Status Epilepticus in Children - Types, Causes, and Treatment

Introduction

Status epilepticus is a medical emergency most commonly found in children and older adults. It consists of persistent and recurring seizures. A seizure can last between five to thirty minutes without returning to an actual mental state. It is one of the most common pediatric neurological emergencies. It is divided into various subtypes according to the underlying cause. It is one of the most common pediatric neurological emergencies. Seizures are usually ongoing and last for more than five minutes. If episodes last more than thirty minutes, a child is prone to neurological complications such as neuronal injury, alteration in neurons, and neuronal death. It is a severe and potentially life-threatening condition that needs immediate medical care.

What Is a Seizure?

A seizure is abnormal electrical activity in the brain, which involves the brain and the body. The abnormal electric discharge interrupts normal functioning. For example, slight electrical release from cerebral neurons results in abnormal motor sensory and autonomic activity. It can last for longer than five minutes or a recurrence of more than one seizure within five minutes without returning to a normal state of mind. There are various complications of attacks, such as fever, abnormal blood sugar and sodium levels, and brain infections. If the seizures repeatedly happen in episodes, the condition is known as status epilepticus. Status epilepticus is a medical emergency that can cause permanent brain damage.

What Is Status Epilepticus?

Status epilepticus is a condition that consists of single or frequent remitting seizures lasting longer than five minutes. Clinical attacks are frequent in this condition without returning to the baseline clinical state. In status epilepticus, convulsive episodes of seizures are found. It is commonly found in children with a peak incidence of two years. Prolonged seizure duration can result in resistance to anticonvulsants and potential permanent neurological injury.

What Are the Causes of Status Epilepticus?

Following are the various causes of status epilepticus-

A. Acquired

1. Fever.

2. Hypoxemia.

3. Head injury.

4. Stroke.

B. Infections

1. Bacterial meningitis.

2. Viral encephalitis.

3. Central nervous systems infections.

C. Metabolic

1. Hypoglycemia.

2. Hyperglycemia.

3. Hyponatremia.

4. Hypernatremia.

5. Hypocalcemia.

6. Hypomagnesemia.

D. Vascular

1. Arterial ischemic stroke.

2. Major sinus venous thrombosis.

E. Trauma

1. Major nervous system trauma.

2. Epidural trauma.

3. Subdural trauma.

4. Subarachnoid hemorrhage.

5. Intraparenchymal hemorrhage.

What Are the Types of Status Epilepticus?

There are two types of status epilepticus.

• Convulsive Status Epilepticus: In this condition, convulsions are more likely to result in long-term injury. Convulsions consist of jerking motions, rapid eye movements, grunting sounds, and drooling of saliva. There is the presence of rhythmic and generalized tonic motor activity. In addition, there is the presence of repetitive convulsive seizures.

• Non-Convulsive Status Epilepticus: It is a prolonged seizure that is manifested as altered mental states. There is a persistent change in the level of consciousness. The patient appears to be confused. They are unable to speak.

What Are the Risk Factors of Status Epilepticus?

The following are risk factors for status epilepticus

• Stroke.

• Low blood sugar level.

• Renal failure.

• Encephalitis.

• Liver failure.

• Head Injuries.

• HIV (human immunodeficiency virus).

• Genetic diseases.

• Drug abuse.

What Are the Sign and Symptoms of Status Epilepticus?

The signs of Status epilepticus are divided into three phases.

• Phase One - There is the presence of less frequent partial seizures. The seizure is discrete and generalized. The blood pressure remains in the normal range.

• Phase Two - The seizures are secondarily generalized. The seizure is in the tonic phase, followed by clonic jerks. There is the presence of sustained muscle relaxation. There is an alteration in blood pressure.

• Phase Three - The seizures become rhythmic clonic. The myoclonic activity is restricted to only one part of the body. It can affect hands, feet, eyes, and facial muscles. There is the presence of respiratory compromise, hypotension, hypoglycemia, and hyperthermia.

Following are the various symptoms of status epilepticus.

• Muscle spasm.

• Confusion.

• Falling.

• Loss of bladder control.

• Clenching of teeth.

• Falling.

• Irregular breathing.

• Difficulty in speaking.

• Different behavior.

• Unusual sounds.

• Presence of daydreaming look.

What Are the Complications of Status Epilepticus?

Following are the various complications of status epilepticus.

• Cerebral edema.

• Cerebral Venous and arterial thrombosis.

• Respiratory failure.

• Pulmonary edema.

• Glycosuria.

• Hyperpyrexia.

• Hyperkalemia.

• Multiple organ failure.

How Is Epilepticus Treated in Children?

If the child suffers from status epilepticus, it should be treated as early as possible. But first, the underlying cause is identified, and symptomatic treatment should be done. Following is the treatment plan.

• Oxygen is given.

• If the blood glucose level is decreased, glucose is given.

• Arterial blood gas, full blood count, serum electrolytes such as calcium, magnesium, and urea creatinine, and liver function tests are done.

• First line drugs are given that includes:

  • Diazepam - It is given in doses of ten milligrams.

  • Midazolam - It is given in doses of ten milligrams.

  • Intramuscular or Intranasal Midazolam is given in a dose of 0.25 milligrams.

• Second-line drugs are given if the seizures continue after two doses of first-line drugs.

  • Phenytoin - It is given in doses of twenty to thirty milligrams.

  • Phenobarbitone - It is given in doses of twenty to thirty milligrams.

• Third-line drugs are given if the seizure continues even after giving the dose of second-line drugs.

  • Sodium Valproate - It is given in doses of forty milligrams. It is contraindicated in cases of hyperammonemia, thrombocytopenia, liver diseases, and other metabolic diseases.

  • Levetiracetam - It is given in doses of forty milligrams over ten minutes.

• If the seizure persists after third-line drugs, the child is moved to pharmacological coma induction. Arterial and venous access is done along with intubation. Midazolam and Thiopentone infusions are given. Continuous electroencephalogram is monitored for twenty-four hours after intake. Vasopressor support is required.

• Additional anticonvulsants such as topiramate and pyridoxine paraldehyde can be given to children.

Conclusion

Generalized status epilepticus is a life-threatening emergency that requires immediate treatment. Immediate treatment can help in preventing neurological complications. It is a time-sensitive emergency; untreated seizures and delayed treatment contribute to mortality. Treatment is essential if an attack lasts more than thirty minutes. Early treatment helps in preventing acute brain injury. Parents should always take care of medicine as directed by a pediatrician.