Evaluation and Management of Status Epilepticus in Children: IAP Guidelines

Status epilepticus (SE) is the most common childhood neurological emergency. Practically, SE is defined as any child presenting convulsing to a healthcare facility or having repeated seizures without regaining of consciousness in between. The International League Against Epilepsy (ILAE) defines SE in terms of time points (t1 and t2).

The Indian Academy of Pediatrics (IAP) has released Standard Treatment Guidelines 2022 for Evaluation and Management of Status Epilepticus in Children. The lead author for these guidelines on Evaluation and Management of Status Epilepticus in Children is Dr. Kavita Srivastava along with co-author Dr. Biswaroop Chakraborty and Dr. Debjani Gupta. The guidelines come Under the Auspices of the IAP Action Plan 2022, and the members of the IAP Standard Treatment Guidelines Committee include Chairperson Remesh Kumar R, IAP Coordinator Vineet Saxena, National Coordinators SS Kamath, Vinod H Ratageri, Member Secretaries Krishna Mohan R, Vishnu Mohan PT and Members Santanu Deb, Surender Singh Bisht, Prashant Kariya, Narmada Ashok, Pawan Kalyan.

Following are the major recommendations of guidelines:

Etiology:

Etiology may be known or unknown:

Known (symptomatic):

• Acute (stroke, toxicity, derangements in serum electrolytes and blood glucose, trauma, hypoxia, febrile seizures, neuroinfections, and inborn errors of metabolism)

• Remote (brain scars due to above causes, genetic, brain malformations, etc.)

• Progressive (neurodegenerative disorders and tumors)

• Known cases of epilepsy: Poor drug compliance or by nature drug-resistant epilepsies such as Lennox–Gastaut syndrome and Dravet syndrome

Unknown cause: Entities like new-onset refractory status epilepticus (NORSE), a subset of which is febrile infection-related epilepsy syndrome (FIRES)

Management:

Status epilepticus is a life-threatening emergency. To improve outcomes, each unit should have a fixed protocol and team members should be familiar with their roles. Diagnosis and management should proceed together. A quick focused history and examination help to search for etiology, which helps in streamlining diagnostic work-up.

Prehospital Management (Home or Clinic):

1. The child should be put in recovery position (to prevent aspiration).

2. Rescue medication: Any of the following can be kept handy in the clinic:

• Midazolam (buccal/nasal)—2 puffs/5 kg weight (0.1–0.2 mg/kg/dose) or

• Lorazepam (intramuscular or intranasal)—0.1–0.2 mg/ kg/dose or

• Diazepam (intramuscular or rectal)—0.5 mg/kg/dose

• Blood sugar can be checked and glucose started, if low

3. Airway, breathing, and circulation should be maintained.

4. Shift the child to a hospital, preferably with oxygen in an ambulance.

Management:

• Special Points:

All caregivers of children with seizures should be taught first aid including recovery position and use of rescue medications.

These three drugs are not preferred in a particular sequence. Avoid phenobarbitone if facility for mechanical ventilation is not available; avoid valproate if suspected inborn error of metabolism or liver dysfunction (levetiracetam is the preferred drug in such cases).

In known cases of epilepsy with breakthrough seizures (on phenytoin ≤6 mg/kg/day, phenobarbitone ≤5 mg/kg/day, valproate ≤30 mg/kg/day or levetiracetam ≤30 mg/kg/day), give half the maintenance dose. For larger doses avoid loading and give the maintenance dose.

• Outcome:

Mortality in acute phase is seen in 10–20 %. Around 15–56% show long-term cognitive and motor disability.

Conclusion:

A structured and systematic approach should be followed for treatment of SE, with the role of individual team members well-specified beforehand, as …. Time is Brain!

Reference:

• Gulati S, Sondhi V, Chakrabarty B, Jauhari P, Lodha R, Sankar J. High dose phenobarbitone coma in pediatric refractory status epilepticus; a retrospective case record analysis, a proposed protocol and review of literature. Brain Dev. 2018;40:316-24.

• McKenzie KC, Hahn CD, Friedman JN. Emergency management of the paediatric patient with convulsive status epilepticus. Paediatr Child Health. 2021;26:50-66.

• McTague A, Martland T, Appleton R. Drug management for acute tonic-clonic convulsions including convulsive status epilepticus in children. Cochrane Database Syst Rev. 2018;1:CD001905.

• Mishra D, Sharma S, Sankhyan N, Konanki R, Kamate M, Kanhere S, et al. Consensus Guidelines on Management of Childhood Convulsive Status Epilepticus. Indian Pediatr. 2014;51:975-90.

• Trinka E, Cock H, Hesdorffer D, Rossetti AO, Scheffer IE, Shinnar S. A definition and classification of status epilepticus—Report of the ILAE Task Force on Classification of Status. Epilepsia. 2015;56: 1515-23.

• The guidelines can be accessed on the official site of IAP: https://iapindia.org/standard-treatment-guidelines/