July 23, 2025 • 21 mins
In this episode, Sam Ashoo, MD and T.R. Eckler, MD discuss the July 2025 Emergency Medicine Practice article, Emergency Department Management of Status Epilepticus in Pediatric Patients
Introduction- Welcome and brief overview of the episode
- Promotion of EB Medicine’s $1 for 7-day trial offer
- Seizures make up ~1% of ED visits and ~3% of EMS calls
- High-risk and high-stakes condition requiring rapid action
- Status epilepticus now defined as ≥5 minutes of seizure activity
- ILAE’s T1 and T2 timelines help define when to treat and when damage begins
- Top contributors:
- Fever/infection
- Structural CNS abnormalities
- Toxic ingestions
- Genetic/metabolic disorders
- Additional factors by age:
- Infants: febrile seizures, chromosomal issues, trauma
- School-age: autoimmune disorders
- Adolescents: eclampsia, hypertension, functional disorders
- Always consider non-accidental trauma
- IM midazolam is effective and recommended (RAMPART trial)
- Other options: intranasal, rectal, or IV benzodiazepines
- Early benzodiazepine administration improves outcomes
- Importance of airway support, glucose check, and EMS flexibility
- Parent-administered home meds (e.g. rectal diazepam) can be helpful
- Prioritize ABCs: Airway, Breathing, Circulation, Consciousness
- Use end-tidal CO₂ to monitor ventilation if available
- Point-of-care glucose is essential
- Labs: CMP, Mg, Phos, lactate, drug levels, pregnancy test (when indicated)
- Imaging: Head CT if concern for trauma, shunt malfunction, or focal signs
- Case examples highlight pitfalls and diagnostic delays
- Benzodiazepines remain the cornerstone
- Lorazepam preferred IV agent (0.1 mg/kg)
- Midazolam preferred if no IV access (IN, IM, or IO)
- Diazepam is also effective, especially rectally
- Be mindful of respiratory depression and the need for airway control
- Based on ESETT trial:
- Levetiracetam, fosphenytoin, and valproate have similar efficacy
- Levetiracetam favored for safety and ease of use
- Fosphenytoin may be avoided in trauma or toxicity
- Valproate not recommended in mitochondrial disease
- Phenobarbital reserved for refractory cases only
- Definition: persistent seizures despite first- and second-line agents
- Requires sedation and likely intubation
- Infusion options:
- Midazolam (preferred for flexibility)
- Propofol (short-term use only due to risk of infusion syndrome)
- Pentobarbital (rare, ICU-level care)
- Need for continuous EEG to assess seizure activity
- Neonates:
- Watch for subtle signs (lip smacking, bicycling, tongue thrusting)
- Broad differential includes asphyxia, infection, metabolic errors
- Febrile Status Epilepticus:
- Higher risk of CNS infections, especially if unvaccinated
- Consider lumbar puncture if indicated
- Electrolyte/Metabolic Triggers:
- Treat hypoglycemia, hyponatremia, and hypocalcemia directly
- Use 3% saline or dextrose as appropriate
- Many children will require ICU-level care
- Some known epilepsy patients may go home if back to baseline
- Ensure rescue medications are up to date (rectal/intranasal benzos)
- Consider “clonazepam bridge” for short-term seizure prevention
- Collaborate with neurology for medication adjustment and follow-up
- Keep treatment tables and dosing references accessible
- Early, aggressive treatment can prevent long-term harm
- Episode closes with gratitude to article authors and a reminder to visit EBMedicine.net
Emergency Medicine Residents, get your free subscription by writing resident@ebmedicine.net
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
T.R. Eckler (00:01):
I don't think I realized how much of a black cloud you were,
but now the more you tell stories,the more I'm like, man, you have
really had quite a black cloud run.
Sam (2) (00:12):
Hi everyone, and welcome back to another episode of Amplify.
I am one of your hosts, Sam Ashoo,and I wanna thank you for being a
listener and encourage you to rateus in whatever podcast app you're
listening in so that we can get theword out there to more listeners.
And I also wanna share with youthat this month, EB Medicine is
running a special $1 for a seven daysubscription to any or even all three
(00:35):
of the journals on eb medicine.net.
That's a great deal.
If you're not already a subscriber,go there and take advantage of
this special and check us out.
You will not believe how many coursesand how many issues and how many
hours of CME you will have access to.
It's an absolutely wonderfultime saving and critical to
your practice subscription.
(00:56):
Do yourself a favor and takeadvantage of that special today.
And now let's jump intothis month's episode.
Sam (01:04):
Ladies and gentlemen, welcome back to another episode of EMPlify.
I am one of your hosts, Sam Ashoo, andon the other side of the microphone.
T.R. Eckler (01:12):
Dr. TR Eckler back again, excited to make
kids do a little less wiggling.
Sam (01:18):
Yes, I'm sure all of our pediatric emergency medicine
colleagues appreciate that notion.
No one wants to have to stand at thebedside and watch a child continuously
seize, and that actually happens tobe what we're talking about today.
This is the July, 2025 issue of pediatricemergency medicine practice on the
emergency department management ofstatus epilepticus in pediatric patients,
(01:42):
which is a frightening scenario for me.
Something I don't enjoywatching or treating.
But still a very, veryimportant disease process.
And if you happen to be the clinicianstanding at the bedside wondering
what the next drug to push is, Ihighly recommend reading this article.
The two authors, Dr. Bowen and Dr. Boltondid a really good job of summarizing all
(02:06):
of the evidence and the guidelines for us.
Especially the guidelines fromthe International League Against
Epilepsy which I just love.
I want a t-shirt with InternationalLeague against Epilepsy on it.
If you're listening to thispodcast and you're a member of
the International League AgainstEpilepsy, send me a t-shirt.
I'll wear it.
T.R. Eckler (02:25):
Same.
I would wear that t-shirt.
That'd be, that'd be rad.
Sam (02:28):
cool.
It reminds me of the Justice League.
We are the epilepsy league.
We will stop seizures.
And I think that's thepoint of this issue really.
If you're wondering why statusepilepticus in children.
Is it really a big deal?
The answer is yes, it is a big deal.
Seizures are like 1% of ED visits here inthe us and 3% of pre-hospital transport.
So if you're listening to this andyou're in pre-hospital medicine,
(02:50):
it is a very important topic andwe'll have some more information on
that for you in just a few minutes.
But it is common, or at leastit's not rare if you're in
the emergency department.
And , the crux of the historical aspectof it is, I remember the days, again,
I'm just dating myself, but I rememberwhen the status Epilepticus definition
(03:11):
was 30 minutes of continual seizing.
And I will tell you in clinicalpractice before the guidelines
changed, I never waited 30 minutesto call it status epilepticus.
Even then, I thought thatwas a ridiculous definition.
But I'm happy to see that theInternational League against
Epilepsy, check my t-shirt, didchange that definition in 2015.
(03:34):
And for convulsive status epilepticus,it's now five minutes, which seems
a much more reasonable timeframe.
Something I'm far more comfortablewith and something that's really
far more in step with clinicalpractice, I think for most of us.
We don't like to just stand by and watchsomebody seize for 20 to 30 minutes.
T.R. Eckler (03:55):
I really liked their, attempt to break that down too, where
they basically, instead of it beinglike, after this time period, you must do
something or This is the danger zone, andI thought it was great how they started
to tease out more of the kind of nuancehere by having a T one and a T two for
each classification of seizures, meaninglike after this amount of time with this
(04:16):
kind of seizures, you know, you shouldtreat, and after this amount of time
with this amount of seizures, your T two,then it starts to have a risk of damage.
I felt like that was a helpful idea.
And I think that was maybe one of theonly things I wanted to enhance with the
article was having more of a sense ofwhat those T one and T two times are.
But I think that those even tendto vary based on age and the
condition that you're dealing with.
(04:36):
But it still gave me a clearer ideaof like, I want to treat sooner
so I don't get to that T two time.
Sam (04:42):
Yeah, and you know, if you're listing and wondering what we're talking about, in
the article, there is the definition fromthe International League against Epilepsy
about, the time at which point it becomesstatus and the time at which you're
starting to have neurological damage.
And it varies by the type of seizure.
So you know, you might have noticed thatI called it convulsive status epilepticus.
And that's because there are nonconvulsive focal motor and myoclonic
(05:06):
seizure types as well, all of whichcome with different timeframes.
But if you're obviously seeingseizure activity and it's
convulsive, then five minutes isthe number you gotta remember there.
And like I said, I just think that'sa much better definition than what
we used to have, and I'm happy to seethat we're moving in that direction.
The authors as usual did a great job withthe literature search and looked at a
(05:28):
number of guidelines, and I thought itwas important to point out that, you know,
this particular issue is on pediatricstatus epilepticus, and much of the
literature comes from national guidelinesand studies performed outside of the ED.
So, it's helpful to have the summaryand I like that they focused it
on the initial management for us.
That was very good.
(05:49):
And as always, before wedive into anything, I like
to pimp you with questions.
So let's just jump into onefor the sake of talking.
That's how we go.
So, which of the following is amongthe leading causes of pediatric status
epilepticus, according to the article.
Asthma, structural CNS abnormalities,diabetes, and hyperlipidemia.
T.R. Eckler (06:12):
Oh B, structural neurologic abnormalities
Sam (06:15):
of course.
Right.
T.R. Eckler (06:16):
Have you had an MRI yet is my favorite question for kids that
come in with seizures, has someone putyour child inside the magical magnet?
The tunnel of truth, as Icall it, to show us if there's
something structural there or not.
Sam (06:29):
Yeah, and that's a really good question because the leading causes
for status epilepticus are the onesyou would think of most commonly
fever and infections, some kind ofcentral nervous system abnormality,
accidental ingestions, and then thegenetic and metabolic disorders.
Those are kind of like the topfour categories for causes of
(06:50):
pediatric status, epilepticus, andagain, it can be multifactorial.
And what we're gonna talk about today istrying to differentiate these causes and
how your initial therapy might change.
But the finger member is those fourcategories because you've gotta
run through 'em super fast in yourhead if you've got somebody who's
actively seizing in front of you.
T.R. Eckler (07:08):
I really liked just the quick summary they had in
this, that 10% of seizure patientsare gonna come in in status.
And I think that that kind ofhelped me like feel better about
the sense that like nine outta 10of these patients are gonna be okay.
They'll have a seizure,but they're gonna stop.
But I need to be on my guard for that oneout 10 that isn't gonna stop and be ready.
(07:29):
So, you know, not that I'm necessarilymedicating every one of these patients
when they come in, but I'm readyfor the ones that aren't stopping or
the ones that start up again, thatI have a plan of where I'm gonna go.
And then I really liked how theygave you that sense that, yeah, 33%
of these, it's due to subtherapeuticlevels of their medicines, but 6% are
gonna be their electrolytes or theirglucose, and 3.6% is toxic ingestions.
