Pediatrics

Status Epilepticus

Diagnosis

Persistent seizures

Diagnosis

Persistent seizures

  1. Confirm ABCs: Airway, Breathing, Circulation

  2. Increase O2 to 100%, consider intubation

  3. Place monitors: ECG, SpO2, BP, EtCO2

  4. Obtain IV access

  5. Stop local anesthetic infusion/injection

  6. Check glucose. If < 60 mg/dL, give D25W IV:

    • < 2 years: 4 mL/kg
    • ≥ 2 years: 2 mL/kg

  7. Preop/PACU/Natural Airway

    Prepare to immediately intubate, if needed

  8. Give benzodiazepine, IF available

    • IF IV access: Lorazepam 0.1-0.2 mg/kg (MAX 4mg) may give 2nd dose
    • OR
    • Midazolam or diazepam 0.1-0.2 mg/kg (MAX 10 mg) may give 2nd dose
    • IF NO IV access: Midazolam intranasal or IM 0.4 mg/kg (MAX 20 mg)
    • 0.1-0.2 mg/kg IV, MAX 4 mg
    • 0.1-0.2 mg/kg IV, MAX 10 mg
    • 0.1-0.2 mg/kg IV, MAX 10 mg
    • 0.4 mg/kg intranasal or IM, MAX 20 mg

  9. If seizures continue, go to "Intraop/Assisted Ventilation"

  10. Intraop/Assisted Ventilation

    Maintain adequate ventilation

  11. Increase inhaled anesthetic to 1.5-2 MAC, or give propofol 2 mg/kg IV (avoid if on ketogenic diet) or midazolam 0.1 mg/kg IV (repeat 2x every 3 min, if needed)

    • 0.1-0.2 mg/kg IV, MAX 10 mg
    • 0.4 mg/kg intranasal or IM, MAX 20 mg
    • 2 mg/kg IV
    • Avoid if on ketogenic diet

  12. If movement could be dangerous, consider neuromuscular blockade and pausing surgery

  13. Create safer environment, if needed (e.g. removal from Mayfield pins)

  14. If seizure >6 minutes, consider anticonvulsants in consultation with ICU and neurology:

    • levetiracetam 50 mg/kg (MAX 4.5 g) IV
    • After 10 min, if needed, give fosphenytoin 20 mg/kg (MAX 1.5 g) IV or valproic acid 40 mg/kg (MAX 3 g) IV
    • 50 mg/kg IV, MAX 4.5 g
    • 20 mg/kg IV, MAX 1.5 g

  15. Watch for myocardial suppression, vasoplegia, or rhabdomyolysis: may be associated with poorly controlled or prolonged seizures

  16. If seizure ≥ 15 min, consult expert and see American Epilepsy Society Guidelines

  17. Consider ABG/VBG and temperature monitoring

  18. Consider PICU postop

  19. Crisis Management (If Severe)

    Notify surgeon, call for help and code cart

  20. Call for Transesophageal Echocardiography

  21. Start chest compressions

  22. Give epinephrine 1-10 MICROgrams/kg IV/IO

  23. If cardiac arrest, go to CARDIAC ARREST

  24. Consider ECMO

Patient weight

Between 0.5 kg and 120 kg

Reset the checklist?

Checked steps, the timer and this crisis log are cleared. The patient’s weight is kept.

Finish the crisis?

The timer pauses, and you can review the case and the event log.