Mon11October0739PM 11

title: Paediatric Status Epilepticus BMJ Question tags: #FFICM notebook: ð-FFICM type: bmj-anki

Whilst on call you are called to the Emergency department to assist in the management of a 5-year-old child with status epilepticus.

He has already received two doses of IV lorazepam but is continuing to have seizures.

What would be the next most appropriate treatment?

(Please select 1 option)

Midazolam 0.5 mg/kg buccally

Thiopentone 4 mg/kg IV Incorrect answer selected

Phenytoin 20 mg/kg IV This is the correct answer

Paraldehyde 0.4 mg/kg PR

Diazepam 0.5 mg/kg PR

Explanation

Flashcard	type:reference	...
What is the current definition of status epilepticus	Convulsions lasting 5+ minutes/Recurrent convulsions without return to pre-convulsive neuro baseline	Advanced Life Support Group. Advanced Paediatric Life Support: The Practical Approach. 5th ed. Chichester: BMJ Books/Wiley-Blackwell; 2011.
What has recently changed in definition of status epilepticus	Time allowed has gone from 30 to 5 minutes	Advanced Life Support Group. Advanced Paediatric Life Support: The Practical Approach. 5th ed. Chichester: BMJ Books/Wiley-Blackwell; 2011.
What is the dose of lorazepam for status epilepticus in kids?	0.1mg/kg	Advanced Life Support Group. Advanced Paediatric Life Support: The Practical Approach. 5th ed. Chichester: BMJ Books/Wiley-Blackwell; 2011.
What is the dose of buccal midazolam or rectal diazepam for status epilepticus in kids?	0.5mg/kg	Advanced Life Support Group. Advanced Paediatric Life Support: The Practical Approach. 5th ed. Chichester: BMJ Books/Wiley-Blackwell; 2011.
What is the dose of phenytoin for status epilepticus in kids?	20mg/kg	Advanced Life Support Group. Advanced Paediatric Life Support: The Practical Approach. 5th ed. Chichester: BMJ Books/Wiley-Blackwell; 2011.
If a kid stops seizing before theyve had all their phenytoin what should you do?	Give it all	Advanced Life Support Group. Advanced Paediatric Life Support: The Practical Approach. 5th ed. Chichester: BMJ Books/Wiley-Blackwell; 2011.
What is the dose of phenobarbitone for status epilepticus in kids?	20mg/kg	Advanced Life Support Group. Advanced Paediatric Life Support: The Practical Approach. 5th ed. Chichester: BMJ Books/Wiley-Blackwell; 2011.
What is the good thing about dosing phenytoin and phenobarb for status epilepticus in kids?	They're both 20mg/kg	Advanced Life Support Group. Advanced Paediatric Life Support: The Practical Approach. 5th ed. Chichester: BMJ Books/Wiley-Blackwell; 2011.

Status epilepticus is defined as convulsions lasting for 5 or more minutes or recurrent episodes of convulsions in a 5-minute period without return to pre-convulsive neurological baseline. A typical secondarily generalize tonic-clonic seizure generally stops by three minutes and almost always by 5-minutes. Status epilepticus was previously defined as continuous seizure activity of at least 30 minutes duration or intermittent seizure activity of at least 30 minutes duration during which consciousness is not regained. In approximately one-third of cases it is the first presentation of epilepsy.

In 2011, the Advanced Life Support Group published a new guideline for the management of status epilepticus in children. The management varies according to the presence or absence of intravenous or intraosseous access.

In all cases the first priority is to establish a patent airway, give high-flow oxygen and ensure blood glucose levels are checked and corrected if needed.

Step 1 (Five minutes after start of seizures):

Many children may have already undergone step 1 before arrival at hospital and it is important to remember this.

If intravascular access is available then initial treatment is lorazepam 0.1 mg/kg IV

If no intravascular access then give buccal midazolam 0.5 mg/kg or rectal diazepam 0.5 mg/kg.

Step 2 (Ten minutes after start of seizure):

If the convulsions continue give a second dose of benzodiazepine, call for senior help and start to prepare phenytoin

No more than two doses or benzodiazepines should be given (including any doses given before arrival at hospital)

If still no IV access then obtain intraosseous access (IO).

Step 3 (Ten minutes after step 2)

Senior help along with anaesthetic/ICU help should be sought

Phenytoin 20 mg/kg IV over 20 minutes

If the seizure stops before the full dose of phenytoin is given then the infusion should be completed as this provides up to 24 hours of anticonvulsant effect

In children already receiving phenytoin as treatment for epilepsy then an alternative is phenobarbitone 20 mg/kg IV over five minutes

Once the phenytoin is started, senior staff may wish to give rectal paraldehyde 0.4 mg/kg although this is no longer incuded in the routine algorithm recommended by APLS.

Step 4 (20 minutes after step 3)

If 20 minutes after starting phenytoin the child remains in status epilepticus then rapid sequence induction of anaestheisa with thiopentone and a short acting paralysing agent is needed and the child transferred to paediatric intensive care.

Reference:

Advanced Life Support Group. Advanced Paediatric Life Support: The Practical Approach. 5th ed. Chichester: BMJ Books/Wiley-Blackwell; 2011.

Answer Statistics

1

2%

2

6%

3

84%

4

6%

5

4%

Times answered: 262