(07:52):
So that same kind of thing.
I'm ready for the common things,but I have those zebras in the
back of my head of, alright, do Ineed to give, you know, glucose?
Do I need to fix an electrolyte?
Do I need to worry aboutsome toxic congestion?
Do I need to start broadening my senseof what I'm gonna do to fix this patient?
Because what I'm doing isn't working?
Sam (08:09):
Yeah.
Yeah.
I did, I mean, I'm a numbersguy, so I enjoy the numbers.
And I did also find it interestingthat 70% of children who are diagnosed
with epilepsy before the age of onewill experience status epilepticus.
That's a l ot.
And if they didn't experienceit on diagnosis, then it's
going to happen at some point.
And that's an importantthing to share with parents.
(08:31):
And it also will tell you that thoseparents are probably well educated
and may have already given a therapyor two before the person even
gets to the emergency department.
So history, history and more history.
And in this scenario, luckily there'sa parent who hopefully knows quite
a bit about this patient right infront of you if it's someone with
a diagnosis of epilepsy already.
(08:51):
Table one is an interesting tablefrom the International League
against Epilepsy classification ofconvulsive status epilepticus to kind
of break down the different types,and if you have the time to try and
differentiate these, this is great.
Sometimes it can help with theconversation with the neurologist
or if the parent already knows.
It can make a difference if it'simpending convulsive status epilepticus
(09:11):
versus established versus refractory,and at what point you're gonna use
what term, but just know that fiveminutes is your timeframe there.
If it lasts five minutes ormore, you're into that status.
And once you get into that area,then you're starting to break
down things like the differentialdiagnosis and what it is we're
supposed to be doing for the patient.
And table two does a great job ofbreaking it down by age because
(09:36):
the causes can vary depending onthe size and age of the patient.
If they're anywhere from birth tosix years old, you're thinking things
like febrile seizures, chromosomaland genetic abnormalities, inborn
errors of metabolism, breath holdingspells, and non-accidental head trauma.
The big key there.
Don't miss that.
(09:56):
If they're school age, then autoimmunedisorders become the most common.
If they're adolescents, now you'rethinking things like eclampsia.
You can't forget about thepossibility of pregnancy.
Hypertensive crisis, autoimmune disorders,and functional neurologic disorder.
And then for all ages, you also haveto keep in mind things like cerebral
vascular accidents, infections, tumors,cortical dysplasia, head trauma,
(10:22):
medication exposures or overdoses,metabolic disturbances, et cetera.
So lots and lots of things tokeep in mind in the differential.
Table two does a really goodjob of breaking it down by age.
T.R. Eckler (10:33):
And it's really the common things that were there at the finish.
I found that table confusing becauseI felt like they led with the rare
things, but then once you get to thebottom, it's really the cerebrovascular
diseases, the CNS infections, the tumors,head trauma, intoxication, overdose.
Those are really the thingsthat are causing most of these.
But I felt like it was great tohave that even broader sense that
(10:53):
occasionally you're gonna get someof these unusual kids with autoimmune
disorders or you know, some otherunusual inborn error metabolism.
And it's great to look for help early fromyour specialists when you realize that
you're getting into something like that.
Sam (11:08):
Yeah.
Yeah.
Great point.
Alright.
When it comes to pre-hospital treatments,there are some significant things that
our pre-hospital personnel can do whichleads me to our next question, which
pre-hospital intervention improvesseizure control before ED arrival?
Number one, rectal acetaminophen.
(11:29):
Number two, oral lorazepam.
Number three, intramuscular midazolam,or number four hypertonic saline.
T.R. Eckler (11:37):
I am gonna go with number three, intramuscular Midazolam,
because I just love that medicinebecause I know intramuscular
is gonna stay in the patient.
I know that the other stuff is gonnahelp, but not necessarily like.
really like give thatimprovement in control.
And I found that the, the RAMPART studythey referred to here, which talked
(11:59):
about how if they got IM Midazolam or IVlorazepam in adults and children, they
were more likely to not need to go to theICU, more likely to have their seizures
terminated prior to the arrival of the ER.
And I felt like that boostedmy own practice, like what I
recommend for EMS in the field.
And I like how Midazolam wears off so Ican kind of have a sense of what I'm doing
(12:21):
next, or I can plan for it as opposed tothe longer term of Lorazepam if you're
getting it in pre-hospital settings.
So I feel like I get more chances toadjust once I know more about the patient.
If they're in the ER, then I'm moreinterested in giving them a longer
acting medicine if I have that chance.
Sam (12:35):
Yeah.
Yeah, and that's a perfect answer.
So the, the pre-hospital treatment isall about targeting seizure control,
and there is good evidence from thatrapid anti-convulsant medication prior
to arrival trial, or RAMPART, thatinvolvement of pre-hospital personnel in
treating seizures is critically importantand does actually improve outcomes.
(12:56):
So definitely IM midazolam and it'sreally great actually that our EMS
personnel now have multiple options.
It used to be you struggle to get the IVin someone who's actively seizing, and
maybe you get it and maybe you don't.
And then your only other option was an IO.
But now we have intranasal, wehave IM, and we have rectal forms.
(13:17):
Again, if the person has a diagnosisof epilepsy and the parent has rectal
diazepam, it's okay to give it,you know, just because you're the
pre-hospital personnel doesn't mean youcan't give them their home diazepam.
So you've got lots of options andlots of delivery mechanisms to
try and get that benzodiazepineon board as fast as you can.
Use whatever you have at your disposal.
T.R. Eckler (13:37):
And having, said that, I think the, key that I, having read
this article that I took away wasto remember how flexible you need
to be, because EMS isn't gonna haveall the medicines that you want.
There's so many often drug shortages.
So things that you're used tousing are not gonna be there.
So being ready to adjust your practiceand, you know, adjust to what's available.
And as you said, the medicinesnow that the patients are having
(14:00):
at home are becoming more common.
An intranasal Valium orintranasal diazepam is now much
more of a common thing that'sgoing home with these patients.
So you can ask EMS in the field, Hey,do they have their intranasal Valium?
Have they given it?
Okay.
Then if you want, you can give that ifyou don't have another option, if you
don't have midazolam or something else.
But really just figuring out quicklywhat your options are, and then
(14:21):
making the best decision you canor helping your EMS crews make the
best decision from what they have.
Sam (14:26):
Yeah.
And then once that's been done,then you turn to your routine ABCs.
So making sure their airway is controlledor patent, making sure they have
adequate ventilation, especially ifyou've just given them a benzodiazepine.
And whether or not that seizure hasterminated, they're gonna need some
supplemental oxygen and perhapssome bag valve mask assistance until
(14:47):
you get to the hospital, especiallyif the benzos are causing a little
bit of respiratory depression.
Circulation.
Certainly if they are getting hypotensiveor having instability, then they need
that IV access and the IV fluid boluses.
And lastly glucose levels.
So point of care glucose, gotta checkthat sugar to make sure, especially
the younger they are, the more likelythey are to be just hypoglycemic.
(15:10):
And so that's an important piece thatyou need to add to your investigation
when you're in the pre-hospital arena.
And hopefully by thenyou are at the hospital.
'cause these can be very anxietyprovoking cases and getting to the
nearest emergency department is important.
You know, hopefully it's a peds emergencydepartment, but if not, that's still okay.
(15:30):
The ABCs and initial resuscitationshould be the same regardless
of wherever you land.
Once you're in the emergencydepartment, our initial evaluation
begins and leads to our next question.
What is the most important firststep in the ED management of
pediatric status epilepticus?
Here we go.
A, obtain a head, CT.
(15:51):
B, secure airwaybreathing, and circulation.
C. Start valproic acid or D order.
An EEG
T.R. Eckler (15:59):
I would tell you that I think the answer to that question is A,
B, C, and a second C. 'cause I liked howthey added consciousness to their ABCs.
'cause I do think sometimes a kid looksokay but is not actually conscious.
Like, you could look at a kid quicklyand be like, all right, they're
not having status epilepticus.
It's not convulsive.
But if that kid's not there, theymight be a non convulsive status.
(16:22):
And I liked how they putthat little nuance to it.
Sam (16:25):
Yeah.
Yes.
Well, first of all, you are correct.
So it is the ABCs.
And second, you know, I recall we talkedabout seizures when we talked about
geriatric emergencies some time agoon a different podcast, and we talked
about alterations in mental status inthe geriatric population, maybe being
something like non convulsive status.
And so similarly in children, as yousaid, if they're not actively convulsing,
(16:49):
but they haven't returned to theirnormal baseline, it's something you need
to keep in mind in your differentialand it can be very challenging to
try and make that diagnosis andfigure out, okay, what is it exactly
that is now causing this alteration?
Especially if they had a doseof benzodiazepines already.
So it can certainly be a challenge.
But yes, you are correct airway is always the first priority, especially if
(17:13):
they've already had some benzodiazepine.
So positioning suctioning,oxygen administration for the
hypoxia because you're tryingto reduce the neuronal injury.
Second is making sure they're not apnic.
Third is checking, breathing andcirculation and hooking up the monitor.
And if you have end tidal CO2, thisis an ideal time to use it because not
only are you interested in preventinghypoxia, but you also want to know if
(17:37):
they've got hypoventilation and theyneed some assistance with ventilation.
Bag valve mask ventilation isokay to use even briefly after
administration of benzodiazepines.
So they may need that for afew minutes until they start to
adequately ventilate on their own.
And then that'll start hopefully, yourbrain going down the pathway of, you
know, at one point, do I need to decideabout intubating this patient now?
(17:59):
But if you're doing well with bagvalve mask ventilation, that's okay.
You got time.
Establishing IV access or IO access.
So if the pre-hospital personnelwere unable to do so, then
this is a good time to do it.
And then gathering history, right?
Talking to mom or dad about previoushistory, medication exposures, recent
illnesses and if they're in the neonatalperiod or infant period, formula
(18:23):
mixing is a big deal because you'retrying to also exclude hypoglycemia and
hyponatremia your differential diagnosis.
And then lastly, trauma.
Non-accidental trauma.
I recall having a neonate comethrough the emergency department
who had some abnormal movements.
We weren't really sureif they were seizing.
(18:43):
We gave some benzos.
It didn't really change much, butit did cause respiratory depression.
And at that point I was callingthe ICU and we had gathered a
bunch of labs and we weren'treally sure if this was infectious.
There was no fever.
Ended up doing a lumbar puncture andas soon as I walked out of the room
my ICU colleague was there and I said,gosh, you know, I'm really sorry.
Like I got CSF.
This was a really tiny neonate.
(19:04):
I got CSF, but I think it was a traumatictap because it was all just bloody.
And he kinda looked at me and went, Hmm.
Okay, well we're gonna send it anyway.
