General Data
• Name: JS• Age: 14 months old• Gender: Female• Date of Birth: August 12, 2009• Religion: Roman Catholic• Informant: Mother• Reliability: Good
Chief Complaint
• generalized seizures
History of Present IllnessSince birth
•Recurrent grand mal seizures•lasting up to 1 hour•maintained on carbamazepine and topiramate.
Few hours PTC •6 times vomiting and high grade fever.
30 minutes PTC •Generalized tonic clonic seizures with upward rolling of eyeballs and circumoral cyanosis.
Review of Systems General: (-) weight loss, (-) diminished activity,
(-) delayed growth Cutaneous: (-) rash, (-) pigmentation, (-) hair
loss HEENT: (-) headache, (-) dizziness, (-) visual
difficulties, (-) excessive lacrimation, (-) hearing difficulties, (-) aural discharge, (-) nasal discharge, (-) toothache, (-) sore throat
Cardiovascular: (-) easy fatigability, (-) cyanosis, (-) fainting spells
Review of Systems Gastrointestinal: (-) constipation, (-) diarrhea,
(-) abdominal pain, (-) jaundice, (-) pica Genitourinary: (-) dysuria, (-) edema, (-)
discharge Endocrine: (-) heat/cold intolerance, (-)
polyuria, (-) polydipsia, (-) polyphagia Musculoskeletal: (-) joint pain, (-) limitation of
motion Hematopoietic: (-) pallor, (-) easy bruisability
Personal HistoryGestational History
Patient was born to a 23-year old G1P0 housewife married to a 24-year old driver.
Patient’s mother had regular prenatal check-up at USTH with an OB-GYN. She was given unrecalled medication.
She denied illicit drug use, alcoholic intake, exposure to viral exanthems, teratogenic drugs, cigarette smoke and radiation.
Personal HistoryBirth, Neonatal History
Mother denied any illnesses during the pregnancy. No maternal fever, no pruritis and no discharge before labor.
Patient was born live, term (39-40 weeks), singleton, female, via NSD at USTH.
The patient weighed 3 kg upon delivery.
Personal History
Feeding history Patient was exclusively breastfed during the first
three months. she was then shifted to Bonamil on the 4th
month and then Nido fortified milk on his 1st year.
Complementary food was introduced at 6 months.
The patient has good appetite and is not a picky eater. He likes to eat biscuits, cookies, and milk.
Physical Examination• Awake, irritable, not in cardiorespiratory
distress, poorly hydrated• HR 180, RR 28, T 40.3, O2 sat 82%• Warm to touch skin, poor skin turgor, no
active dermatoses, pale nail beds• Normocephalic head, symmetric face, no
lumps/bumps, black hair evenly distributed • Pale palpebral conjunctivae, anicteric sclerae,
pupils 2-3 mm ERTL, (+) ROR, sunken eyes
Physical Examination• No aural discharge, no tragal tenderness, non
hyperemic EAC, tympanic membrane intact• No nasal discharge, midline septum, turbinates
congested, no alar flaring• dry buccal mucosa, no oral ulcers, non-
hyperemic posterior pharyngeal wall, circumoral cyanosis
• Supple neck, no palpable cervical lymph nodes, thyroid not enlarged
• Symmetrical chest expansion, no retractions, equal tactile and vocal fremiti, clear breath sounds
Physical Examination
• Adynamic precordium, AB at 4th LICS MCL, no thrills, no heaves, S1 and S2 normal, no murmurs
• globularabdomen, normoactive bowel sounds, soft, no direct or rebound tenderness, no appreciable masses
• No limitations in range of motion, no joint swelling, no erythema
• Pulses full and equal, no edema, no cyanosis, no clubbing
Neurologic Examination
Alert, awake, irritableNo asymmetry, no gross deformities, no bulging of fontanels, no hydrocephalusSpontaneous muscle movements, no involuntary movements, no tremors
Neurologic Examination• Cranial Nerves: • CN2- visual tracking, blinks with bright light• CN3, 4, 6- no ptosis, pupils 2-3 mm ERTL• CN5- blinks upon gentle air blowing • CN7- no facial asymmetry• CN8- turns head to stimulus• CN9, 10- normal suck and swallowing • CN 11- symmetry of SCM muscle bulk • (-) Involuntary movements• MMT 5/5 in all extremities• DTR: ++ on all• No meningeal signs: (-) nuchal rigidity, Kernig’s and Brudzinski’s• (-) Babinski
Diagnosis
Status epilepticus• Continuous clinical or EEG seizures lasting
atleast 30 minutes or recurrent seizures without return of consciousness during interictal period; the series lasting for 30 minutes or more
Pertinent History
• History of infections, including meningitis• Any history of previous seizures• Compliance to anticonvulsant drugs/ abrupt
withdrawal• Drug use (INH) or exposure to toxins• Anoxia• Vascular disturbances• Metabolic disturbances ( electrolyte
abnormalities)
Pertinent History
• History of static encephalopathies• Cerebral palsy• Head trauma• Underlying chronic illness
Physical & Neurologic Examination
• Vital signs• Observation of seizure activity• Skin bruises, petechiae or needle marks• Papilledema and retinal hemorrhage• Organomegaly and abdominal tenderness
Diagnostic Tests• Determine the cause of the seizure1. Blood glucose level2. Toxic scree3. CBC4. Electrolytes including Ca5. BUN6. Anticonvulsant drug level7. ABG8. Bacterial and viral cultures9. EEG10. CT/MRI11. CSF determination
