Pediatric Status Epilepticus

In this episode, Sam Ashoo, MD and T.R. Eckler, MD discuss the July 2025 Emergency Medicine Practice article, Emergency Department Management of Status Epilepticus in Pediatric PatientsIntroductionWelcome and brief overview of the episodePromotion of EB Medicine’s $1 for 7-day trial offerWhy Pediatric Status Epilepticus MattersSeizures make up ~1% of ED visits and ~3% of EMS callsHigh-risk and high-stakes condition requiring rapid actionStatus epilepticus now defined as ≥5 minutes of seizure activityILAE’s T1 and T2 timelines help define when to treat and when damage beginsCommon CausesTop contributors:Fever/infectionStructural CNS abnormalitiesToxic ingestionsGenetic/metabolic disordersAdditional factors by age:Infants: febrile seizures, chromosomal issues, traumaSchool-age: autoimmune disordersAdolescents: eclampsia, hypertension, functional disordersAlways consider non-accidental traumaPrehospital CareIM midazolam is effective and recommended (RAMPART trial)Other options: intranasal, rectal, or IV benzodiazepinesEarly benzodiazepine administration improves outcomesImportance of airway support, glucose check, and EMS flexibilityParent-administered home meds (e.g. rectal diazepam) can be helpfulED Evaluation and Initial ManagementPrioritize ABCs: Airway, Breathing, Circulation, ConsciousnessUse end-tidal CO₂ to monitor ventilation if availablePoint-of-care glucose is essentialLabs: CMP, Mg, Phos, lactate, drug levels, pregnancy test (when indicated)Imaging: Head CT if concern for trauma, shunt malfunction, or focal signsCase examples highlight pitfalls and diagnostic delaysFirst-Line TreatmentBenzodiazepines remain the cornerstoneLorazepam preferred IV agent (0.1 mg/kg)Midazolam preferred if no IV access (IN, IM, or IO)Diazepam is also effective, especially rectallyBe mindful of respiratory depression and the need for airway controlSecond- and Third-Line TherapiesBased on ESETT trial:Levetiracetam, fosphenytoin, and valproate have similar efficacyLevetiracetam favored for safety and ease of useFosphenytoin may be avoided in trauma or toxicityValproate not recommended in mitochondrial diseasePhenobarbital reserved for refractory cases onlyRefractory Status EpilepticusDefinition: persistent seizures despite first- and second-line agentsRequires sedation and likely intubationInfusion options:Midazolam (preferred for flexibility)Propofol (short-term use only due to risk of infusion syndrome)Pentobarbital (rare, ICU-level care)Need for continuous EEG to assess seizure activitySpecial ScenariosNeonates:Watch for subtle signs (lip smacking, bicycling, tongue thrusting)Broad differential includes asphyxia, infection, metabolic errorsFebrile Status Epilepticus:Higher risk of CNS infections, especially if unvaccinatedConsider lumbar puncture if indicatedElectrolyte/Metabolic Triggers:Treat hypoglycemia, hyponatremia, and hypocalcemia directlyUse 3% saline or dextrose as appropriateDisposition and Discharge ConsiderationsMany children will require ICU-level careSome known epilepsy patients may go home if back to baselineEnsure rescue medications are up to date (rectal/intranasal benzos)Consider “clonazepam bridge” for short-term seizure preventionCollaborate with neurology for medication adjustment and follow-upFinal ThoughtsKeep treatment tables and dosing references accessibleEarly, aggressive treatment can prevent long-term harmEpisode closes with gratitude to article authors and a reminder to visit EBMedicine.netEmergency Medicine Residents, get your free subscription by writing [email protected]