And I said, oh yeah, we'llsend it for fluid analysis.
And we started the antibiotics and sureenough, the next day, now we'd already
obtained a head CT, which was normal.
And the next day the MRI showed, youknow, bilateral subdural hemorrhages.
And so it was not atraumatic lumbar puncture.
(19:25):
It was trauma that was thecause of the blood in the CSF.
And so, uh with a normal head CT
T.R. Eckler (19:32):
Oh, that's so.
Sam (19:33):
because there were like subacute, bilateral subdural hematomas.
So trauma, trauma, trauma.
Don't forget the non-accidentaltrauma in your differential.
And then when we start, talking aboutinitial management, so what are we
gonna give first, first line therapy
T.R. Eckler (19:50):
Can I stop us for one second because I think this is a question I ask
med students and residents all the time,and I thought they did a great job, is
when do you intubate the seizure patient?
Like what are your indicationsfor rapid sequence intubation
and mechanical ventilation.
I like how they put that together.
You gotta plan for both.
It's inability to maintain their airway.
Meaning they're not able to holdtheir airway open despite what
(20:12):
other things you're gonna do.
Hypoxemia, inadequate ventilation,apnea, and refractory status
lasting longer than 30 minutes.
So I think if you don't feelcomfortable with any of those
things, take that airway, it's time.
I thought that was a nice line in thesand in a very gray world that we live in.
I thought that was a nice, clear thingof you can feel comfortable if this
(20:34):
is what you're looking at, then that'swhen you should take that airway.
Sam (20:38):
Yeah, they did actually mention under circulation as well that bradycardia can
be the harbinger of impending badness.
If it's not from hypoxia then it canbe the potential clue that this person
needs invasive ventilation as well.
So lots of physical examination cluesthere, or if their seizure is persisting
and you're not able to control it.
(20:59):
Once we've passed through theABCs the authors then had a little
discussion here about diagnosticstudies and what you should be
ordering in the emergency department.
And we you know, arepretty good about this.
Really, most of these are protocoledor fit in line with the things
that we're trying to eliminatefrom our differential diagnosis.
So obviously we're going to get a pointof care glucose if that wasn't already
(21:19):
done by EMS, and then you're gonna getyour comprehensive metabolic panels in
order to exclude metabolic inborn errors,calcium, magnesium, and phosphorus.
So your calcium may be part of your CMP.
Your magnesium and phosphorus are usuallynot, so you gotta remember to order those.
A lactic acid can be helpful.
A serum pH, even if it's avenous pH, can be helpful.
(21:39):
If they're already on seizure medications,you might be interested in getting levels
for those to see if they're therapeutic.
If you know that they've had a toxicingestion, you may be able to send
levels for those if that comes acrossin the history from the parent.
If they're of age, youneed a pregnancy test.
Again, not to be the harbinger ofterrible stories, but , I recall
being in the emergency departmentand having a 15-year-old obese female
(22:01):
come in with a seizure first time.
No past medical history.
EMS had given a dose of LorazepamIV prior to arrival and the seizure
stopped and she arrived appropriatelypostictal and sedated from the Lorazepam.
And I was waiting for a parent toshow up and a second seizure ensued.
And so we gave another dose ofLorazepam and off went to CT because
(22:24):
the rest of the vitals were normal.
And while she was in CT, a parentshowed up and confirmed, Hey,
there's no history of this.
And while she was in CT, she had athird seizure and got a third dose
of Lorazepam, and then as soon asshe came back from CT she gave birth.
T.R. Eckler (22:40):
Wow.
Sam (22:40):
no one knew that she was pregnant, she was obese.
And unfortunately she gave birth to afetal demise that was probably somewhere
in the second trimester, so she hadn'teven made it to the third trimester.
And then now we were in the midstof trying to resuscitate what
we thought were two patients.
And so we've got the neonate bornstill, and then the 15-year-old who
(23:03):
has received a bunch of Lorazepamwho is now excessively sedated and
still having seizures and now movingdown a different differential and
diagnosis and treatment modality.
So don't forget to get the pregnancytest, and don't forget to consider
that in anyone who is of the age
T.R. Eckler (23:20):
Also a patient like that is gonna be challenging
To get a urine out of.
But I like to remind people mostof the rapid urine pregnancy
cartridges that we use in theUnited States are dual certified for
blood, like whole blood and urine.
So you can drop whole blood onto thosecartridges and then wait a few minutes.
And just like a urine pregnancytest, it will show you if the
patient is pregnant or not.
(23:41):
Just from their whole blood.
So if your lab tells you, oh, we can'trun this, we have to run the quant, or
it has to be a urine, you can basicallyjust have them send you a cartridge and
you can put blood on that cartridge.
If the cartridge says it's okay,and you will know very, very quickly
if your patient is pregnant or not.
And you don't need to wait a couple hoursfor somebody to cath the patient for
urine while they're altered and confused.
Sam (24:01):
Yeah.
Yeah, great point.
And sometimes, you know, it seemsstrange that we even have to say
things like this, but sometimes itdoes take the physician to just say.
Send me the cartridge, send me whateverit is that I have to put the drop on.
I'll just do it myself because thelab technician is constrained by
lab policies or rules or whatever itis from somebody who's nonclinical.
Then you, you just have to say,okay, look, I'll do it and I'll
(24:22):
take the heat for it, but Igotta save this person's life.
T.R. Eckler (24:25):
I gotta save this person.
Yep.
Sam (24:27):
so diagnostic imaging, if you're suspecting some kind of intracranial
lesion or they got a history of it,or if they come with a history of a
VP shunt and you're worried about aVP shunt failure then yes, you have
to obtain the CT imaging of the brain.
And then there's other ancillary testing,ECG EEG, et cetera, that comes later
down the line if you have the time.
(24:48):
If they have a history of VP shuntor if they have a focal seizure or
if you're worried about head trauma,you need to order the head CT.
Now we are usually radiationsparing, especially in our
children and pediatric populations.
But in this scenario, this is notthe time to be radiation sparing.
If they have a history of anythingintracranial or if you're suspecting
(25:13):
even mildly suspecting somethingtraumatic, you need to get that head CT.
You know, reducing radiation exposure isnot the appropriate step in this scenario.
T.R. Eckler (25:22):
I think the key to that is we're not talking about all seizure
patients that come into the ER.
We're not talking about yourfebrile seizure children.
We're talking about patients instatus that are not returning to
their baseline, that you're havingtrouble controlling their seizures.
You want to get the CT inthat patient because it's
often gonna change management.
I remember I had a well-knownseizure patient that came in
in rural Colorado, and I justcouldn't get his seizures to stop.
(25:45):
And I finally, after like three differentmedications, got his seizures under
control and got him intubated and gothim to CT and he had a huge brain bleed.
and that was just somethingthat stuck with me.
That if you can't control the seizures,take pictures, do more things because
there's something there that, that youjust need to get there and you'll find it.
Sam (26:02):
Yeah.
And really that brings usto first line treatment.
So again, we're in theemergency department.
We're going to give somethingregardless of what EMS has given so far.
Which leads me to the next question.
Which benzodiazepine is preferred?
If IV access is available, is itdiazepam, midazolam, or clonazepam?
T.R. Eckler (26:23):
So I will tell you that I know the right answer
to this question is Lorazepam.
And I will tell you that I firmly disagreewith the authors and I would like someone
to check my record because I have along track record of being appreciative
and supportive of the authors.
But I find in clinical practice it isso much easier to dose stack Lorazepam
(26:43):
where you give some, nothing happens,and then you give more and then they get
respiratory depression and get intubated.
I think that in my practice I haveseen better results from Diazepam,
but I do like how they focusedclearly on a weight-based dosing where
Lorazepam should be 0.1 mg per kilos.
But then diazepam can be 0.1 to0.3, and I think that Lorazepam is
(27:05):
a significantly stronger medication.
So I would be more inclined to go 0.1of Lorazepam, 0.2 of Midazolam, or 0.3
of Diazepam if I was treating patients.
And I think that as we talked aboutearlier, you need to be ready to use
any of these medications because yourfavorites aren't always gonna be there.
So I think you need to have a sense ofthat dosing, or you need to have a sense
(27:26):
that I know the medicines I need, butI can't keep these doses in my head.
So you need to either have support froman ER pharmacist to help you dose, or
you need to be your own ER pharmacistand have an application like PD stat.
I love PD stat for basically makingsure when I'm running a complex
pediatric resuscitation that Iknow exactly the doses I'm giving.
'cause I put in the child'sBraslow or their weight, and then
(27:46):
I hand the phone to the nursesand say, I'm gonna give you drugs.
You just look down and tell mewhat the doses are from that
.Sam: Yeah.
Perfect.
and I will say, page seven of thearticle table four medications
for status epilepticus first lineanti-seizure medications lists all
three of those as an option, right?
Lorazepam midazolam and diazepam.
Now, they do have a preferencefor Lorazepam, but it's not to
(28:07):
the exclusion of the other two.
So whatever of the three that you havethey do recommend Lorazepam because of
its reliable onset and its duration.
But if you don't have, or if youhave a preference, it's okay.
, You've got some flexibility there.
Midazolam does come with theother delivery options too, so IO,
intranasal, intramuscular and hashad efficacy in all of those areas.
(28:31):
So if you don't have an IV in place,that's probably the better choice.
To clarify, you can use any of those through an IV
or an IO, but if you need to givethem IN like nasally or muscularly,
then you have to use Midazolam.
But I think that to be clear, midazolamis a significantly shorter acting drug.
So you need to know if you're givingMidazolam that you need to be ready
(28:53):
to catch that patient an hour or two,either by starting them on infusion or
giving them other medications that aregonna gain control of that seizure.
'cause the, solution you'veprovided is a shorter term one
than the four to six hours you'llget out of Diazepam or Lorazepam.
Sam (29:07):
Yeah.
Which brings us to secondand third line medications.
The authors cited the ECET study, which isefficacy of levetiracetam, fosphenytoin,
and valproate for establishedstatus epilepticus by age group.
And that study looked at which of theseagents has the best efficacy as a second
and third line anti-seizure medication.
(29:28):
The point being that levetiracetam,fosphenytoin, and valproate were
all shown to have similar efficacy.
But there are some specificscenarios where you might wanna
give one instead of the other.
T.R. Eckler (29:40):
my takeaway from this was just that, you know, if you're
worried about trauma, if you'reworried about ingestion, there's a
case to be made for levetiracetambeing the best first choice.
And I also think that it has such ahigh threshold for how high you can
dose it in status, that even if they'reon Keppra, you can give them another
dose safely 'cause it's gonna take alot to get them to 60 mgs per kilo.
(30:04):
And I think that that's the reasonyou're seeing so much of it given in
clinical practices that there's sucha better safety profile and such an
ease of administration that's there asopposed to some of the other medicines in
terms of like needing the pharmacy to beinvolved to get those other medications.
