STEP BY STEPMANAGEMENT OF

Seizures / STATUS EPILEPTICUS

Dr. D. Alvarez

2007

INITIAL PROCES1. Call from the ED requesting bed for a patient with Seizures /

Status Epilepticus.2. PICU Resident / Supervisor (if applicable) obtains

information on patients condition, on the phone or going to the ED.

3. Information needed:A. Base line patient’s: Previously healthy Or if any chronic

condition.- If previous diagnosed with Seizures > since ? age- Taking medications? Name, doses, Since when

- time last dose ?, did tolerated or vomited?

- Follow up by Neurology? Last visit- Previous studies (head CT, MRI) - Seizure control- Last Hospitalization?; intubation?; ED visit?

INITIAL PROCES (continue)

B. Is this is first Episode?Information of Current event/exacerbation:• Triggering factors, fever? Trauma?, medications?

Or No obvious triggering /“Unprovoked”• Describe seizures,

– Focal?, generalized – Onset: when awake ?, sleeping?, watching TV?– Duration– Interventions?

• Treatments / management at home.- EMS, findings - treatments if applicable

ED Events… (continue)4.- Review ED-Events

– Condition on arrival > mental status Post ictal?– Airway maintainable? / intubated for airway protection

(Fill up Mechanical Ventilation Order guidelines if applicable)

– Studies / labs done (Start laboratory flow sheets record)– Radiological studies: Head CT, CxR– Lab reports– Treatments given: note, dose and time.

5.- Communicate with PICU Attending and inform on patient’s condition using the “30 sec assessment guideline”

6.- Inform PICU Nurses that patient was accepted and up-date them on patient’s condition.

ASSESSMENT

Physiological Problems that need to be Address / Assess.

1. Is Airway maintainable? / Secured (intubated)2. Is Ventilation and oxygenation adequate

• O2 Sats RA or % O2 needed• RR, deepness of respiratory effort, air entry.• ABG if patient is intubataed

3. Mental Status changes, any effect of medications given.

4. Focal neuro findings?• Pupilary reaction

3. Cardiovascular Assess– HR, Rhythm / Tachycardia– BP: Hypertension, hypotension, perfusion.

4. Hydration Status / Fluid-Electrolyte and ABB.– FS: hyperglycemia / hypoglycemia– Hyponatremia / hypernatremia– Metabolic acidosis

Process.• By History

– Fever– Respiratory symptoms– GI symptoms: vomiting / diarrhea– Travelinig– Contacts.

• By Physical exam• By Studies:

– CBC with diff (manual count) if clinically indicated

– CxR, (if respiratory symptoms) looking for signs of aspiration.

– Blood, U/A, CSF culture if indicated.

Assessment > If associated infection

MANAGEMENT

Initial Management (0-10min)

1. ABC• OXYGEN should be given to all pat.actively seizing

and/or alter mental status.• Open airway• Position patient• Assess if adequate ventilation

• Observe for depth of respiration• Listen for air entry

2. Start IV • Check FS• Send for basic studies (CBC, Lytes)

Initial Management (10-20min)

2. If hypoglycemia give• D25 > 2 ml/kg

3. Anticonvulsant Medication (see precalculated dose/drip protocole)

– Lorazepan 0.1 mg/kg (2 mg/min) OR

– Diazepan 0.2 mg/kg (5mg/min) OR

– Diastat PR• 1-5 y ……….. 0.5 mg/kg• 6-10 y ……….. 0.3 mg/kg• > 12 y ……….. 0.2 mg/kg

Repeat ONCE if seizure does not stop within 5-10 min

Management Cont. (20-40min)Keep Patient on continues C-R monitoring with

– frequent VS including BP and – monitoring A&B, keep airway open and continue

given oxygen.

4. Fosphenytoin: – 20 mg/kg (slow infusion 150 mg/min, pat. On continuous

monitoring)– If seizure persist, give additional 10 mg/kg

AND / OR

5. Phenobarbital– 20 mg/kg (50 mg/min)

POST BOLUS BLOOD LEVEL SHOULD BE DONE IN 1-2 HRS POST INFUSION.

Management > 60 min)

Refractory Status– Intubate

• Premedicate with:– Midazolan:

» 0.1 –0.3 mg/kg Load F/U by

» 0.05-0.4 mg/kg/hr Maintenance

And / OR

– Pentobarbital

» 5-20 mg/kg load

» 0.5-5 mg/kg/hr Maintenance

Intubation Process

1. Call anesthesia (Emergency Beeper posted) if PICU attending not in house)

2. Calculate / Order / Prepare Medications• Rapid Sequence (RSI) INTUBATION

MEDICATIONS Midazolam: 0.05 to 0.1 mg/kg

– Pentobarbital

» 5-20 mg/kg load

» 0.5-5 mg/kg/hr Maintenance Call Respiratory therapy

Principles of Mechanical Ventilation Support

1. Order initial Mechanical Ventilatory setting according to guidelines after discussion with PICU attending

2. Continues drip (if indicated) with:• Midazolan: 0.05-0.4 mg/kg//min

OR• Pentobarbital: 0.5 – 5mg/kg/hr.

Fluid TherapyNPO until patient is awake and responsive

Calculate patient’s maintenance fluids (requirements); Wt. base OR per SA(m2)

A. Basic Requiremente• Wt base:

• 100 ml/kg for the first 10 kg

• 50 ml/kg for the next 10 kg

• 20 ml/kg for the rest…. kg.

• Per SA (m2) 1500 mL/M2

B. Add Insensitive extra loses given by:• Tachypnea

• Fever

Check electrolytes, follow up Glucose

Dilantin (To be use only in case that phosphenitoin not available)

• Remember, this is consider a High Risk Medication, because serious side effect if not given correctly.

• This are the recommendations– Dilute only in Normal Saline just before infusion. Not soluble in D5W

and will precipitate.

– 1 gm in 100 mL OR 500 mg in 50 mL of NS

– Infusion rate at no faster than 50 mg/min by pump.• 5 mL/hr of either solution 1 gm in 100 ml or the 500 mg in 50 mL of NS

solution

– Monitor EKG and BP during infusion

– Do not give Dilantin IM

– The dose is 15 to 20 mg/kg

– Adverse reactions: Hypotension, Bradicardia, phlegitis, purple glove syndrome.