How To Approach A Fitting Child

Generalised convulsive status epilepticus is defined as a generalized convulsion lasting 30 minutes or longer or when successive convulsions occur so frequently over a 30-minute period that the patient does not recover consciousness between them. Non-convulsive status (NCSE) is diagnosed with electroencephalography (EEG) and should beconsidered in the child with unexplained alterationsin conscious level.However, it is difficult to get the exact insight about its onset and duration. As we know a seizure lasting for 5 minutes or more may cause neuronal damage and hence poor neurological outcome. So the usual practice is to start the seizure management if the duration is 5 minutes or more.

First line treatment in the community:

General protective measures. E.g. put the child in a recovery position, ensure the head is protected, release any tight clothing, and move away from a dangerous position.

  • Use intranasal midazolam (Insed or Midaspray 0.5 mg/kg, each spray contains 0.5 mg) as first-line treatment. Administer rectal diazepam, if nasal midazolam is not available.
  • If intravenous access is established and resuscitation facilities are available, administer intravenous lorazepam.
  • Depending on response to treatment, the person's situation and any personalised care plan, call an ambulance, particularly if:
  • The seizure is continuing five minutes after the emergency medication has been administered.
  • The person has a history of frequent episodes of serial seizures or has convulsive status epilepticus.
  • This is the first episode requiring emergency treatment
  • There are concerns or difficulties monitoring the person's airway, breathing, circulation or other vital signs.

Treatment in hospital

  • ABCs (Airway, Breathing and circulation) before starting any pharmacologic intervention.
  • Place patients in the lateral decubitus position to avoid aspiration of emesis and to prevent epiglottis closure over the glottis.
  • Make further adjustments of the head and neck if necessary to improve airway patency.
  • Immobilize the cervical spine if trauma is suspected.
  • Administer 100% oxygen by facemask.
  • Assist ventilation and use artificial airways (eg. endotracheal intubation) as needed.
  • Suction secretions and decompress the stomach with a nasogastric tube.
  • Maintain normothermia
  • Cefotaxime, acyclovir and erythromycin are recommended if aetiology is uncertain and acyclovir should always be used for focal fits of unknown cause
  • In the first 5 minutes of seizure activity, try to establish IV access and samples for blood glucose, calcium, magnesium, electrolytes, ABG, CBC, blood culture, etc.
  • Send urine for microscopy and toxicology.
  • If serum glucose is low or cannot be measured, give children 2 mL/kg of 25% glucose.
  • If the seizure fails to stop within 5 minutes, prompt administration of anticonvulsants may be indicated.
  • Lorazepam (0.1 mg/kg IV or IO slowly infused over 2-5 min); or diazepam per rectum at 0.5 mg/kg, not to exceed 10 mg
  • Phenytoin or fosphenytoin, not to exceed infusion rate of 1 mg/kg/min; if unsuccessful, phenobarbital 10-20 mg/kg IV (not to exceed 700 mg IV); increase
  • infusion rate by 100 mg/min; phenobarbital may be used in infants before phenytoin
  • Refractor Seizures: Convulsive status epilepticus that is refractory to a benzodiazepine and an appropriate longer-acting anticonvulsant occurs in
  • approximately 40% of cases and is associated with higher morbidity and mortality. Please follow the steps below to manage the refractory convulsions.
  • Midazolam, loading dose 0.1-0.3 mg/kg IV followed by continuous IV infusion at a rate of 0.1-0.3 mg/kg/h
  • Thiopentol anaesthesia (patient already intubated); load by 4 mg/kg and maintain at 1 mg/kg/hr, increase by 1 mg/kg/hr, max 6 mg/kg/hr. Discontinue
  • midazolam infusion.
  • If difficulty weaning Thiopental, then restart Midazolam infusion during weaning.
  • Consider Pyridoxine 100mg IV if under 18 months old.
  • Consider urgent CT- Brain, if any suspicion of raised intracranial pressure. If proved, intravenous mannitol should be considered.
  • Continuous EEG monitoring can be very helpful particularly to detect non convulsive seizures.
  • Do not perform lumbar puncture in the acute state.
  • Maintain therapeutic drug levels.
  • Continue baseline antiepileptic drugs when possible.