So I think that, that was my takeaway wasjust Keppra if I can get it and if I think
(30:24):
it's safe to give another dose, great.
If not, if I need to use the othermedicines, then I go to those because
that's what I have available to meand that's where I'm at at the moment.
Sam (30:32):
And, and honestly, I, I like Levetiracetam.
It is definitely my preferred agent,and I think the, our, really, our
neurologists feel the same way.
You can give fosphenytoin,even in the setting of trauma.
But you know, sometimes inthe settings of drug or toxic
ingestions, it's less effective.
And it has the potential for arrhythmiaand hypotension, especially if
(30:52):
you're exceeding certain doses.
Valproate is an option.
You do have to avoid it if there's anykind of history of mitochondrial disease.
And there used to be a stipulationthat you couldn't give it to children
under two years old, but recentstudies have actually said that
that's not true and that the sideeffects are similar to older children.
And so that is an option as well.
This might come up in a conversation withyour peds neurologist, which hopefully
(31:15):
you've already contacted at this point.
Phenobarbital is recommended bythe American Epilepsy Society
only if your usual first or secondline medications are unavailable.
So just know that it's another option.
It's probably not the ideal secondor third line option, but, if it's
all you got, it's all you got.
And if you've tried others andthey've failed, something to consider.
T.R. Eckler (31:34):
They listed under second, but they really want you to
think about it in the third line.
Sam (31:39):
Yeah, maybe even fourth.
T.R. Eckler (31:40):
Yeah.
Or, or refractory only.
Super, super refractory.
You're allowed to start at that point.
Sam (31:46):
That's right, that's right.
And then when we're talking about therefractory category, so this is someone
who's had two doses of benzodiazepines,has had a second and maybe third
line agent, and is still seizing.
Now we're looking at infusions and atthis point it is very likely that you've
already controlled the airway or you'regoing to control the airway before
(32:07):
you move on to one of these infusions,because these things are heavily sedating.
You're in the induction of coma kindof portion of the treatment protocol,
and we're talking about thingslike Midazolam continuous infusion,
pentobarbital continuous infusion,or Propofol continuous infusion.
And again, another clinical case.
(32:28):
I recall actually being in abrand new freestanding emergency
department which unfortunatelymeant we were separate from the main
hospital and had a limited pharmacy.
And in came a child in status, firstline benzos by EMS unsuccessful.
Second dose of benzo given in theemergency department and seizure stopped
(32:50):
and then came the clinical examination.
And the nurse and I are undressing thechild and she's looking at the skin
and then looks up at me with these big,glaring eyes as we're looking at bruises.
And she's thinking isthis child getting beaten?
Is there some non-accidental trauma?
Mom is there and I'm looking atthe child and thinking something
completely different because thebruises have no pattern whatsoever.
(33:13):
There's small little petechialhemorrhages all over this patient's body.
There's some larger confluent ecchymosis,but mostly on the back and the buttocks.
And I'm thinking, yes, thisis definitely a problem.
But this doesn't look likenon-accidental trauma.
And then the third seizure ensued.
And in that case, we were pretty limited.
We did not have levetiracetam orfosphenytoin at the time was a brand
(33:35):
new freestanding emergency department.
It was benzos or propofol, and Ithink we had one vial of propofol.
So it was okay get the propofol.
Here we go.
So we gave the thirddose of benzodiazepine.
It didn't work.
And I ended up havingto intubate this child.
And unfortunately the child did havewhat looked like new onset leukemia,
had severe thrombocytopenia, CT scan ofthe head showed petechial hemorrhages.
(33:59):
And so there we were trying tostabilize this patient and send them
out somewhere where they could take careof them to a pediatric tertiary center.
But the point being that sometimesyou have to go to this third infusion
state, and when you do, you reallyneed to control the airway at this
point because you're inducing a coma.
And again, I thought the authors dida good job of reminding us that at
(34:20):
some point, an EEG needs to enter thispathway because even after you induce
a coma or intubate this person andsedate them with a continuous infusion,
now they're just no longer moving.
But you don't know if they'reno longer seizing, and that's
really where you need the EEG.
T.R. Eckler (34:37):
I think excellent.
Super well said.
I don't think I realized how much of ablack cloud you were, but now the more you
tell stories, the more I'm like, man, youhave really had quite a black cloud run.
I think that when you're dealing withsuch a challenging patient like this,
I like that midazolam infusion becauseof its short acting nature that, you
know, you can back out of it if youneed to, but I just think that that's
(34:59):
a nice thing to gain short term controlas you're figuring out what's going on.
And I think if you only have propofol,that's okay short term, but you need
to be aware that that can't continuelong term because of the potential
for propofol infusion syndrome.
So I think that's something where youneed to quickly have a plan for how am
I gonna get this kid somewhere else?
Or to someone else that has otherkinds of medications they can try.
Sam (35:21):
Yes, and that propofol infusion syndrome specifically is characterized
by rhabdomyolysis, ECG changes,severe metabolic acidosis, renal
failure, transaminitis, and sometimescardiovascular decompensation.
So it's a big deal.
And the primary risk factor therebeing a history of a ketogenic diet or
(35:42):
high infusion rates of your propofol.
So if they have epilepsy and they're on aspecial diet, or if you're having to crank
up the propofol to stop the seizures, bothof those are reasons to keep that infusion
syndrome in your mind and maybe get themoff the propofol as soon as possible
after they reach, for example, the PICU.
And another thing to keep in mindis that about 14 to 20% of these
(36:03):
patients will continue to seizeafter being placed on this infusion
for persistent status epilepticus.
So even though you can't see it,this is just driving home that point.
Again, they need that EEG.
And then just to touch onsome special scenarios.
So if you happen to do a point of careglucose, especially in the neonate,
and they're hypoglycemic, you treatthat to stop the seizure, right?
(36:26):
Benzos are not the idealchoice in this scenario.
You're gonna be giving them the D 10or if they're a young child, the D 25.
And if they are in the neonatalperiod and they're on the formula and
it's being inappropriately mixed andthey're hyponatremic and their sodium
is less than 120, then you're gonnatreat the hyponatremia with 3% saline.
(36:46):
Give them that three to five milliliterper kilogram dose over 20 minutes to try
and stop the seizures, and then you stopthat infusion as soon as the seizures end.
And then the rest isslowly treated over time.
And the same with hypocalcemia.
So if they're hypocalcemic and you'regonna treat that, then calcium gluconate,
or if they have a central line, thecalcium chloride and all of those
(37:07):
doses are there for you in the issue.
Neonatal seizures was anotherone of those special populations
that the authors brought up.
And just as a reminder, some of the thingsyou may see on clinical exam include
the automatisms like blinking, chewing,lip smacking, tongue thrusting, or the
bicycling of the lower extremities.
(37:28):
Those are the kinds of symptoms thatyou might pick up on physical exam for
a child that's persistently seizingin this neonatal period and that they
might have jitteriness and kind of anexaggerated Moro reflex that sometimes
can be misconstrued as seizing.
So you just gotta be careful.
Do your own exam, be thorough.
And then the etiology there is very broad.
It does include trauma, but includesthings like asphyxia, maternal
(37:51):
medication use, especially if they'rebreastfeeding, maternal substance
abuse, maternal infections, theneonatal infections, the inborn errors.
And this is where, you know, if they wereborn at your hospital, you might be able
to look up their birth history and seeif they had a genetic screening at birth.
And if not, then, you know, maybeask Mom about those kinds of things.
And then keep in mind that CNS infections,especially with herpes simplex virus, can
(38:13):
also cause seizures in this population.
So lots of special considerationsfor the neonatal seizures.
T.R. Eckler (38:21):
I think febrile status epilepticus is something you need
to be a little more cautious aboutjust because those kids that are not
your common febrile seizures, thatlike they have one and they stop.
Or even if they're, you know, likethe complex ones where they have
one or two and then they stop.
The ones that are really truly febrileand in status, you need to be more
cautious and especially ask aboutvaccine status because you need to be
(38:45):
more aggressive about considering anLP in these kids and basically making
sure that you talk to the parents aboutyour recommendation to do that LP.
'cause I don't think I would want inpractice to admit a child with febrile
status and not have recommended in mychart that I wanted to get an LP and
let the parents make that decision.
Sam (39:03):
I think that's well said.
So febrile status epilepticusis very different than just
a simple febrile seizure.
Those two entities do have the wordfebrile in them, but otherwise there's
really very little overlap there.
So just be sure that you're makingthat distinction and understanding
that you really need to rule out theinfectious causes there for sure.
And that your first line treatmentin those is going to include
(39:26):
benzodiazepines, but also caninclude things to treat fever.
You know, the fever does lowerseizure threshold and you
want to address that as well.
T.R. Eckler (39:35):
to clarify my point, the authors said basically that if
there's signs of meningitis, youneed to consider a lumbar puncture.
But I think in the unvaccinated child,making sure that you were clear, that you
were really concerned and really wanted tomake sure you worked them up thoroughly.
I think you wanna be really cautiousabout making sure that you think
carefully about, does this child needan LP If they're in febrile status.
Sam (39:57):
Yeah, I mean, honestly again, it is just a reflection of my age.
I tend to be pretty aggressivewith lumbar punctures.
You know, having treated patientsat the very cusp or the beginning
of the, super effective vaccine era.
We were lumbar puncturing all ofthese infants and, honestly, it's
a relatively benign procedure.
Now, it may be difficult for you toget CSF out of a neonate, but still
(40:19):
I have a very low threshold for justsaying, yeah, we're gonna do the lumbar
puncture, and this is why and there's noother way to really make this diagnosis
if they have something infectious,especially if they're at risk for HSV.
It's something you don't wannamiss and can certainly be
catastrophic for the patient.
The authors did do a good job of talkingabout some of the other newer medications,
and we won't get into those today.
But I do wanna just touch on ketamine.
(40:41):
We have used ketamine significantlyin the adult population for treatment
of seizures, and there are casereports in the pediatric literature
but still limited case reports sowasn't a strong recommendation for
ketamine in status epilepticus.
It doesn't mean your pediatricneurologist might not recommend it.
But there are some others.
things like lacosamide and brivaracetamuh, like a longer more potent acting
(41:06):
version of levetiracetam that binds to thesame receptor but has a higher affinity.
So lots of other things thatyour pediatric neurologist might
recommend if you get to the pointwhere you've thrown everything in
the kitchen sink at the patient.
But hopefully by thenthey're in the pediatric ICU.
T.R. Eckler (41:21):
I think the last thing I would wanna say is I really like their
note about disposition, and I think someof these patients are gonna come in with
seizures that are, you know, epilepsypatients that are on their medications.
You give them medications, things calmdown, they go back to the baseline.
And if you talk to their neurologist,a lot of times these kids can go home.
