• Give 20 ml/kg rapid bolus of crystalloid to any patient with signs of shock. Colloid and an antibiotic such as cefotaxime should be used for those in whom a diagnosis of septicaemia is made obvious by the presence of a purpuric rash after blood has been taken for culture.
• Give an antibiotic such as cefotaxime to any child in whom a diagnosis of meningitis is made obvious by a stiff neck or bulging fontanelle after blood has been taken for culture.
Key features
While the primary assessment and resuscitation are being carried out a focused history of the child’s health and activity over the previous 24 hours and any significant previous illness should be gained.
Specific points for history taking include:
• Current febrile illness
• Recent trauma
• History of epilepsy
• Poison ingestion
• Last meal
The immediate emergency treatment requirement, after ABC stabilisation and exclusion or treatment of hypoglycaemia is to stop the convulsion.
Reassess ABC
Step 3
At this stage senior help is needed to reassess the child and advise on management.
It is also wise to seek anaesthetic or intensive care advice as the child will need anaesthetising and intubating if this step is unsuccessful.
• While the phenytoin (18 mg/kg over 20 minutes) is being prepared, paraldehyde should be given to any child who has not yet received it.
• If the convulsion stops before phenytoin is started, the infusion should not be commenced without specialist advice.
• If the convulsion stops after phenytoin has been started, the complete dose should still be given as this will have an anticonvulsive effect for up to 24 hours.
• In the case of children already receiving phenytoin as maintenance treatment for their epilepsy, phenobarbitone (20 mg/kg over 20 minutes) should be used in place of phenytoin.
Step 4
If 20 minutes after Step 3 has started, the child remains in CSE an anaesthetist must be present. Check airway, breathing, and circulation. Take blood for glucose, arterial blood gas, urea, electrolytes, and calcium. Treat any vital function problem and correct metabolic abnormalities slowly. Treat pyrexia with paracetamol or diclofenac rectally.
Consider mannitol (0·5 g/kg intravenously over 30–60 minutes).
• Rapid sequence induction of anaesthesia is performed with thiopentone and a short-acting paralysing agent.
• Further advice on management should be sought from a paediatric neurologist.
In children under three years with a history of chronic, active epilepsy, a trial of pyridoxine should be insituted.
Drugs Lorazepam
Lorazepam is equally or more effective than diazepam and possibly produces less respiratory depression. It has a longer duration of action (12–24 hours) than diazepam (less than one hour). It appears to be poorly absorbed from the rectal route.
Lorazepam is not available in every country. If this is the case, diazepam can be substituted at a dose of 0·25 mg/kg IV/IO.
Diazepam
This is an effective, quick-acting anticonvulsant, which takes effect within minutes but whose action is short-lasting (about 40 minutes to 1 hour). It has a depressant effect on respiration and this is enhanced by the addition of other anticonvulsants such as phenobarbitone. Also, repeated doses make side effects more marked. The rectal dose is well absorbed.
Paraldehyde
Dose: 0·4 ml/kg per rectum (0·3 ml/kg under 6 months of age), made up as a 50:50 solution in olive oil or physiological saline. Arachis oil should be avoided as children with peanut allergy may react to it. Paraldehyde can cause rectal irritation, but intramuscular paraldehyde causes severe pain and may lead to sterile abscess formation.
Paraldehyde causes little respiratory depression. It should not be used in liver disease.
THE CONVULSING CHILD
THE CONVULSING CHILD
Figure 13.1. Status epilepticus algorithm
Lorazepam
0·1 mg/kg IV/IO
Lorazepam
0·1 mg/kg IV/IO
Diazepam
0·5 mg/kg PR
Paraldehyde
0·4 ml/kg PR
i.e. 0·8 ml/kg of prepared solution
Phenytoin
18 mg/kg IV/IO over 20 min
or if already on Phenytoin, give
Phenobarbitone 15–20 mg/kg IV/IO over 10 minutes CALL ANAESTHETIST
RSI with Thiopentone
4 mg/kg IV/IO
Airway
High flow oxygen Don’t ever forget glucose
VASCULAR ACCESS?
VASCULAR ACCESS?
NO
NO YES
YES 10 minutes
10 minutes
10 minutes
BMJ Paediatrics 9/11/0 10:05 pm Page 144
Paraldehyde takes 10–15 minutes to act and its action is sustained for 2–4 hours.
Do not leave paraldehyde standing in a plastic syringe for longer than a few minutes.
Phenytoin
Dose: 18 mg/kg intravenously. Rate of infusion no greater than 1 mg/kg/min. Infusion to be made up in 0·9% sodium chloride solution to a maximum concentration of 10 mg in 1 ml.
Measure plasma phenytoin levels 90–120 minutes after the completion of the infusion.
Phenytoin can cause dysrhythmias and hypotension, and therefore an ECG monitor should be used and the BP monitored. It has little depressant effect on respiration.
Do not use this if the child is known to be on oral phenytoin until the blood level of phenytoin is known. Then only give it if the phenytoin level is less than 2·5 micrograms/ml. Phenytoin has a peak action within 1 hour but a long half-life that is dose-dependent. Its action therefore is more sustained than diazepam.
Fosphenytoin
This is a recently produced pro-drug of phenytoin. It is not itself anticonvulsant but is rapidly converted into phenytoin once administered. Because it does not need propylene glycol as a solvent, it can be administered more rapidly than phenytoin over 7–10 minutes and is said to cause fewer cardiac side effects. It can be given intramuscularly At present there are no paediatric efficacy data on use in CSE in children. If used it is prescribed in “phenytoin equivalents” which could cause confusion. 75 mg fosphenytoin is equivalent to 50 mg phenytoin.
Thiopentone sodium
Induction dose 4–8 mg/kg intravenously.
This is an alkaline solution which will cause irritation if the solution leaks into subcutaneous tissues.
It has no analgesic effect and is a general anaesthetic agent. Repeated doses have a cumulative effect. It is a potent drug with marked cardiorespiratory effects and should be used only by experienced staff who can intubate a child.
It is not an effective long-term anticonvulsant and its principal use in status epilepticus is to facilitate ventilation and the subsequent management of cerebral oedema due to the prolonged seizure activity. Other antiepileptic medication must be continued.
The child should not remain paralysed as continued seizure activity cannot universally be adequately monitored by cerebral function analysis monitoring. When the child is stable he or she will need transfer to a paediatric intensive care unit. A paediatric neurologist should continue to give clinical advice and support. There are several regimes for continued drug control of the convulsions but they are outside the scope of this text.
General measures
Fluid input should be kept to 50–60% normal requirements, using 0·45% saline and 5% dextrose. Monitoring includes pulse, blood pressure, respiratory rate, oxygen saturation, urine output, blood levels of glucose, urea, creatinine and electrolytes. The role of cerebral function analysis monitoring is still unclear. At the current time clinical features and standard EEG are the preferred method of assessing seizure activity.
Additional treatments will depend on the clinical situation.
Frequent reassessment of ABC is mandatory as therapy may cause depression of ventilation or hypotension.
THE CONVULSING CHILD
Further management
Following cessation of the fit, all children will need continuous monitoring for vital functions and to observe for further convulsions. It is particularly important to ensure that breathing is adequate since the benzodiazepines used to control the fit may cause respiratory depression.
After the fit has been controlled the clinician must consider the underlying cause of the convulsion. In many cases there will be an infectious cause, either a benign, self-limiting infection causing ‘febrile status’ or possibly meningitis. See Chapter 12.