Clincal Care Guideline Status Epilepticus Algorithm

© Ann & Robert H. Lurie Children’s Hospital of Chicago Last update: 07.28.17

This clinical care guideline is meant as a guide for the healthcare provider, does not establish a standard of care and is not a substitute for medical judgment which should be applied based upon the individual circumstances and clinical condition of the patient.

Status Epilepticus Algorithm

INCLUSION

⦁Patients with one continuous seizure lasting ≥5 min

⦁Patients with multiple, intermittent seizures lasting ≥ 5 min between which the patient does not regain consciousness

KEY POINT

The care team’s ability to stop a patient’s seizure/seizures depends on timely administration of medications.

The longer the seizure, the more treatment-resistant it becomes.

EXCLUSION

⦁ For patients with readily accessible individualized seizure plans, please defer to patient-specific plan

NEONATES ≤28 DAYS

⦁ Treat with benzodiazepine and administer Phenobarbital 20mg/kg as 2nd medication (see Table 3).

Bedside or Primary RNHelper RNPrimary Service Provider

(MD/APN)

20

min

10

min

5m

in

0 m

in Patient Seizure Starts(*RN documents start time)

1) Assess ABCs (See Table 1) 2) Obtain Patient Temp x 1 3) Call Local RN Helper 4) Notify Primary Service Provider

1) CHECK BP to assess for hypotension⦁If normotensive, proceed to step 2. ⦁If hypotensive, initiate care team huddle.

2) ADMINISTER 2nd Medication Dose@ 10min⦁ Preferred Choice ( if > 28 days age): Fosphenytoin 20mg PE/kg IV over 10 minutes ⦁ If No IV Access or Fosphenytoin Not Ready: Repeat 1st Medication Dose 3) DOCUMENT Timing

1) CHECK BP to assess for hypotension⦁If normotensive, proceed to step 2. ⦁If hypotensive, initiate care team huddle.

2) ADMINISTER 2nd Medication Dose@ 20min⦁ Preferred Choice ( if ˃ 28 days age): Fosphenytoin 10mg PE/kg IV over 10 minutes3) DOCUMENT Timing

Provider Arrives⦁ Assess patient ⦁ Order labs per order set

RN Helper ArrivesObtain Labs:⦁ BMP, CBC & iCa⦁ Glucose via iStat or Accucheck.⦁ PRN drug levels⦁ Report glucose aloud to team

⦁ Order PIV Insertion⦁ Order 1st Medication Dose ▪ If atomizer available, IN midazolam 0.2mg/kg (max dose 10mg; split dose between nostrils) OR ▪ Rectal Diazepam (max dose 20mg, see abbreviated table below or pharmacy for expanded table):

⦁ Insert PIV or Page VAT, STAT⦁ Pull 1st Medication Dose (IN midazolam or PR diazepam) from med pyxis

⦁ Confirm IV works⦁ Pull 1st Medication Dose (IV lorazepam) from med pyxis

⦁ Order 1st Medication Dose ▪ IV Lorazepam 0.1mg/kg/dose (max dose 4mg)

1) ADMINISTER 1st Medication Dose @ 5min mark

2) DOCUMENT Timing

Consult Neurology (emergently page Neurology fellow).

⦁ Pull Fosphenytoin from med pyxis⦁ Prepare 2nd Fosphenytoin Dose (see dilution instructions on label/ in MAR)

⦁ If patient >28 days, order 2nd Dose of IV Fosphenytoin 10mg PE/kg (max dose 1500mg/dose). * Consult neurology and see Table 2 if hypotensive or with known Fosphenytoin allergy. *If <28 days, see Table 3.

⦁ Continue to Monitor ABCs⦁ Validate documentation in Epic of seizure duration, medication delivery times and patient vitals

0.5mg/kg0.5mg/kg0.3mg/kg0.2mg/kg

<2yrs: 2-5yrs:

6-11yrs:12+yrs:

TEAM QUESTIONDoes the seizure continue? Has the patient had multiple seizures without regaining consciousness?

TEAM QUESTIONDoes the patient have IV access?

⦁ Pull Fosphenytoin (for IV, when available)⦁ Prepare 1st Fosphenytoin Dose (see dilution instructions on label/in MAR)

⦁ If patient > 28 days, order 1st Dose of IV Fosphenytoin 20mg PE/kg (max dose 1500mg/dose) *Consult neurology and See Table 2 if patient hypotensive or with known Fosphenytoin allergy.*If <28 days, see Table 3.

Continue to Monitor ABCs

TEAM QUESTIONDoes the seizure continue? Has the patient had multiple seizures without regaining consciousness?

⦁ Further Discussion (varies by location) ▪ Acute Care Patients: Call CAT ▪ ED Patients: Call PICU ▪ ICU Patients: Further On-Unit Discussion

⦁ Review Resulted STAT Labs ▪ See Table 4 for diagnostic studies & treat primary cause

TEAM DISCUSSIONIn collaboration with Neurology, determine plan for patient care. See page 2 for considerations after 30 minute mark.