But I think especially if theyhave a concern that they've
(41:42):
outgrown their seizure coverage.
You wanna ask their neurologist ifyou want to adjust their medications.
Or if they need refills of their rectaldiazepam, their intranasal midazolam,
or diazepam, or even what's called aklonopin bridge or clonazepam bridge,
to get them through a period of time,let's say if they have an infection,
that they're gonna be more prone toseizures and you can give them an
additional layer of seizure coverage.
(42:03):
I've seen a few neurologists do thiswhere the patient goes home with a short
course of Clonazepam, and I think itworks really great for helping educated
parents that do a great job of managingtheir kids have the tools to keep them
outta the emergency department again.
Sam (42:16):
Fantastic.
Well said.
And that brings us tothe end of the episode.
Thanks again to Dr. Bowen and Dr.Bolton, our two authors for this
July 2025 pediatric emergencymedicine practice article on the
treatment of peds status epilepticusin the ED and keep this in mind.
Keep those tables in your pocket.
It's a great reference, especiallywhen you're standing there at the
(42:37):
bedside treating this critical patient.
And until next time, everyone, be safe.
I am one of your hosts , Sam Ashoo.
T.R. Eckler (42:45):
Dr. TR Eckler, stay safe out there.
Good luck.
Try to deal with your newfoundcelebrity from the pit.
Sam (42:51):
and that's a wrap.
Thanks for joining us forthis episode of EMPlify.
I hope you found it informative, and Iwant to remind you that ebmedicine.net
is your one stop shop for all of yourCME needs, whether that be for emergency
medicine or urgent care medicine.
There are three journals, there'stons of CME, there's lots of
courses, there's so many clinicalpathways, all this information at
(43:13):
your fingertips at ebmedicine.net.
Until next time, everyone,I'm your host, Sam Ashoo.
Be safe.
I don't think I realized how much of a black cloud you were,
but now the more you tell stories,the more I'm like, man, you have
really had quite a black cloud run.
Sam (2) (00:12):
Hi everyone, and welcome back to another episode of Amplify.
I am one of your hosts, Sam Ashoo,and I wanna thank you for being a
listener and encourage you to rateus in whatever podcast app you're
listening in so that we can get theword out there to more listeners.
And I also wanna share with youthat this month, EB Medicine is
running a special $1 for a seven daysubscription to any or even all three
(00:35):
of the journals on eb medicine.net.
That's a great deal.
If you're not already a subscriber,go there and take advantage of
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You will not believe how many coursesand how many issues and how many
hours of CME you will have access to.
It's an absolutely wonderfultime saving and critical to
your practice subscription.
(00:56):
Do yourself a favor and takeadvantage of that special today.
And now let's jump intothis month's episode.
Sam (01:04):
Ladies and gentlemen, welcome back to another episode of EMPlify.
I am one of your hosts, Sam Ashoo, andon the other side of the microphone.
T.R. Eckler (01:12):
Dr. TR Eckler back again, excited to make
kids do a little less wiggling.
Sam (01:18):
Yes, I'm sure all of our pediatric emergency medicine
colleagues appreciate that notion.
No one wants to have to stand at thebedside and watch a child continuously
seize, and that actually happens tobe what we're talking about today.
This is the July, 2025 issue of pediatricemergency medicine practice on the
emergency department management ofstatus epilepticus in pediatric patients,
(01:42):
which is a frightening scenario for me.
Something I don't enjoywatching or treating.
But still a very, veryimportant disease process.
And if you happen to be the clinicianstanding at the bedside wondering
what the next drug to push is, Ihighly recommend reading this article.
The two authors, Dr. Bowen and Dr. Boltondid a really good job of summarizing all
(02:06):
of the evidence and the guidelines for us.
Especially the guidelines fromthe International League Against
Epilepsy which I just love.
I want a t-shirt with InternationalLeague against Epilepsy on it.
If you're listening to thispodcast and you're a member of
the International League AgainstEpilepsy, send me a t-shirt.
I'll wear it.
T.R. Eckler (02:25):
Same.
I would wear that t-shirt.
That'd be, that'd be rad.
Sam (02:28):
cool.
It reminds me of the Justice League.
We are the epilepsy league.
We will stop seizures.
And I think that's thepoint of this issue really.
If you're wondering why statusepilepticus in children.
Is it really a big deal?
The answer is yes, it is a big deal.
Seizures are like 1% of ED visits here inthe us and 3% of pre-hospital transport.
So if you're listening to this andyou're in pre-hospital medicine,
(02:50):
it is a very important topic andwe'll have some more information on
that for you in just a few minutes.
But it is common, or at leastit's not rare if you're in
the emergency department.
And , the crux of the historical aspectof it is, I remember the days, again,
I'm just dating myself, but I rememberwhen the status Epilepticus definition
(03:11):
was 30 minutes of continual seizing.
And I will tell you in clinicalpractice before the guidelines
changed, I never waited 30 minutesto call it status epilepticus.
Even then, I thought thatwas a ridiculous definition.
But I'm happy to see that theInternational League against
Epilepsy, check my t-shirt, didchange that definition in 2015.
(03:34):
And for convulsive status epilepticus,it's now five minutes, which seems
a much more reasonable timeframe.
Something I'm far more comfortablewith and something that's really
far more in step with clinicalpractice, I think for most of us.
We don't like to just stand by and watchsomebody seize for 20 to 30 minutes.
T.R. Eckler (03:55):
I really liked their, attempt to break that down too, where
they basically, instead of it beinglike, after this time period, you must do
something or This is the danger zone, andI thought it was great how they started
to tease out more of the kind of nuancehere by having a T one and a T two for
each classification of seizures, meaninglike after this amount of time with this
(04:16):
kind of seizures, you know, you shouldtreat, and after this amount of time
with this amount of seizures, your T two,then it starts to have a risk of damage.
I felt like that was a helpful idea.
And I think that was maybe one of theonly things I wanted to enhance with the
article was having more of a sense ofwhat those T one and T two times are.
But I think that those even tendto vary based on age and the
condition that you're dealing with.
(04:36):
But it still gave me a clearer ideaof like, I want to treat sooner
so I don't get to that T two time.
Sam (04:42):
Yeah, and you know, if you're listing and wondering what we're talking about, in
the article, there is the definition fromthe International League against Epilepsy
about, the time at which point it becomesstatus and the time at which you're
starting to have neurological damage.
And it varies by the type of seizure.
So you know, you might have noticed thatI called it convulsive status epilepticus.
And that's because there are nonconvulsive focal motor and myoclonic
(05:06):
seizure types as well, all of whichcome with different timeframes.
But if you're obviously seeingseizure activity and it's
convulsive, then five minutes isthe number you gotta remember there.
And like I said, I just think that'sa much better definition than what
we used to have, and I'm happy to seethat we're moving in that direction.
The authors as usual did a great job withthe literature search and looked at a
(05:28):
number of guidelines, and I thought itwas important to point out that, you know,
this particular issue is on pediatricstatus epilepticus, and much of the
literature comes from national guidelinesand studies performed outside of the ED.
So, it's helpful to have the summaryand I like that they focused it
on the initial management for us.
That was very good.
(05:49):
And as always, before wedive into anything, I like
to pimp you with questions.
So let's just jump into onefor the sake of talking.
That's how we go.
So, which of the following is amongthe leading causes of pediatric status
epilepticus, according to the article.
Asthma, structural CNS abnormalities,diabetes, and hyperlipidemia.
T.R. Eckler (06:12):
Oh B, structural neurologic abnormalities
Sam (06:15):
of course.
Right.
T.R. Eckler (06:16):
Have you had an MRI yet is my favorite question for kids that
come in with seizures, has someone putyour child inside the magical magnet?
The tunnel of truth, as Icall it, to show us if there's
something structural there or not.
Sam (06:29):
Yeah, and that's a really good question because the leading causes
for status epilepticus are the onesyou would think of most commonly
fever and infections, some kind ofcentral nervous system abnormality,
accidental ingestions, and then thegenetic and metabolic disorders.
Those are kind of like the topfour categories for causes of
(06:50):
pediatric status, epilepticus, andagain, it can be multifactorial.
And what we're gonna talk about today istrying to differentiate these causes and
how your initial therapy might change.
But the finger member is those fourcategories because you've gotta
run through 'em super fast in yourhead if you've got somebody who's
actively seizing in front of you.
T.R. Eckler (07:08):
I really liked just the quick summary they had in
this, that 10% of seizure patientsare gonna come in in status.
And I think that that kind ofhelped me like feel better about
the sense that like nine outta 10of these patients are gonna be okay.
They'll have a seizure,but they're gonna stop.
But I need to be on my guard for that oneout 10 that isn't gonna stop and be ready.
(07:29):
So, you know, not that I'm necessarilymedicating every one of these patients
when they come in, but I'm readyfor the ones that aren't stopping or
the ones that start up again, thatI have a plan of where I'm gonna go.
And then I really liked how theygave you that sense that, yeah, 33%
of these, it's due to subtherapeuticlevels of their medicines, but 6% are
gonna be their electrolytes or theirglucose, and 3.6% is toxic ingestions.
(07:52):
So that same kind of thing.
I'm ready for the common things,but I have those zebras in the
back of my head of, alright, do Ineed to give, you know, glucose?
Do I need to fix an electrolyte?
Do I need to worry aboutsome toxic congestion?
Do I need to start broadening my senseof what I'm gonna do to fix this patient?
Because what I'm doing isn't working?
Sam (08:09):
Yeah.
Yeah.
I did, I mean, I'm a numbersguy, so I enjoy the numbers.
And I did also find it interestingthat 70% of children who are diagnosed
with epilepsy before the age of onewill experience status epilepticus.
That's a l ot.
And if they didn't experienceit on diagnosis, then it's
going to happen at some point.
And that's an importantthing to share with parents.
(08:31):
And it also will tell you that thoseparents are probably well educated
and may have already given a therapyor two before the person even
gets to the emergency department.
So history, history and more history.
And in this scenario, luckily there'sa parent who hopefully knows quite
a bit about this patient right infront of you if it's someone with
a diagnosis of epilepsy already.
(08:51):
Table one is an interesting tablefrom the International League
against Epilepsy classification ofconvulsive status epilepticus to kind
of break down the different types,and if you have the time to try and
differentiate these, this is great.
Sometimes it can help with theconversation with the neurologist
or if the parent already knows.
It can make a difference if it'simpending convulsive status epilepticus
(09:11):
versus established versus refractory,and at what point you're gonna use
what term, but just know that fiveminutes is your timeframe there.
If it lasts five minutes ormore, you're into that status.
And once you get into that area,then you're starting to break
down things like the differentialdiagnosis and what it is we're
supposed to be doing for the patient.
And table two does a great job ofbreaking it down by age because
(09:36):
the causes can vary depending onthe size and age of the patient.
