Pediatric emergency medicine trisk 1432 1432
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This section will focus on patients with generalized convulsive status. The first
priority in the seizing patient is to address airway, breathing, and circulation (see
Chapter 7 A General Approach to the Ill or Injured Child ). An adequate airway is
necessary to allow for effective ventilation and oxygenation. Patients with
impaired consciousness are at risk for obstruction (the tongue, oral secretions,
emesis), aspiration (loss of protective reflexes), and hypoventilation. Simple
maneuvers such as the jaw thrust or suctioning of the oropharynx may improve
the compromised airflow. The use of adjunctive airways (oral or nasopharyngeal)
may also help maintain an adequate airway. In patients who are actively seizing,
it may be difficult to insert these adjuncts and may cause injury if the intervention
is forced. Furthermore, in patients for whom trauma is a possibility, these
maneuvers must be undertaken with cervical spine (C-spine) immobilization. In
patients in whom the airway remains unstable despite these actions, endotracheal
intubation is warranted. When it is necessary to use a muscle relaxant to intubate
a seizing patient, one should use the shortest-acting agent possible. The presence
of motor activity may be the only clinical manifestation of seizure, and a longacting muscle relaxant will mask the ongoing seizure activity. One should
consider alternatives to succinylcholine in the setting of prolonged seizures
because of the potential risk of hyperkalemia related to rhabdomyolysis.
While securing the airway takes priority over other clinical assessment
elements, one will lose the ability to assess whether the clinical seizure activity
has stopped in a medically paralyzed child. Parameters such as heart rate are
notoriously unreliable. Missed “iatrogenic nonconvulsive status epilepticus” will
result in neuronal death despite lack of clonic or tonic features. The clinician must
consider interventions to avoid these dilemmas. For example, a patient may have
a potentially short-lived apneic episode following the rapid administration of a
benzodiazepine. When possible, such a drug should be administered over 1 to 2
minutes rather than rapid infusion, and short apneic/hypopneic episodes that may
follow can often be managed with a short period of bag–mask ventilation prior to
endotracheal intubation. If endotracheal intubation does take place, many
institutions offer an urgent limited-lead EEG that can help evaluating background
activity for possible ongoing seizure. If not available, an emergent EEG should be
obtained. Intubated patients often receive continuous infusions of a
benzodiazepine after endotracheal intubation to maintain sedation. However,
continuous infusions of benzodiazepines may also be used in the treatment of
refractory seizures. Aligning the dose of a benzodiazepine infusion with the latter
protocol may further mitigate the risk of ongoing “subclinical” seizure and
neuronal death.