Classification of status epilepticus
1. Overt generalized convulsive status epilepticus- continuous convulsive activity and intermittent convulsive activity without regaining full consciousness
• Convulsive (tonic-clonic)• Tonic• Clonic• Myoclonic
Classification of status epilepticus
2. Subtle generalized convulsive status epilepticus• Coma following generalized convulsive status
epilepticus with or w/o motor activity3. Simple status epilepticus• Consciousness preserved• Simple motor status epilepticus• Sensory status epilepticus• Aphasic status epilepticus
Classification of status epilepticus
4. Non convulsive status epilepticus• Consciousness impaired; twilight or fugue
state• Petit mal seizures (absence seizure)• Complex partial status epilepticus
Management
Goals of emergency management for status epilepticus
• Ensure adequate brain oxygenation and cardiorespiratory function
• Terminate clinical and electrical activity as rapidly as possible
• Prevent seizure recurrence• Identify precipitating factors such as hypoglycemia,
electrolyte imbalance, lowered drug levels, infection and fever
• Correct metabolic imbalance• Prevent systemic complications• Further evaluate and treat etiology of status epilepticus
• In practice, treatment should start within, and certainly 10 minutes of continuous generalized tonic-clonic seizure activity
Protocol
• ABC principle of resuscitation– Oral airway– High flow O2 (100% O2 by nasal cannula or
nonrebreathing mask), intubate if necessary– Continuous ECG monitoring and pulse oximetry– IV 5% dextrose in 0.3% saline or PNSS– In the absence of dehydration or shock, fluids may
be given at 75% of maintenance level or at 100 mk/m2
• Blood glucose by stick testing– If hypoglycemic, give 2-4 mg/kg of 25% glucose
solution by bolus injection
• Drug therapy– IV diazepam 0.3 mg/kg or lorazepam 0.1 mg/kg– If IV access failed, recatl diazepam 0.5 mg/kg– 2nd dose hould be given in children who do not
respond after 10 mins and with recurrence of convulsions
– If following the 1st dose of rectal diazepam an IV access is still not established, rectal paraldehyde 0.4 mg/kg
• If seizures persist– Verify that the convulsion is a genuine epileptic
seizure– Confirm that no treatable cause like
hyperglycemia is overlooked– If IV access is still not possible, interosseous
needle should be inserted
Phenobarbital
• Loading dose of 20 mg/kg by slow IV bolus• If seizures are controlled before full loading
dose is given, remaining dose may be given 1-2h after by either slow IV or IM
• May produce respiratory depression and arrest – elective intubation
Phenytoin
• 20 mg/kg (made up of 0.9% saline at a maximum concentration of 10 mg in 1 mL, infused at no more than 1 mg/kg/min)
• Preferred drug• Less respiratory and CNS depression
• Children on maintenance oral phenytoin and compliant, IV phenobarbital over 10 min should be given
• Other management– Diazepam or midazolam infusion– Barbiturate coma– General anesthesia
• If after 20 mins after phenobarbital and phenytoin infusion, patient remains in convulsive status epilepticus, consider rapid sequence induction of anesthesia by experienced anesthesia personnel using thiopental or propofol
• Ideally, EEG should be done• Children <3 years old with prior history of CSE
should be treated with IV pyridoxine
• Diazepam, loeazepam, or valproate – best drug for treatment of nonconvulsive status
• Valproate – administered by NGT or rectally; effective in absence status epilepticus
• Common medical complications: – CHF– Hypertension– Hypotension– Pulmonary edema– Pneumonia– Oliguria
Treatment guideline for an acute tonic-clonic convulsion including established convulsive status epilepticus.
et al. Arch Dis Child 2000;83:415-419
©2000 by BMJ Publishing Group Ltd and Royal College of Paediatrics and Child Health
CURRENT GUIDELINES FOR TREATMENT OF CONVULSIVE STATUS EPILEPTICUS BY COUNTRY
• Japan: “Research Committee on Clinical Evidence of Medical Treatment for Status Epilepticus in Childhood has a proposed guideline for the treatment of CSE in childhood. Initial management of seizures should be attempted mainly with i.v. diazepam, the second-line treatment involves i.v. midazolam followed by i.v. phenytoin if seizures persist, and the third-line treatment requires barbiturate coma”
• France: “as intravenous lorazepam not available, clonazepam, rectal diazepam or buccal midazolam as the best choice for initial therapy of CSE in infants and young children. Intravenous phenytoin / fosphenytoin and phenobarbital are the second-line drugs. Of the third line AEDs, high-dose midazolam infusion rather than thiopental to minimize serious side effects from barbiturate anesthesia”
The Role of Intravenous Valproate in Convulsive Status Epilepticus in the Future. Shang-Yeong Kwan, Acta Neurol Taiwan 2010;19:78-81