Pediatrics · Year 3 · from Pediatrics
Case 2: Status Epilepticus
Patient Demographics
- Age: 5-year-old male
- Sex: Male
Chief Complaint
"He's been having a seizure for 10 minutes."
History of Present Illness
A 5-year-old boy with a history of epilepsy (on levetiracetam) is brought to the emergency department by EMS after having a generalized tonic-clonic seizure that started at home approximately 15 minutes ago. His mother gave rectal diazepam (0.5 mg/kg) at home 5 minutes after seizure onset, but the seizure has not stopped. EMS reports continuous seizure activity en route. He had a cold for the past 2 days but no fever. His mother thinks he may have missed his evening medication last night. His last documented seizure was 8 months ago.
Physical Examination
- Vital Signs: HR 165 bpm, RR 28/min (assisted), BP 135/85 mmHg, SpO2 88% on room air, Temperature 37.2C
- Neurologic: Active generalized tonic-clonic seizure activity; bilateral rhythmic jerking of all extremities; eyes deviated to the right; unresponsive to voice or painful stimuli
Immediate Actions Taken
- Time 0 (ED arrival, 15 min into seizure):
- Airway positioning, suction secretions
- Bag-valve mask ventilation with 100% O2, SpO2 improves to 95%
- IV access obtained
Diagnosis
Status epilepticus
Clinical Reasoning
Status epilepticus is defined as continuous seizure activity lasting 5 or more minutes, or recurrent seizures without return to baseline. This child has been seizing for >15 minutes, meeting criteria for established status epilepticus. He has received one dose of benzodiazepine without effect. Risk factors include underlying epilepsy and possible medication non-adherence. Status epilepticus is a medical emergency because prolonged seizure activity causes neuronal injury and is associated with increased morbidity and mortality. Time is critical - the longer a seizure continues, the more refractory it becomes to treatment.
Management Protocol
Stabilization Phase (0-5 minutes):
- Airway, breathing, circulation
- Obtain IV/IO access
- Check glucose (result: 85 mg/dL - normal)
- Continuous monitoring
First-Line Anticonvulsant (5-10 minutes):
- Lorazepam 0.1 mg/kg (2 mg) IV push
- Reassess in 5 minutes
- Seizure continues
Second Dose Benzodiazepine (10-15 minutes):
- Repeat lorazepam 0.1 mg/kg (2 mg) IV
- Seizure continues at 20 minutes total
Second-Line Anticonvulsant (15-20 minutes):
- Options: Fosphenytoin, levetiracetam, or valproate
- Fosphenytoin 20 mg PE/kg IV over 10-15 minutes
- Monitor BP and ECG during infusion
Ongoing status at 30+ minutes = Refractory Status Epilepticus:
- Consider third-line agents: phenobarbital 20 mg/kg
- Prepare for RSI and continuous EEG monitoring
- ICU admission
Outcome
Seizure terminated after fosphenytoin loading. Total seizure duration approximately 25 minutes. Patient intubated for airway protection given prolonged post-ictal state. Admitted to PICU for monitoring.
Clinical Image
Image Description: Electroencephalogram (EEG) tracing demonstrating generalized epileptiform discharges during a seizure, showing the characteristic rhythmic waveform patterns seen in status epilepticus.
Source: Wikimedia Commons URL: https://commons.wikimedia.org/wiki/File:EEG_seizure.svg License: CC BY-SA 4.0