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Status Epilepticus in Children - Types, Causes, and Treatment

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Generalized status epilepticus is a medical emergency that requires immediate targeted treatment.

Written byDr. Kriti Singh

Medically reviewed byDr. Bhaisara Baraturam Bhagrati

Published At November 16, 2022
Reviewed AtJuly 25, 2024

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 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 include jerking motions, rapid eye movements, grunting sounds, and saliva drooling. There is rhythmic and generalized tonic motor activity, as well as repetitive convulsive seizures.

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

What Are the Causes of Status Epilepticus?

Following are the various causes of status epilepticus-

A. Acquired

  • Fever.

  • Hypoxemia (low oxygen levels).

  • Head injury.

  • Stroke (blood flow to the brain is stopped).

B. Infections

  • Bacterial meningitis (brain covering infection).

  • Viral encephalitis (viral brain inflammation).

  • Central nervous system infections.

C. Metabolic

D. Vascular

  • Arterial ischemic stroke (a narrow artery can cause a stoppage of blood to the brain).

  • Major sinus venous thrombosis (blood clot formation in brain venous sinuses).

E. Trauma

  • Major nervous system trauma.

  • Epidural trauma (trauma to the outermost brain covering).

  • Subdural trauma (brain injury).

  • Subarachnoid hemorrhage (bleeding between the brain and outer membrane).

  • Intraparenchymal hemorrhage (brain parenchymal bleeding).

What Are the Risk Factors of Status Epilepticus?

The following are risk factors for status epilepticus.

  • Stroke.

  • Low blood sugar level.

  • Renal failure.

  • Encephalitis (brain inflammation).

  • Liver failure.

  • Head Injuries.

  • HIV (human immunodeficiency virus).

  • Genetic diseases.

  • Drug abuse.

What Are the Signs and Symptoms of Status Epilepticus?

The signs of Status epilepticus are divided into three phases.

  • Phase One: There are less frequent partial seizures, which are discrete and generalized. The blood pressure remains in the normal range.

  • Phase Two: The seizures are secondarily generalized. They are in the tonic phase, followed by clonic jerks. There is sustained muscle relaxation and blood pressure alters.

  • 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.

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.

Status Epilepticus Treatment Guidelines:

  • 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, urea creatinine, and liver function tests are done.

  • First-line drugs are given that include:

    • 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 (increased ammonia level), thrombocytopenia (low blood count), 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.

What Are the Complications of Status Epilepticus?

Following are the various complications of status epilepticus.

  • Cerebral edema (brain swelling).

  • Cerebral Venous and arterial thrombosis (blood clot formation in the artery).

  • Respiratory failure.

  • Pulmonary edema (fluid in the lungs).

  • Glycosuria (glucose in the urine).

  • Hyperpyrexia (extreme high fever).

  • Hyperkalemia (high potassium level).

  • Multiple organ failure.

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.

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Frequently Asked Questions

Emergent treatment with benzodiazepines (intramuscular Midazolam, rectally Diazepam, and intravenously Lorazepam) followed by immediate therapy (Phenytoin/Fosphenytoin, Phenobarbital, Valproate sodium or Levetiracetam). Giving one dose of Diazepam gel into the rectum or nasal spray treatment with intranasal Midazolam or intranasal Diazepam is usually used as a home treatment.
Status epilepticus is a recurrent or prolonged seizure without returning to baseline. And it is the most common pediatric neurological emergency seen in childhood. Every year, of 100,000 children, only 18 to 23 show an incidence ratio of status epilepticus.
According to guidelines, if five minutes of continuous clinical or electrographic seizure activity occurs, it is defined as a status epilepticus because it helps to provide a goal to achieve absolute control within 60 min of the onset of status epilepticus. Usually, most tonic-clonic seizures end within one to two minutes, but they may have postictal (after-effects) symptoms for longer. Therefore, it will make it hard to tell when a seizure begins and ends.
For early-status epilepticus, the first-line treatment mainly includes the administration of benzodiazepines. And the most oftenly used drugs include Diazepam, Lorazepam, and Midazolam.
When normal connections between the nerve cells in the brain are interrupted by anything, it can lead to seizures, which include high or low blood sugar, high fever, alcohol or drug withdrawal, or a brain concussion. But epilepsy can also be diagnosed when a child has two or more seizures without a known cause.
One can diagnose status epilepticus by clinical observation, and the most commonly used diagnosis to verify the status epilepticus was an electroencephalogram (EEG), brain imaging, or lumbar puncture. Electrodes are attached to an individual's scalp to record the brain's electrical activity. On the EEG recording, the electrical activity shows up as wavy lines. And this EEG will reveal the pattern, which tells whether the seizure may likely occur again.
If an individual experiences multiple episodes of seizures within five minutes or lasts longer than five minutes without returning to a normal level of consciousness between episodes is called status epilepticus. Permanent brain damage or death is caused due to medical emergencies.
If a status epilepticus approaches 20 percent of an individual's mortality rate, it is associated with the overall fatality case in an individual. And the mortality risk will depend largely on the underlying etiology.
Poorly controlled epilepsy, stroke, and low blood sugar are the risk factors for status epilepticus.
In older adults and children, epilepsy is most commonly seen, but it can be seen at any age. If there is a history of seizures in the family, they are at increased risk of developing a seizure disorder.
By the time they reach adolescence, nearly two-thirds of all epileptic children have outgrown their seizure disorders. Epilepsy, however, may be a chronic illness for certain people. Therefore, parents need to partner with their healthcare professionals to evaluate the condition of the child and accurate management.
Children with epilepsy, in about two-thirds, will stop their seizures at the time of their teenage. Eventhough, in some cases, epilepsy may be a lifelong condition, it should be important for every parent to partner with their healthcare providers to help and understand a child's condition and treatment.
Eventhough seizures are not dangerous and do not require immediate medical attention in the majority of kids. But one kind, known as status epilepticus, will come under this dangerous zone. It is a life-threatening condition in which a person shows continuous seizures or one after another seizures without regaining consciousness in between them.
In total, there are more than five times as many children with epilepsy as are more likely than other children to die within 15 to 20 years of the diagnosis. So it is not good news, but doctors have shown large differences in their treatment, which will reassure most kids and their families.
Kids can continue their normal life with epilepsy by living fully and actively, including school, friends, sports, and other activities. Depending on the kind of epilepsy, the success of treatment, and many other factors will help to decide how epilepsy has interrupted the child's life. However, in a few cases, epilepsy is difficult to control and leads to higher risks, like people needing assistance in their daily activities.
There are three stages of status epilepticus, according to a study conducted to determine the incidence in Eastern Finland. They are:
- The early stage of status epilepticus (SE) is a prolonged seizure lasting over five minutes.
- Refractory SE (RSE).
- Super refractory SE (SRSE).
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Dr. Bhaisara Baraturam Bhagrati from iCliniq
Dr. Bhaisara Baraturam Bhagrati

Pediatrics

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