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PNA Epilepsy Council Recommendations for the Treatment of Status Epilepticus in Children >2months Old & in Adults (2010)

Status Epilepticus -Recurrent or continuous seizures lasting atleat 30mins. -recommendation: treatment when seizures persist for >5mins Classification A. Generalized SE a. Convulsive (tonic-clonic, myoclonic) b. Nonconvulsive (absence) B. Partial SE a. Simple (no alteration of consciousness) b. Complex (alteration of awareness) Generalized tonic-clonic status epilepticus Paroxysmal or continuous tonic and or clonic motor activity, symmetrical or asymmetrical, overt or sublte associated w/ marked impairment of consciousness & w/ bilateral ictal discharges on EEG Etiology SE or febrile seizure Complication of encephalopathy For children <16 Fever/infection (most common) Medication Unknown cause Metabolic

Adult Cerbrovascular events (most common) Medication Alcohol related Metabolic

Treatment First line Benzodiazepine o highly effective and potent o diazepam & lorazepam most widely use 1. Diazepam a. 5-10mg IV bolus at a rate of 25mg/min utill seizure stops b. Or total of 20mg has been given c. 0.2-0.4mg/kg/dose IV bolus at a rate of 1mg/min until seizure stops* d. Or total of 8-10mg* 2. Lorazepam a. Not available in Phil. b. 4mg IV bolus at a rate of 1mg/min until seizure stops c. Or total of 8mg has given. d. 0.1mg/kg/dose max of 4mg IV bolus at a rate of 1mg/min until seizure stops* e. Or total of 8mg* *For Children beyond the neonatal period (2mons & above) 3. Midazolam a. 0.3mg/kg/dose buccal b. 0.2mg/kg/dose intranasal c. IM

Second Line -maintenance to prevent recurrence Drugs Phenobarbital Adult 15-20mg/kg loading dose Rate: <100mg/min 18-20mg/kg IV loading dose Rate: not exceeding 50mg/min 20-30mg/IV loading bolus over 15min Rate: 40mg/min 20mg/kg IV loading then 15mg/kg Q12 after 6hrs after loading Children 20mg/kg IV at <100mg/min

Refractory Status Epilepticus Drugs Midazolam Adult Bolus 0.2 mg/kg IV Start at 1ug/kg/min may increase by 1ug/kg/min every 15min until seizure controlled 40140mg/kg/d daily dose 1-2mg/kg to terminate seizure Infusion: 215mg/kg/hr titrate by 1mg/kg/hr 5mg/kg bolus Infusion: 0.56mg/kg/hr Children 0.2mg/kg Infusion 2.010.0ug/kg/min Atleast 6hrs, tapered over 12-24hrs

Phenytoin

20mg/kg IV rate not exceeding 25mg/min Phenobarbital 20-30mg/iv bolus over 15min rate: 40mg/min ----------------

Valproate

Propofol

Bolus 12mg/kg Infusion 15mkh

Levetiracetam

Thiopental

Non Pharmacologic Recommendation ABCs o BP, temp, hr, rr When to consider intubation? o Respiratory compromise Admission to ICU o If persist after loading dose Transfer to another institution o After SE stop o Vital signs stabilized After status epilepticus o Close monitoring, maintenance, treat nderlying cause Diazepam

Valproate

lidocaine

Loading dose not specified aimed blood level of 20mg/ml after 6hrs Infusion: 0.010.1mg/kg/min increase by 0.01mg/kg/min every 5min until seizure controlled Tapering off start atleast 6hrs bolus 30mg/kg 5mg/kg/hr 6hrs seizure free reduced by 1mg/kg/hr every 2hrs Bolus 2mg/kg then infusion at 4mg/kg/hr

Definition (Johns Hopkins) Tonic o

Persons muscle inially stiffen, lose consciousness o Eyes roll back into their head as the muscle Tonic-clonic o Grand mal o Accompanied by clonic seizure Myoclonic o Myo: Muscle, clonic: jerk o Increase muscle tone Clonic o Individual muscles begin to spasm & jerk. o Elbows, legs, head will flex then relax rapidly at first frequency of spasm will gradually subside until cease Absence o Petit mal o Uncommon o Begins suddenly o Occurs w/o warning