NO YES YESNO

YES YES YES

YES YESYES




Provide oxygen to maintain SO2 >92% Cycle blood pressure cuff every 3

minutes, administer NS bolus if hypotensive

Monitor heart rate

TABLE 1: ABC Assessment

If Fosphenytoin is contraindicated, can administer:

Levitaracetam 60mg/kg (max 4500mg/dose) OR

Phenobarbital 20mg/kg

TABLE 2: Alternatives to Fosphenytoin

Initial Studies: Serum electrolytes & glucose Complete blood count Antiepileptic drug levels (if applicable) Lumbar puncture:

▪Consider if febrile or concern for CNS infection▪Obtain cell count, glucose, protein and culture

Imaging Studies: ▪ MR Ventricle with DWI and GRE or CT Head

Additional/Expanded Studies to Consider (for unusual presentation, refractory seizures): CSF: meningoencephalitis panel, viral studies, lactate, autoimmune encephalitis panel Metabolic studies: lactate, pyruvate, acylcarnitine profile, serum amino acids, urine organic acids Blood and urine cultures Expanded CNS imaging (once seizures controlled): ▪ Full MRI Brain ▪ Vascular imaging (MRA/CTA, MR venogram) ▪ MR Spectroscopy

TABLE 4: Studies for SE without Identified Etiology

Consult Neurology Preferred 2nd medication at 10 minutes

is Phenobarbital 20mg/kg Discuss 3rd medication choice/dose with

Neurology In partnership with Neurology, expedite

order of MR Ventricle DWI/ADC/GRE

TABLE 3: Neonates <28 days




If seizures continue despite appropriate doses of a benzodiazepine and a loading dose of another anticonvulsant, the patient is in refractory SE.

Key management principles include:

▪ Advance drug dosing quickly

▪ Use bolus doses to initiate therapy

▪ Use physiologic management (BP, oxygenation, CO2, temperature) and attention to metabolic stressors to attenuate secondary injury

▪ If possible identify and treat the underlying cause

Initial Steps:

▪ If not already done, call CAT for patients outside of the ER or ICU

▪ Patients are likely to require intubation. Anticipate the need for pressors as therapy is escalated (consider a-line, central line).

▪ Video-EEG monitoring should be initiated for all patients in refractory SE

▪ Emergently consult neurology if not already done

Second Line Therapy

Pentobarbital

▪ Load with 6-8mg/kg IV

▪ DO NOT use if hypotension cannot be controlled

▪ Start maintenance 1-4mg/kg/h

▪ Titrate to burst suppression on EEG

Further steps for super-refractory SE, or if pentobarbital contraindicated

Possible medication choices include:

▪ Topiramate (enteral loading dose)

▪ Ketamine

▪ Ketogenic diet

Considerations for after 30 min: Overview of Treatment of Refractory Status Epilepticus

First Line Therapy

Midazolam

▪ Load with 100-200mcg/kg

▪ Continuous infusion starting at 100mcg/kg/h

▪ Increase dose every 15 minutes by 50mcg/kg/h until electrographic seizure control achieved

▪ Max dose 600-800mcg/kg/h




Evidence Chin R.F., Neville B.G., Peckham C., Bedford H., Wade A., Scott R.C. Incidence, cause, and short-term outcome of convulsive status epilepticus in childhood: Prospective population-based study. Lancet. 2006; 368:222–229.

Chin RFM, Neville BGR, Peckham C, et al. Treatment of community-onset, childhood convulsive status epilepticus: a prospective, population-based study. Lancet Neurol. 2008;7: 696–703.

Fernandez I., Abend N., Agadi S., An S., Arya R., et al. Time from convulsive status epilepticus onset to anticonvulsant administration in children. Neurology. 2015; 84: 2304-2311.

Glauser T., Shinnar S., Gloss D., Alldredge B., Arya R., et al. Evidence-based guidelines: treatment of convulsive status epilepticus in children and adults: report of the guideline committee of the American epilepsy society. Epilepsy Currents. 2016; 16: 48-61.

Hillman J, Lehtimaki K, Peltola J, et al. Clinical significance of treatment delay in status epilepticus. Int J of Emerg Med. 2013; 6:6.

Legriel S, Mourvillier B, Bele N, et al. Outcomes in 140 critically ill patients with status epilepticus. Instensive Care Med. 2008; 34: 476-80.

Naylor DE, Liu H, Wasterlain CG. Trafficking of GABA(A) receptors, loss of inhibition, and a mechanism for pharmacoresistance in status epilepticus. J Neurosci. 2005;25(34): 7724–33.

Raspall-Chaure M, Chin RF, Neville BG, Scott RC. Outcome of paediatric convulsive status epilepticus: a systematic review. Lancet Neurol 2006; 5:769-779

Seinfeld S., Shinnar , Sun S, et al. Emergency management of febrile status epilepticus: results of the FEBSTAT study. Epilepsia 2014; 55: 388-395.

Tobias J., Berkenbosch J. Management of status epilepticus in infants and children prior to pediatric ICU admission: deviations from the current guidelines. Southern Medical Journal. 2008; 101: 268-272.

Towne AR, Pellock JM, Ko D, et al. Determinants of mortality in status epilepticus. Epilepsia. 1994;35(1):27–34.

Treatment of convulsive status epilepticus. Recommendations of the Epilepsy Foundation of America’s Working Group on status epilepticus. JAMA 1993; 270:854-859

Wheeler, Derek S., Tom LeMaster, Hector R. Wong, and Thomas P. Shanley. "Emergency Medical Services for Children." Resuscitation and Stabilization of the Critically Ill Child. London: Springer, 2009. 8. Print.




Contributors:

Ann Beland, RN Michele Mills, BSN, MSN Kim Denicolo, RN, MSN, CNL Briseyda Morales, APRN-NP Eric Jones Michael Olsen, RN Kim Kato, RN, BSN, MS Manisha Patel, RN, BSN, MSHI Jonathan Kurz, MD, PhD Mark Wainwright, MD, PhD Brenda Laughlin, PharmD Margie Wisniewski, RN

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Clincal Care Guideline Status Epilepticus Algorithm