If they're anywhere from birth tosix years old, you're thinking things
like febrile seizures, chromosomaland genetic abnormalities, inborn
errors of metabolism, breath holdingspells, and non-accidental head trauma.
The big key there.
Don't miss that.
(09:56):
If they're school age, then autoimmunedisorders become the most common.
If they're adolescents, now you'rethinking things like eclampsia.
You can't forget about thepossibility of pregnancy.
Hypertensive crisis, autoimmune disorders,and functional neurologic disorder.
And then for all ages, you also haveto keep in mind things like cerebral
vascular accidents, infections, tumors,cortical dysplasia, head trauma,
(10:22):
medication exposures or overdoses,metabolic disturbances, et cetera.
So lots and lots of things tokeep in mind in the differential.
Table two does a really goodjob of breaking it down by age.
T.R. Eckler (10:33):
And it's really the common things that were there at the finish.
I found that table confusing becauseI felt like they led with the rare
things, but then once you get to thebottom, it's really the cerebrovascular
diseases, the CNS infections, the tumors,head trauma, intoxication, overdose.
Those are really the thingsthat are causing most of these.
But I felt like it was great tohave that even broader sense that
(10:53):
occasionally you're gonna get someof these unusual kids with autoimmune
disorders or you know, some otherunusual inborn error metabolism.
And it's great to look for help early fromyour specialists when you realize that
you're getting into something like that.
Sam (11:08):
Yeah.
Yeah.
Great point.
Alright.
When it comes to pre-hospital treatments,there are some significant things that
our pre-hospital personnel can do whichleads me to our next question, which
pre-hospital intervention improvesseizure control before ED arrival?
Number one, rectal acetaminophen.
(11:29):
Number two, oral lorazepam.
Number three, intramuscular midazolam,or number four hypertonic saline.
T.R. Eckler (11:37):
I am gonna go with number three, intramuscular Midazolam,
because I just love that medicinebecause I know intramuscular
is gonna stay in the patient.
I know that the other stuff is gonnahelp, but not necessarily like.
really like give thatimprovement in control.
And I found that the, the RAMPART studythey referred to here, which talked
(11:59):
about how if they got IM Midazolam or IVlorazepam in adults and children, they
were more likely to not need to go to theICU, more likely to have their seizures
terminated prior to the arrival of the ER.
And I felt like that boostedmy own practice, like what I
recommend for EMS in the field.
And I like how Midazolam wears off so Ican kind of have a sense of what I'm doing
(12:21):
next, or I can plan for it as opposed tothe longer term of Lorazepam if you're
getting it in pre-hospital settings.
So I feel like I get more chances toadjust once I know more about the patient.
If they're in the ER, then I'm moreinterested in giving them a longer
acting medicine if I have that chance.
Sam (12:35):
Yeah.
Yeah, and that's a perfect answer.
So the, the pre-hospital treatment isall about targeting seizure control,
and there is good evidence from thatrapid anti-convulsant medication prior
to arrival trial, or RAMPART, thatinvolvement of pre-hospital personnel in
treating seizures is critically importantand does actually improve outcomes.
(12:56):
So definitely IM midazolam and it'sreally great actually that our EMS
personnel now have multiple options.
It used to be you struggle to get the IVin someone who's actively seizing, and
maybe you get it and maybe you don't.
And then your only other option was an IO.
But now we have intranasal, wehave IM, and we have rectal forms.
(13:17):
Again, if the person has a diagnosisof epilepsy and the parent has rectal
diazepam, it's okay to give it,you know, just because you're the
pre-hospital personnel doesn't mean youcan't give them their home diazepam.
So you've got lots of options andlots of delivery mechanisms to
try and get that benzodiazepineon board as fast as you can.
Use whatever you have at your disposal.
T.R. Eckler (13:37):
And having, said that, I think the, key that I, having read
this article that I took away wasto remember how flexible you need
to be, because EMS isn't gonna haveall the medicines that you want.
There's so many often drug shortages.
So things that you're used tousing are not gonna be there.
So being ready to adjust your practiceand, you know, adjust to what's available.
And as you said, the medicinesnow that the patients are having
(14:00):
at home are becoming more common.
An intranasal Valium orintranasal diazepam is now much
more of a common thing that'sgoing home with these patients.
So you can ask EMS in the field, Hey,do they have their intranasal Valium?
Have they given it?
Okay.
Then if you want, you can give that ifyou don't have another option, if you
don't have midazolam or something else.
But really just figuring out quicklywhat your options are, and then
(14:21):
making the best decision you canor helping your EMS crews make the
best decision from what they have.
Sam (14:26):
Yeah.
And then once that's been done,then you turn to your routine ABCs.
So making sure their airway is controlledor patent, making sure they have
adequate ventilation, especially ifyou've just given them a benzodiazepine.
And whether or not that seizure hasterminated, they're gonna need some
supplemental oxygen and perhapssome bag valve mask assistance until
(14:47):
you get to the hospital, especiallyif the benzos are causing a little
bit of respiratory depression.
Circulation.
Certainly if they are getting hypotensiveor having instability, then they need
that IV access and the IV fluid boluses.
And lastly glucose levels.
So point of care glucose, gotta checkthat sugar to make sure, especially
the younger they are, the more likelythey are to be just hypoglycemic.
(15:10):
And so that's an important piece thatyou need to add to your investigation
when you're in the pre-hospital arena.
And hopefully by thenyou are at the hospital.
'cause these can be very anxietyprovoking cases and getting to the
nearest emergency department is important.
You know, hopefully it's a peds emergencydepartment, but if not, that's still okay.
(15:30):
The ABCs and initial resuscitationshould be the same regardless
of wherever you land.
Once you're in the emergencydepartment, our initial evaluation
begins and leads to our next question.
What is the most important firststep in the ED management of
pediatric status epilepticus?
Here we go.
A, obtain a head, CT.
(15:51):
B, secure airwaybreathing, and circulation.
C. Start valproic acid or D order.
An EEG
T.R. Eckler (15:59):
I would tell you that I think the answer to that question is A,
B, C, and a second C. 'cause I liked howthey added consciousness to their ABCs.
'cause I do think sometimes a kid looksokay but is not actually conscious.
Like, you could look at a kid quicklyand be like, all right, they're
not having status epilepticus.
It's not convulsive.
But if that kid's not there, theymight be a non convulsive status.
(16:22):
And I liked how they putthat little nuance to it.
Sam (16:25):
Yeah.
Yes.
Well, first of all, you are correct.
So it is the ABCs.
And second, you know, I recall we talkedabout seizures when we talked about
geriatric emergencies some time agoon a different podcast, and we talked
about alterations in mental status inthe geriatric population, maybe being
something like non convulsive status.
And so similarly in children, as yousaid, if they're not actively convulsing,
(16:49):
but they haven't returned to theirnormal baseline, it's something you need
to keep in mind in your differentialand it can be very challenging to
try and make that diagnosis andfigure out, okay, what is it exactly
that is now causing this alteration?
Especially if they had a doseof benzodiazepines already.
So it can certainly be a challenge.
But yes, you are correct airway is always the first priority, especially if
(17:13):
they've already had some benzodiazepine.
So positioning suctioning,oxygen administration for the
hypoxia because you're tryingto reduce the neuronal injury.
Second is making sure they're not apnic.
Third is checking, breathing andcirculation and hooking up the monitor.
And if you have end tidal CO2, thisis an ideal time to use it because not
only are you interested in preventinghypoxia, but you also want to know if
(17:37):
they've got hypoventilation and theyneed some assistance with ventilation.
Bag valve mask ventilation isokay to use even briefly after
administration of benzodiazepines.
So they may need that for afew minutes until they start to
adequately ventilate on their own.
And then that'll start hopefully, yourbrain going down the pathway of, you
know, at one point, do I need to decideabout intubating this patient now?
(17:59):
But if you're doing well with bagvalve mask ventilation, that's okay.
You got time.
Establishing IV access or IO access.
So if the pre-hospital personnelwere unable to do so, then
this is a good time to do it.
And then gathering history, right?
Talking to mom or dad about previoushistory, medication exposures, recent
illnesses and if they're in the neonatalperiod or infant period, formula
(18:23):
mixing is a big deal because you'retrying to also exclude hypoglycemia and
hyponatremia your differential diagnosis.
And then lastly, trauma.
Non-accidental trauma.
I recall having a neonate comethrough the emergency department
who had some abnormal movements.
We weren't really sureif they were seizing.
(18:43):
We gave some benzos.
It didn't really change much, butit did cause respiratory depression.
And at that point I was callingthe ICU and we had gathered a
bunch of labs and we weren'treally sure if this was infectious.
There was no fever.
Ended up doing a lumbar puncture andas soon as I walked out of the room
my ICU colleague was there and I said,gosh, you know, I'm really sorry.
Like I got CSF.
This was a really tiny neonate.
(19:04):
I got CSF, but I think it was a traumatictap because it was all just bloody.
And he kinda looked at me and went, Hmm.
Okay, well we're gonna send it anyway.
And I said, oh yeah, we'llsend it for fluid analysis.
And we started the antibiotics and sureenough, the next day, now we'd already
obtained a head CT, which was normal.
And the next day the MRI showed, youknow, bilateral subdural hemorrhages.
And so it was not atraumatic lumbar puncture.
(19:25):
It was trauma that was thecause of the blood in the CSF.
And so, uh with a normal head CT
T.R. Eckler (19:32):
Oh, that's so.
Sam (19:33):
because there were like subacute, bilateral subdural hematomas.
So trauma, trauma, trauma.
Don't forget the non-accidentaltrauma in your differential.
And then when we start, talking aboutinitial management, so what are we
gonna give first, first line therapy
T.R. Eckler (19:50):
Can I stop us for one second because I think this is a question I ask
med students and residents all the time,and I thought they did a great job, is
when do you intubate the seizure patient?
Like what are your indicationsfor rapid sequence intubation
and mechanical ventilation.
I like how they put that together.
You gotta plan for both.
It's inability to maintain their airway.
Meaning they're not able to holdtheir airway open despite what
(20:12):
other things you're gonna do.
Hypoxemia, inadequate ventilation,apnea, and refractory status
lasting longer than 30 minutes.
So I think if you don't feelcomfortable with any of those
things, take that airway, it's time.
I thought that was a nice line in thesand in a very gray world that we live in.
I thought that was a nice, clear thingof you can feel comfortable if this
(20:34):
is what you're looking at, then that'swhen you should take that airway.
Sam (20:38):
Yeah, they did actually mention under circulation as well that bradycardia can
be the harbinger of impending badness.
If it's not from hypoxia then it canbe the potential clue that this person
needs invasive ventilation as well.
So lots of physical examination cluesthere, or if their seizure is persisting
and you're not able to control it.
