THE CRITICALLY ILL CHILD: MANAGEMENT OF STATUS EPILEPTICUS

Abstract

Status epilepticus is the clinical definition of a state in which the patient has a series of recurrent convulsions without recovering consciousness between episodes. It can occur with any seizure type, but a true medical emergency usually exists only with the generalized or focal motor varieties of status. This definition of status epilepticus clearly excludes epilepsia partialis continua, in which there is no alteration of the state of consciousness, and serial epilepsy, where consciousness is regained between attacks. Status epilepticus occurs in 5 to 10% of children with epilepsy and requires immediate and continued medical attention, for, if uncontrolled, death or permanent neuronal damage could result. Death occurs in approximately 15% of patients with status and may either be related directly to status epilepticus or, as emphasized by Lombroso, may result from the untoward effect of intravenous sedatives or hypnotic compounds on the already depressed medullary centers. The immature nervous system is particularly vulnerable to status epilepticus; and, in one recently reported study, 50% of the children were 2 years of age or less. Prompt management is mandatory, as both the neurologic residua from irreversible cerebral damage and mortality are higher in this young age group. The true pathophysiology of status epilepticus is poorly understood. However, the condition is more common in children with symptomatic epilepsy of infectious, metabolic, vascular, or structural etiology. Rapid or sudden withdrawal of anticonvulsants and intercurrent infections are the common triggering mechanisms. Injudicious withdrawal of drugs either prior to an electroencephalogram or after a seizure-free state of relatively short duration, and a sudden change in the anti-convulsant regimen, are frequent precipitating factors.