Pediatric emergency medicine trisk 1440 1440
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Prolonged seizure activity is a true medical emergency. Although the duration of
seizures used to define status has varied over time, an accepted definition for the
purposes of clinical practice defines SE as a single unremitting seizure lasting
longer than 5 minutes or frequent clinical seizures without an interictal return to
the baseline clinical state. This corresponds with the time at which urgent
treatment should be initiated, which is the new focus of the definition.
With this proactive, management based definition, following stabilization of
the ABCs, further treatment is directed at stopping any seizure activity. This
section will focus on three elements of seizure management: prevention and
preparation, antiepileptic medication use, and post stabilization measures.
Prevention and Preparation
PEM providers often encounter patients who start seizing during the ED visit.
Many of these patients are patients with known epilepsy, some are being treated
with antiepileptic drugs (AEDs), and for some increased seizure frequency or a
breakthrough seizure is the reason for the ED encounter. The PEM clinician will
be best advised to assess these patients promptly and be able to answer the
following questions:
What AEDs is this patient taking, what is the dosage and when is the next dose
due? Were any doses missed? Were any doses possibly un(der)absorbed (e.g.,
vomiting or diarrhea)? Are the parents aware of any recent AED levels of any of
the medications involved? When in doubt, AED levels should be obtained
promptly. Subtherapeutic levels of AEDs are found in nearly a third of pediatric
epilepsy patients actively seizing in the ED. Furthermore, some AEDs, including
phenytoin, carbamazepine, gabapentin, tiagabine, and vigabatrin, can precipitate
generalized convulsive SE, particularly the myoclonic type, as well as
nonconvulsive (absence) SE.
What is the active seizure plan for this patient? Many children with refractory
epilepsy have their own status epilepticus (SE) plan, which may different that the
one proposed for first time seizures. These patients should be advised to seek
such a plan with their primary neurologist if they have not yet done so. History of
prior SE episodes, including whether certain AEDs were successful or failed, may
guide the PEM clinician in decisions about treatment.
If any drug needs to be loaded on an active alert patient, it should be loaded
promptly in the fastest way possible (which may very well be oral
administration). Also, oral administration is less likely to generate excessive
sedation and respiratory depression.