(20:59):
Once we've passed through theABCs the authors then had a little
discussion here about diagnosticstudies and what you should be
ordering in the emergency department.
And we you know, arepretty good about this.
Really, most of these are protocoledor fit in line with the things
that we're trying to eliminatefrom our differential diagnosis.
So obviously we're going to get a pointof care glucose if that wasn't already
(21:19):
done by EMS, and then you're gonna getyour comprehensive metabolic panels in
order to exclude metabolic inborn errors,calcium, magnesium, and phosphorus.
So your calcium may be part of your CMP.
Your magnesium and phosphorus are usuallynot, so you gotta remember to order those.
A lactic acid can be helpful.
A serum pH, even if it's avenous pH, can be helpful.
(21:39):
If they're already on seizure medications,you might be interested in getting levels
for those to see if they're therapeutic.
If you know that they've had a toxicingestion, you may be able to send
levels for those if that comes acrossin the history from the parent.
If they're of age, youneed a pregnancy test.
Again, not to be the harbinger ofterrible stories, but , I recall
being in the emergency departmentand having a 15-year-old obese female
(22:01):
come in with a seizure first time.
No past medical history.
EMS had given a dose of LorazepamIV prior to arrival and the seizure
stopped and she arrived appropriatelypostictal and sedated from the Lorazepam.
And I was waiting for a parent toshow up and a second seizure ensued.
And so we gave another dose ofLorazepam and off went to CT because
(22:24):
the rest of the vitals were normal.
And while she was in CT, a parentshowed up and confirmed, Hey,
there's no history of this.
And while she was in CT, she had athird seizure and got a third dose
of Lorazepam, and then as soon asshe came back from CT she gave birth.
T.R. Eckler (22:40):
Wow.
Sam (22:40):
no one knew that she was pregnant, she was obese.
And unfortunately she gave birth to afetal demise that was probably somewhere
in the second trimester, so she hadn'teven made it to the third trimester.
And then now we were in the midstof trying to resuscitate what
we thought were two patients.
And so we've got the neonate bornstill, and then the 15-year-old who
(23:03):
has received a bunch of Lorazepamwho is now excessively sedated and
still having seizures and now movingdown a different differential and
diagnosis and treatment modality.
So don't forget to get the pregnancytest, and don't forget to consider
that in anyone who is of the age
T.R. Eckler (23:20):
Also a patient like that is gonna be challenging
To get a urine out of.
But I like to remind people mostof the rapid urine pregnancy
cartridges that we use in theUnited States are dual certified for
blood, like whole blood and urine.
So you can drop whole blood onto thosecartridges and then wait a few minutes.
And just like a urine pregnancytest, it will show you if the
patient is pregnant or not.
(23:41):
Just from their whole blood.
So if your lab tells you, oh, we can'trun this, we have to run the quant, or
it has to be a urine, you can basicallyjust have them send you a cartridge and
you can put blood on that cartridge.
If the cartridge says it's okay,and you will know very, very quickly
if your patient is pregnant or not.
And you don't need to wait a couple hoursfor somebody to cath the patient for
urine while they're altered and confused.
Sam (24:01):
Yeah.
Yeah, great point.
And sometimes, you know, it seemsstrange that we even have to say
things like this, but sometimes itdoes take the physician to just say.
Send me the cartridge, send me whateverit is that I have to put the drop on.
I'll just do it myself because thelab technician is constrained by
lab policies or rules or whatever itis from somebody who's nonclinical.
Then you, you just have to say,okay, look, I'll do it and I'll
(24:22):
take the heat for it, but Igotta save this person's life.
T.R. Eckler (24:25):
I gotta save this person.
Yep.
Sam (24:27):
so diagnostic imaging, if you're suspecting some kind of intracranial
lesion or they got a history of it,or if they come with a history of a
VP shunt and you're worried about aVP shunt failure then yes, you have
to obtain the CT imaging of the brain.
And then there's other ancillary testing,ECG EEG, et cetera, that comes later
down the line if you have the time.
(24:48):
If they have a history of VP shuntor if they have a focal seizure or
if you're worried about head trauma,you need to order the head CT.
Now we are usually radiationsparing, especially in our
children and pediatric populations.
But in this scenario, this is notthe time to be radiation sparing.
If they have a history of anythingintracranial or if you're suspecting
(25:13):
even mildly suspecting somethingtraumatic, you need to get that head CT.
You know, reducing radiation exposure isnot the appropriate step in this scenario.
T.R. Eckler (25:22):
I think the key to that is we're not talking about all seizure
patients that come into the ER.
We're not talking about yourfebrile seizure children.
We're talking about patients instatus that are not returning to
their baseline, that you're havingtrouble controlling their seizures.
You want to get the CT inthat patient because it's
often gonna change management.
I remember I had a well-knownseizure patient that came in
in rural Colorado, and I justcouldn't get his seizures to stop.
(25:45):
And I finally, after like three differentmedications, got his seizures under
control and got him intubated and gothim to CT and he had a huge brain bleed.
and that was just somethingthat stuck with me.
That if you can't control the seizures,take pictures, do more things because
there's something there that, that youjust need to get there and you'll find it.
Sam (26:02):
Yeah.
And really that brings usto first line treatment.
So again, we're in theemergency department.
We're going to give somethingregardless of what EMS has given so far.
Which leads me to the next question.
Which benzodiazepine is preferred?
If IV access is available, is itdiazepam, midazolam, or clonazepam?
T.R. Eckler (26:23):
So I will tell you that I know the right answer
to this question is Lorazepam.
And I will tell you that I firmly disagreewith the authors and I would like someone
to check my record because I have along track record of being appreciative
and supportive of the authors.
But I find in clinical practice it isso much easier to dose stack Lorazepam
(26:43):
where you give some, nothing happens,and then you give more and then they get
respiratory depression and get intubated.
I think that in my practice I haveseen better results from Diazepam,
but I do like how they focusedclearly on a weight-based dosing where
Lorazepam should be 0.1 mg per kilos.
But then diazepam can be 0.1 to0.3, and I think that Lorazepam is
(27:05):
a significantly stronger medication.
So I would be more inclined to go 0.1of Lorazepam, 0.2 of Midazolam, or 0.3
of Diazepam if I was treating patients.
And I think that as we talked aboutearlier, you need to be ready to use
any of these medications because yourfavorites aren't always gonna be there.
So I think you need to have a sense ofthat dosing, or you need to have a sense
(27:26):
that I know the medicines I need, butI can't keep these doses in my head.
So you need to either have support froman ER pharmacist to help you dose, or
you need to be your own ER pharmacistand have an application like PD stat.
I love PD stat for basically makingsure when I'm running a complex
pediatric resuscitation that Iknow exactly the doses I'm giving.
'cause I put in the child'sBraslow or their weight, and then
(27:46):
I hand the phone to the nursesand say, I'm gonna give you drugs.
You just look down and tell mewhat the doses are from that
.Sam: Yeah.
Perfect.
and I will say, page seven of thearticle table four medications
for status epilepticus first lineanti-seizure medications lists all
three of those as an option, right?
Lorazepam midazolam and diazepam.
Now, they do have a preferencefor Lorazepam, but it's not to
(28:07):
the exclusion of the other two.
So whatever of the three that you havethey do recommend Lorazepam because of
its reliable onset and its duration.
But if you don't have, or if youhave a preference, it's okay.
, You've got some flexibility there.
Midazolam does come with theother delivery options too, so IO,
intranasal, intramuscular and hashad efficacy in all of those areas.
(28:31):
So if you don't have an IV in place,that's probably the better choice.
To clarify, you can use any of those through an IV
or an IO, but if you need to givethem IN like nasally or muscularly,
then you have to use Midazolam.
But I think that to be clear, midazolamis a significantly shorter acting drug.
So you need to know if you're givingMidazolam that you need to be ready
(28:53):
to catch that patient an hour or two,either by starting them on infusion or
giving them other medications that aregonna gain control of that seizure.
'cause the, solution you'veprovided is a shorter term one
than the four to six hours you'llget out of Diazepam or Lorazepam.
Sam (29:07):
Yeah.
Which brings us to secondand third line medications.
The authors cited the ECET study, which isefficacy of levetiracetam, fosphenytoin,
and valproate for establishedstatus epilepticus by age group.
And that study looked at which of theseagents has the best efficacy as a second
and third line anti-seizure medication.
(29:28):
The point being that levetiracetam,fosphenytoin, and valproate were
all shown to have similar efficacy.
But there are some specificscenarios where you might wanna
give one instead of the other.
T.R. Eckler (29:40):
my takeaway from this was just that, you know, if you're
worried about trauma, if you'reworried about ingestion, there's a
case to be made for levetiracetambeing the best first choice.
And I also think that it has such ahigh threshold for how high you can
dose it in status, that even if they'reon Keppra, you can give them another
dose safely 'cause it's gonna take alot to get them to 60 mgs per kilo.
(30:04):
And I think that that's the reasonyou're seeing so much of it given in
clinical practices that there's sucha better safety profile and such an
ease of administration that's there asopposed to some of the other medicines in
terms of like needing the pharmacy to beinvolved to get those other medications.
So I think that, that was my takeaway wasjust Keppra if I can get it and if I think
(30:24):
it's safe to give another dose, great.
If not, if I need to use the othermedicines, then I go to those because
that's what I have available to meand that's where I'm at at the moment.
Sam (30:32):
And, and honestly, I, I like Levetiracetam.
It is definitely my preferred agent,and I think the, our, really, our
neurologists feel the same way.
You can give fosphenytoin,even in the setting of trauma.
But you know, sometimes inthe settings of drug or toxic
ingestions, it's less effective.
And it has the potential for arrhythmiaand hypotension, especially if
(30:52):
you're exceeding certain doses.
Valproate is an option.
You do have to avoid it if there's anykind of history of mitochondrial disease.
And there used to be a stipulationthat you couldn't give it to children
under two years old, but recentstudies have actually said that
that's not true and that the sideeffects are similar to older children.
And so that is an option as well.
This might come up in a conversation withyour peds neurologist, which hopefully
(31:15):
you've already contacted at this point.
Phenobarbital is recommended bythe American Epilepsy Society
only if your usual first or secondline medications are unavailable.
So just know that it's another option.
It's probably not the ideal secondor third line option, but, if it's
all you got, it's all you got.
And if you've tried others andthey've failed, something to consider.
T.R. Eckler (31:34):
They listed under second, but they really want you to
think about it in the third line.
Sam (31:39):
Yeah, maybe even fourth.
T.R. Eckler (31:40):
Yeah.
Or, or refractory only.
Super, super refractory.
You're allowed to start at that point.
Sam (31:46):
That's right, that's right.
And then when we're talking about therefractory category, so this is someone
who's had two doses of benzodiazepines,has had a second and maybe third
line agent, and is still seizing.
