion (rate <50 mg / min).

Treatment of complications of epileptic status - hyperthermia, rhabdomyolysis (screening for myoglobinuria and measurement of creatine kinase), cardiac arrhythmias, pulmonary aspiration and neurogenic pulmonary edema.

Anticonvulsant treatment of epileptic status

Epileptic status in children should not be treated with drugs that are unknown to the treating doctor. Currently, diazepam (seduxen, Relanium) or midazolam is more often used. The drug of choice for epileptic seizures may be phenytoin (diphenin). In the case of continuing seizures, phenobarbital or thiopental sodium is used. Possible intravenous injection of magnesium sulfate.

When an uncontaminated seizure or with prolonged transport should begin treatment of cerebral edema: inject dexamethasone, mannitol. Furosemide (Lasix). In addition, the mode of hyperventilation of the lungs is shown, if necessary - an inhalation anesthesia is performed with halothane (fluorotane). After the elimination of seizures for the purpose of mild dehydration continue to use magnesium sulfate and acetazolamide (diacarb).

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Special Considerations

• Refractory epileptic status in children is purposefully treated with general anesthesia. It should be applied in a specialized unit, with the possibility of continuous monitoring of the EEG to monitor the effectiveness of treatment.
• In the past, the drug of choice was thiopental, but the profile of the side effects of high doses severely limited its use at the present time. Bolus 250 mg, further infusion 2-5 mg / kg / h.
• Propofol has powerful anticonvulsant properties and is increasingly used to treat refractory status. Begin with a bolus of 1 mg / kg, which is administered for 5 minutes and repeated if convulsive activity can not be suppressed. The rate of maintenance infusion is selected in the range of 2-10 mg / kg, using the smallest, sufficient to suppress zleleptiform activity on the EEG.
• Phosphenytoin is a precursor of phenytoin - 1.5 mg of phosphenytoin is equivalent to 1 mg of phenytoin. Since phosphenytoin is soluble in water, it can be administered as an intravenous infusion three times faster than phenytoin (up to 225 mg / min, equivalent to 150 mg / min phenytoin), with a therapeutic concentration within 10 minutes. The doses are expressed in phenytoin equivalents (PE).