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

Introduction

• Welcome and brief overview of the episode
• Promotion of EB Medicine’s $1 for 7-day trial offer

Why Pediatric Status Epilepticus Matters

• Seizures 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 Causes

• Top 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 Care

• IM 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 Management

• Prioritize 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 Treatment

• Benzodiazepines 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 Therapies

• Based 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 Epilepticus

• Definition: 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 Scenarios

• Neonates:
  • 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 Considerations

• Many 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 Thoughts

• Keep 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

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