Now we're looking at infusions and atthis point it is very likely that you've
already controlled the airway or you'regoing to control the airway before
(32:07):
you move on to one of these infusions,because these things are heavily sedating.
You're in the induction of coma kindof portion of the treatment protocol,
and we're talking about thingslike Midazolam continuous infusion,
pentobarbital continuous infusion,or Propofol continuous infusion.
And again, another clinical case.
(32:28):
I recall actually being in abrand new freestanding emergency
department which unfortunatelymeant we were separate from the main
hospital and had a limited pharmacy.
And in came a child in status, firstline benzos by EMS unsuccessful.
Second dose of benzo given in theemergency department and seizure stopped
(32:50):
and then came the clinical examination.
And the nurse and I are undressing thechild and she's looking at the skin
and then looks up at me with these big,glaring eyes as we're looking at bruises.
And she's thinking isthis child getting beaten?
Is there some non-accidental trauma?
Mom is there and I'm looking atthe child and thinking something
completely different because thebruises have no pattern whatsoever.
(33:13):
There's small little petechialhemorrhages all over this patient's body.
There's some larger confluent ecchymosis,but mostly on the back and the buttocks.
And I'm thinking, yes, thisis definitely a problem.
But this doesn't look likenon-accidental trauma.
And then the third seizure ensued.
And in that case, we were pretty limited.
We did not have levetiracetam orfosphenytoin at the time was a brand
(33:35):
new freestanding emergency department.
It was benzos or propofol, and Ithink we had one vial of propofol.
So it was okay get the propofol.
Here we go.
So we gave the thirddose of benzodiazepine.
It didn't work.
And I ended up havingto intubate this child.
And unfortunately the child did havewhat looked like new onset leukemia,
had severe thrombocytopenia, CT scan ofthe head showed petechial hemorrhages.
(33:59):
And so there we were trying tostabilize this patient and send them
out somewhere where they could take careof them to a pediatric tertiary center.
But the point being that sometimesyou have to go to this third infusion
state, and when you do, you reallyneed to control the airway at this
point because you're inducing a coma.
And again, I thought the authors dida good job of reminding us that at
(34:20):
some point, an EEG needs to enter thispathway because even after you induce
a coma or intubate this person andsedate them with a continuous infusion,
now they're just no longer moving.
But you don't know if they'reno longer seizing, and that's
really where you need the EEG.
T.R. Eckler (34:37):
I think excellent.
Super well said.
I don't think I realized how much of ablack cloud you were, but now the more you
tell stories, the more I'm like, man, youhave really had quite a black cloud run.
I think that when you're dealing withsuch a challenging patient like this,
I like that midazolam infusion becauseof its short acting nature that, you
know, you can back out of it if youneed to, but I just think that that's
(34:59):
a nice thing to gain short term controlas you're figuring out what's going on.
And I think if you only have propofol,that's okay short term, but you need
to be aware that that can't continuelong term because of the potential
for propofol infusion syndrome.
So I think that's something where youneed to quickly have a plan for how am
I gonna get this kid somewhere else?
Or to someone else that has otherkinds of medications they can try.
Sam (35:21):
Yes, and that propofol infusion syndrome specifically is characterized
by rhabdomyolysis, ECG changes,severe metabolic acidosis, renal
failure, transaminitis, and sometimescardiovascular decompensation.
So it's a big deal.
And the primary risk factor therebeing a history of a ketogenic diet or
(35:42):
high infusion rates of your propofol.
So if they have epilepsy and they're on aspecial diet, or if you're having to crank
up the propofol to stop the seizures, bothof those are reasons to keep that infusion
syndrome in your mind and maybe get themoff the propofol as soon as possible
after they reach, for example, the PICU.
And another thing to keep in mindis that about 14 to 20% of these
(36:03):
patients will continue to seizeafter being placed on this infusion
for persistent status epilepticus.
So even though you can't see it,this is just driving home that point.
Again, they need that EEG.
And then just to touch onsome special scenarios.
So if you happen to do a point of careglucose, especially in the neonate,
and they're hypoglycemic, you treatthat to stop the seizure, right?
(36:26):
Benzos are not the idealchoice in this scenario.
You're gonna be giving them the D 10or if they're a young child, the D 25.
And if they are in the neonatalperiod and they're on the formula and
it's being inappropriately mixed andthey're hyponatremic and their sodium
is less than 120, then you're gonnatreat the hyponatremia with 3% saline.
(36:46):
Give them that three to five milliliterper kilogram dose over 20 minutes to try
and stop the seizures, and then you stopthat infusion as soon as the seizures end.
And then the rest isslowly treated over time.
And the same with hypocalcemia.
So if they're hypocalcemic and you'regonna treat that, then calcium gluconate,
or if they have a central line, thecalcium chloride and all of those
(37:07):
doses are there for you in the issue.
Neonatal seizures was anotherone of those special populations
that the authors brought up.
And just as a reminder, some of the thingsyou may see on clinical exam include
the automatisms like blinking, chewing,lip smacking, tongue thrusting, or the
bicycling of the lower extremities.
(37:28):
Those are the kinds of symptoms thatyou might pick up on physical exam for
a child that's persistently seizingin this neonatal period and that they
might have jitteriness and kind of anexaggerated Moro reflex that sometimes
can be misconstrued as seizing.
So you just gotta be careful.
Do your own exam, be thorough.
And then the etiology there is very broad.
It does include trauma, but includesthings like asphyxia, maternal
(37:51):
medication use, especially if they'rebreastfeeding, maternal substance
abuse, maternal infections, theneonatal infections, the inborn errors.
And this is where, you know, if they wereborn at your hospital, you might be able
to look up their birth history and seeif they had a genetic screening at birth.
And if not, then, you know, maybeask Mom about those kinds of things.
And then keep in mind that CNS infections,especially with herpes simplex virus, can
(38:13):
also cause seizures in this population.
So lots of special considerationsfor the neonatal seizures.
T.R. Eckler (38:21):
I think febrile status epilepticus is something you need
to be a little more cautious aboutjust because those kids that are not
your common febrile seizures, thatlike they have one and they stop.
Or even if they're, you know, likethe complex ones where they have
one or two and then they stop.
The ones that are really truly febrileand in status, you need to be more
cautious and especially ask aboutvaccine status because you need to be
(38:45):
more aggressive about considering anLP in these kids and basically making
sure that you talk to the parents aboutyour recommendation to do that LP.
'cause I don't think I would want inpractice to admit a child with febrile
status and not have recommended in mychart that I wanted to get an LP and
let the parents make that decision.
Sam (39:03):
I think that's well said.
So febrile status epilepticusis very different than just
a simple febrile seizure.
Those two entities do have the wordfebrile in them, but otherwise there's
really very little overlap there.
So just be sure that you're makingthat distinction and understanding
that you really need to rule out theinfectious causes there for sure.
And that your first line treatmentin those is going to include
(39:26):
benzodiazepines, but also caninclude things to treat fever.
You know, the fever does lowerseizure threshold and you
want to address that as well.
T.R. Eckler (39:35):
to clarify my point, the authors said basically that if
there's signs of meningitis, youneed to consider a lumbar puncture.
But I think in the unvaccinated child,making sure that you were clear, that you
were really concerned and really wanted tomake sure you worked them up thoroughly.
I think you wanna be really cautiousabout making sure that you think
carefully about, does this child needan LP If they're in febrile status.
Sam (39:57):
Yeah, I mean, honestly again, it is just a reflection of my age.
I tend to be pretty aggressivewith lumbar punctures.
You know, having treated patientsat the very cusp or the beginning
of the, super effective vaccine era.
We were lumbar puncturing all ofthese infants and, honestly, it's
a relatively benign procedure.
Now, it may be difficult for you toget CSF out of a neonate, but still
(40:19):
I have a very low threshold for justsaying, yeah, we're gonna do the lumbar
puncture, and this is why and there's noother way to really make this diagnosis
if they have something infectious,especially if they're at risk for HSV.
It's something you don't wannamiss and can certainly be
catastrophic for the patient.
The authors did do a good job of talkingabout some of the other newer medications,
and we won't get into those today.
But I do wanna just touch on ketamine.
(40:41):
We have used ketamine significantlyin the adult population for treatment
of seizures, and there are casereports in the pediatric literature
but still limited case reports sowasn't a strong recommendation for
ketamine in status epilepticus.
It doesn't mean your pediatricneurologist might not recommend it.
But there are some others.
things like lacosamide and brivaracetamuh, like a longer more potent acting
(41:06):
version of levetiracetam that binds to thesame receptor but has a higher affinity.
So lots of other things thatyour pediatric neurologist might
recommend if you get to the pointwhere you've thrown everything in
the kitchen sink at the patient.
But hopefully by thenthey're in the pediatric ICU.
T.R. Eckler (41:21):
I think the last thing I would wanna say is I really like their
note about disposition, and I think someof these patients are gonna come in with
seizures that are, you know, epilepsypatients that are on their medications.
You give them medications, things calmdown, they go back to the baseline.
And if you talk to their neurologist,a lot of times these kids can go home.
But I think especially if theyhave a concern that they've
(41:42):
outgrown their seizure coverage.
You wanna ask their neurologist ifyou want to adjust their medications.
Or if they need refills of their rectaldiazepam, their intranasal midazolam,
or diazepam, or even what's called aklonopin bridge or clonazepam bridge,
to get them through a period of time,let's say if they have an infection,
that they're gonna be more prone toseizures and you can give them an
additional layer of seizure coverage.
(42:03):
I've seen a few neurologists do thiswhere the patient goes home with a short
course of Clonazepam, and I think itworks really great for helping educated
parents that do a great job of managingtheir kids have the tools to keep them
outta the emergency department again.
Sam (42:16):
Fantastic.
Well said.
And that brings us tothe end of the episode.
Thanks again to Dr. Bowen and Dr.Bolton, our two authors for this
July 2025 pediatric emergencymedicine practice article on the
treatment of peds status epilepticusin the ED and keep this in mind.
Keep those tables in your pocket.
It's a great reference, especiallywhen you're standing there at the
(42:37):
bedside treating this critical patient.
And until next time, everyone, be safe.
I am one of your hosts , Sam Ashoo.
T.R. Eckler (42:45):
Dr. TR Eckler, stay safe out there.
Good luck.
Try to deal with your newfoundcelebrity from the pit.
Sam (42:51):
and that's a wrap.
Thanks for joining us forthis episode of EMPlify.
I hope you found it informative, and Iwant to remind you that ebmedicine.net
is your one stop shop for all of yourCME needs, whether that be for emergency
medicine or urgent care medicine.
There are three journals, there'stons of CME, there's lots of
courses, there's so many clinicalpathways, all this information at
(43:13):
your fingertips at ebmedicine.net.
Until next time, everyone,I'm your host, Sam Ashoo.
Be safe.
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