Overview
Definition:
Status epilepticus (SE) is a medical emergency characterized by a prolonged seizure or a series of seizures without recovery of consciousness between them
In children, SE is typically defined as a single seizure lasting longer than 5 minutes, or two or more seizures in a 10-minute period without complete return to baseline consciousness
It represents a failure of the mechanisms responsible for seizure termination.
Epidemiology:
The incidence of SE varies, but it is estimated to occur in approximately 4-20 per 100,000 children per year
Febrile status epilepticus is the most common type in young children
In older children and adults, underlying brain abnormalities, CNS infections, or stroke are more common causes
Neonatal SE has a higher incidence and mortality rate.
Clinical Significance:
SE is a time-critical emergency due to the risk of neuronal injury, excitotoxicity, and potential long-term neurological sequelae including cognitive deficits, learning disabilities, and secondary epilepsy
Prompt recognition and initial management, even at home by trained caregivers, are crucial to prevent these adverse outcomes and reduce the need for intensive care.
Home Preparedness And Recognition
Creating A Seizure Action Plan:
Develop a clear, written Seizure Action Plan (SAP) with the child's neurologist
This plan should outline when to administer emergency medication, whom to call, and when to seek immediate medical attention
Share the SAP with all caregivers, including family, school staff, and babysitters.
Recognizing A Seizure In Progress:
Understand the typical seizure presentation for the child
This can include generalized tonic-clonic movements, focal motor or non-motor symptoms, staring spells, or changes in behavior
Recognize that SE may not always present as a dramatic, full-body convulsion
Look for prolonged or repetitive seizure activity.
What To Do During A Seizure:
Stay calm
Protect the child from injury by clearing the area around them and placing them on their side to prevent choking on secretions
Do not restrain the child or place anything in their mouth
Note the time the seizure started and observe its characteristics.
Recognizing Status Epilepticus At Home:
Understand the emergency criteria for SE (seizure >5 minutes, or multiple seizures without recovery)
Differentiate between a typical, self-limiting seizure and a prolonged or recurrent seizure that requires immediate intervention according to the SAP.
Home Management Protocol
Initial Emergency Medication:
Administer the first-line emergency anti-seizure medication (ASM) as prescribed by the neurologist
This is typically a benzodiazepine given rectally (e.g., diazepam gel) or intranasally (e.g., midazolam spray)
Follow the SAP precisely for dosage and timing.
Timing And Dosage Guidelines:
Use the exact dosage and administration instructions provided in the SAP
If the first dose is ineffective after the recommended time interval (usually 2-5 minutes), administer the second dose as outlined in the plan
Always have the medication readily accessible and check its expiry date regularly.
Monitoring After Medication:
Observe the child closely after administering medication
Note if the seizure stops, if the child becomes drowsy, or if breathing changes
Report any adverse effects or persistent seizure activity to the physician as per the SAP.
When To Seek Immediate Medical Help:
Call emergency services (e.g., 108/102 in India) immediately if the seizure does not stop within the timeframe specified in the SAP after administering emergency medication, or if there are any signs of respiratory distress or loss of consciousness
Provide clear information about the child's condition and the medications administered.
Follow Up And Prevention
Post Status Epilepticus Care:
Ensure the child is seen by their neurologist soon after an episode of SE
Discuss the event, review the SAP, and adjust the long-term epilepsy management plan if necessary
Monitor for any new seizure types or increased seizure frequency.
Medication Adherence And Storage:
Strictly adhere to the prescribed daily ASM regimen
Store emergency medications in a cool, dry place, away from direct sunlight, and out of reach of children
Keep track of expiry dates and obtain refills promptly.
Identifying And Managing Triggers:
Work with the neurologist to identify potential seizure triggers (e.g., fever, sleep deprivation, stress, flashing lights)
Implement strategies to avoid or manage these triggers where possible
For febrile seizures, prompt fever reduction is key.
Education For Caregivers:
Ensure all caregivers understand the child's epilepsy, the SAP, and the importance of prompt intervention
Encourage open communication with the medical team and participation in support groups
Regular review and updates to the SAP are essential.
Key Points
Exam Focus:
SE is a medical emergency requiring prompt recognition and intervention
Home management protocols are critical for families to act swiftly
Benzodiazepines (rectal diazepam, intranasal midazolam) are first-line treatments
SAP is crucial for guiding home management.
Clinical Pearls:
Emphasize empowering families with knowledge and a clear plan
Stress the importance of distinguishing prolonged seizures from typical ones
Always have emergency medication accessible and within its expiry date
Never leave a child having a seizure unattended.
Common Mistakes:
Delaying administration of emergency medication
Underestimating the duration of a seizure
Forgetting to call for emergency services when indicated
Not having an updated Seizure Action Plan
Improper storage or failure to check expiry dates of emergency medications.