Convulsive Status Epilepticus (CSE)
According to the UK’s Advanced Paediatric Life Support (APLS) guidelines, convulsive status epilepticus is defined as either a single, continuous seizure or multiple seizures without recovery of consciousness in between, lasting more than 5 minutes. Prompt intervention is critical because the longer the seizure continues, the more difficult it becomes to control and the higher the risk of complications.
Causes of Convulsive Status Epilepticus (CSE) in Children
Identifying the cause of CSE is a key part of management. Common causes include:
Prolonged febrile seizures, especially in young children.
Central nervous system infections, such as meningitis or encephalitis.
Metabolic derangements, including hypoglycaemia, hyponatraemia, hypocalcaemia, or other metabolic disorders.
Drug toxicity or accidental ingestion.
Non-accidental injury (NAI) resulting in a head injury or raised intracranial pressure.
Hypoxia or other systemic insults.
In children with a known epilepsy diagnosis, it can be due to poor medication compliance or an underlying illness.
Assessment and Management
The management of CSE is a time-critical emergency that follows a clear, staged protocol. APLS guidelines stress a structured, time-based approach.
Initial Assessment (0-5 minutes)
A – Airway: Ensure a patent airway. Use airway adjuncts if necessary.
B – Breathing: Administer high-flow oxygen. If breathing is inadequate, prepare for assisted ventilation.
C – Circulation: Establish vascular access. Check heart rate and blood pressure.
D – Disability: Assess the child’s level of consciousness using the AVPU scale (Alert, Voice, Pain, Unresponsive) or GCS. Check pupils and for any focal neurological signs.
E – Exposure/Environment: Check the child’s temperature and look for any rashes, signs of trauma, or evidence of a specific cause. Check blood glucose immediately.
Management (5-10 minutes)
First-line therapy: Administer a benzodiazepine. According to APLS, first-line options are:
Buccal Midazolam: The preferred first choice in the community or pre-hospital setting.
Rectal Diazepam: An alternative if buccal access is not possible.
Intravenous Lorazepam: A highly effective option if IV access has been obtained.
Start monitoring: Continuous monitoring of oxygen saturation (SaO2), heart rate, and blood pressure is crucial.
Management (10-20 minutes)
If the seizure continues, this is considered established SE.
Second-line therapy: A second dose of a benzodiazepine can be given if the initial dose was ineffective. At this stage, a non-benzodiazepine anti-epileptic drug (AED) should be initiated.
Levetiracetam and Phenytoin are common choices. Levetiracetam is often preferred due to its faster administration time and fewer cardiac side effects.
Phenobarbital may be considered.
Management (> 20 minutes)
If the seizure persists, it is now considered refractory SE.
Call for help: Inform the on-call anaesthetist and paediatric intensive care unit (PICU) team early.
Third-line therapy: The choice of treatment often involves a continuous intravenous infusion to suppress the seizure.
Continuous infusions of Midazolam or Phenobarbital are commonly used.
Propofol or Ketamine may also be used in the intensive care setting, but only by anaesthetists.
Investigate and Treat Underlying Cause: While medications are being given, ongoing efforts to identify and treat the underlying cause are essential. This may include antibiotics for suspected sepsis/meningitis or specific treatments for metabolic derangements.
Complications: Monitor for and treat potential complications of prolonged seizures, such as cerebral oedema, pulmonary oedema, hyperthermia, metabolic acidosis, and cardiac arrhythmias.
Prognosis
The prognosis of CSE is highly dependent on the underlying cause and the duration of the seizure. The longer the seizure, the higher the risk of long-term neurological damage or even death. Prompt, aggressive, and guideline-based management is crucial for a better outcome.