Pediatrics · Year 3 · from Pediatrics

Case 2: Status Epilepticus

Patient Demographics

  • Age: 5-year-old female
  • Sex: Female

Chief Complaint

"She's been seizing for 10 minutes and won't stop."

History of Present Illness

A 5-year-old female with known epilepsy (childhood absence epilepsy diagnosed 1 year ago, on ethosuximide) is brought by EMS with ongoing generalized tonic-clonic seizure activity. According to the mother, the child was watching television when she suddenly fell to the floor and began having a generalized seizure. The seizure has been continuous for approximately 15 minutes. EMS administered rectal diazepam 0.5 mg/kg en route 5 minutes ago, but seizure activity continues. The mother reports the child had a viral illness last week and has been vomiting, which may have affected her medication absorption. She has never had a generalized tonic-clonic seizure before; her typical seizures are brief staring spells.

Physical Examination

  • General: Actively seizing with generalized tonic-clonic movements
  • Vital signs: Temp 37.2°C, HR 160 bpm, RR 32/min, SpO2 88% on room air, BP 100/60 mmHg
  • HEENT: Cyanosis around lips, clenched jaw
  • Neurologic: Continuous generalized tonic-clonic activity, pupils mid-sized and reactive

Workup

  • Point-of-care glucose: 72 mg/dL (low-normal)
  • ABG: pH 7.22, pCO2 48 mmHg, pO2 65 mmHg
  • Serum ethosuximide level: 28 mcg/mL (therapeutic 40-100)
  • CBC: WBC 8,500/μL, Hgb 12.2 g/dL
  • CMP: Na 138, K 3.8, BUN 12, Cr 0.4
  • CT head (after seizure control): Normal

Diagnosis

Convulsive status epilepticus in a patient with childhood absence epilepsy, likely precipitated by subtherapeutic medication level

Clinical Reasoning

Status epilepticus is defined as a seizure lasting more than 5 minutes or multiple seizures without return to baseline. This child has been seizing for 15 minutes despite initial benzodiazepine treatment, representing established status epilepticus. The subtherapeutic ethosuximide level (due to poor absorption during viral illness) likely contributed to breakthrough seizure activity. Notably, ethosuximide only treats absence seizures; this patient has likely developed generalized tonic-clonic seizures, suggesting evolution of her epilepsy syndrome or a secondary generalized tonic-clonic seizure.

Management

  1. ABCs: Supplemental oxygen, suction, position for airway protection
  2. Repeat benzodiazepine: Lorazepam 0.1 mg/kg IV (given at time 15 min)
  3. Second-line agent (at 20 min if seizure continues): Fosphenytoin 20 PE/kg IV or Levetiracetam 60 mg/kg IV
  4. If refractory (>40 min): Prepare for anesthetic doses of midazolam infusion, propofol, or pentobarbital; intubation; ICU admission
  5. Post-seizure workup: EEG monitoring, review medication regimen
  6. Long-term management: Consider adding a broad-spectrum AED (e.g., valproate) that covers both absence and GTC seizures; optimize medication adherence

Clinical Image

Image Description: EEG recording demonstrating epileptiform activity, illustrating the electroencephalographic findings used in diagnosing and monitoring seizure disorders.

Source: Wikimedia Commons URL: https://commons.wikimedia.org/wiki/File:Spike-waves.png License: CC BY-SA 3.0

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