Advocate Hope Children's Hospital

 

¨      Ensure patient’s airway: Oral airway available, turn head to one side and keep limbs of opposite side free for possible lateral prone position if vomiting or not handling secretions.

¨      Monitoring: HR, RR, SaO₂, BP, cardiac rhythm, and body temperature. Provide oxygen by nasal cannula or facemask.

¨      Establish IV access: IV or IO

¨      Use rectal route as an option to administer: Benzodiazepines, valproic acid

¨      Consider elective intubation if the patient develops neurogenic respiratory depression with hypoventilation or significant distress/hypoxemia secondary to aspiration, in the event of raised ICP or hypothermia.

¨      Initial drug therapy:

♦         Lorazepam 0.05-0.1 mg/kg IV/IO. Can repeat after 5 minutes for a total of 3 doses. Can consider initial rectal administration at same doses as IV administration or

♦         Diazepam 0.2-0.3 mg/kg IV/IO

♦         Midazolam - useful as first line therapy when no IV/IO access can be given. IM, nasal, rectal oral:          0.1 mg/kg IM

¨      Concomitant with benzodiazepine infuse:

♦         Fosphenytoin 20 mg/kg, IM or IV, can be given IM if no IV, and can be given rapidly → consider if no IV/IO access or if patient is in stage II (decompensated) of status epilepticus.

♦         Phenytoin 20 mg/kg (IV) in 0.9% NaC1 solution at a rate not faster than 1 mg/kg/minute while monitoring ECG and BP.

♦         Phenobarbital (IV) 20 mg/kg in newborns, patients with cardiac conduction abnormalities, failed Phenytoin therapy.

¨      Immediate diagnostic investigations:

♦         CBC/differential

♦         Glucose → one touch confirmed by serum level

♦         Electrolytes (serum), calcium, magnesium

♦         Bun & creatinine

♦         Toxicology screen

♦         Anticonvulsant levels if indicated

♦         UA and appropriate cultures if indicated

♦         LP searching for infections if necessary. It should be deferred until seizures have ceased and the patient is hemodynamically stable.

♦         CT scan: if considered, it should be done as soon as possible if intracranial bleed or increased ICP is suspected, or it should be deferred until status is controlled and a normal respiratory pattern is established. If there are no genuine respiratory indications, a child should not be intubated for transfer for a CT of the head.

¨      Admit to PICU

¨      Endotracheal intubation might be required.

¨      Continuous monitoring of vital functions, low threshold for intubation to ensure airway protection and adequate gas exchange.

¨      Drugs

♦         If patient received 20 mg/kg of Phenytoin, infuse 10 mg/kg IV more, if no response, infuse Phenobarbital 20 mg/kg rate faster than 100 mg/minutes.

♦         If patient received Phenobarbital 20 mg/kg initially, consider repeating 5 mg/kg IV x 1. If patient doesn’t respond and continues to seize, administer Midazolam 200 mcg/kg bolus followed by a continuous infusion starting at 0.75 mcg/kg/minute and increasing as necessary up to 11 mcg/kg/minute.

♦         Pentobarbital coma: 10 mg/kg IV loading dose given slowly over 1-2 hours, monitoring BP closely. Then start maintenance infusion at 1 mg/kg/hour, and increase to 2-3 mg/kg/hour to attain burst suppression on EEG.

♦         Propofol continuous infusion 50-100 mcg/kg/minute

♦         Ketamine continuous infusion, starting at 1 mg/kg/hour

♦         General anesthesia: Halothane, Isoflurane