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 Patients IntroductionWelcome and brief overview of the episode Promotion of EB Medicine’s $1 for 7-day trial offer Why Pediatric Status Epilepticus MattersSeizures make up ~1% of ED visits and ~3% of EMS calls High-risk and high-stakes condition requiring rapid action Status epilepticus now defined as ≥5 minutes of seizure activity ILAE’s T1 and T2 timelines help define when to treat and when damage begins Common CausesTop contributors: Fever/infection Structural CNS abnormalities Toxic ingestions Genetic/metabolic disorders Additional factors by age: Infants: febrile seizures, chromosomal issues, trauma School-age: autoimmune disorders Adolescents: eclampsia, hypertension, functional disorders Always consider non-accidental trauma Prehospital CareIM midazolam is effective and recommended (RAMPART trial) Other options: intranasal, rectal, or IV benzodiazepines Early benzodiazepine administration improves outcomes Importance of airway support, glucose check, and EMS flexibility Parent-administered home meds (e.g. rectal diazepam) can be helpful ED Evaluation and Initial ManagementPrioritize ABCs: Airway, Breathing, Circulation, Consciousness Use end-tidal CO₂ to monitor ventilation if available Point-of-care glucose is essential Labs: CMP, Mg, Phos, lactate, drug levels, pregnancy test (when indicated) Imaging: Head CT if concern for trauma, shunt malfunction, or focal signs Case examples highlight pitfalls and diagnostic delays First-Line TreatmentBenzodiazepines remain the cornerstone Lorazepam preferred IV agent (0.1 mg/kg) Midazolam preferred if no IV access (IN, IM, or IO) Diazepam is also effective, especially rectally Be mindful of respiratory depression and the need for airway control Second- and Third-Line TherapiesBased on ESETT trial: Levetiracetam, fosphenytoin, and valproate have similar efficacy Levetiracetam favored for safety and ease of use Fosphenytoin may be avoided in trauma or toxicity Valproate not recommended in mitochondrial disease Phenobarbital reserved for refractory cases only Refractory Status EpilepticusDefinition: persistent seizures despite first- and second-line agents Requires sedation and likely intubation Infusion 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 activity Special ScenariosNeonates: Watch for subtle signs (lip smacking, bicycling, tongue thrusting) Broad differential includes asphyxia, infection, metabolic errors Febrile Status Epilepticus: Higher risk of CNS infections, especially if unvaccinated Consider lumbar puncture if indicated Electrolyte/Metabolic Triggers: Treat hypoglycemia, hyponatremia, and hypocalcemia directly Use 3% saline or dextrose as appropriate Disposition and Discharge ConsiderationsMany children will require ICU-level care Some known epilepsy patients may go home if back to baseline Ensure rescue medications are up to date (rectal/intranasal benzos) Consider “clonazepam bridge” for short-term seizure prevention Collaborate with neurology for medication adjustment and follow-up Final ThoughtsKeep treatment tables and dosing references accessible Early, aggressive treatment can prevent long-term harm Episode closes with gratitude to article authors and a reminder to visit EBMedicine.net Emergency Medicine Residents, get your free subscription by writing [email protected]