In this episode, Sam Ashoo, MD and T.R. Eckler, MD discuss the July 2025 Emergency Medicine Practice article, Emergency Department Management of Status Epilepticus in Pediatric Patients

Introduction

• Welcome and brief overview of the episode
• Promotion of EB Medicine’s $1 for 7-day trial offer

Why Pediatric Status Epilepticus Matters

• Seizures make up ~1% of ED visits and ~3% of EMS calls
• High-risk and high-stakes condition requiring rapid action
• Status epilepticus now defined as ≥5 minutes of seizure activity
• ILAE’s T1 and T2 timelines help define when to treat and when damage begins

Common Causes

• Top contributors:
• Fever/infection
• Structural CNS abnormalities
• Toxic ingestions
• Genetic/metabolic disorders
• Additional factors by age:
• Infants: febrile seizures, chromosomal issues, trauma
• School-age: autoimmune disorders
• Adolescents: eclampsia, hypertension, functional disorders
• Always consider non-accidental trauma

Prehospital Care

• IM midazolam is effective and recommended (RAMPART trial)
• Other options: intranasal, rectal, or IV benzodiazepines
• Early benzodiazepine administration improves outcomes
• Importance of airway support, glucose check, and EMS flexibility
• Parent-administered home meds (e.g. rectal diazepam) can be helpful

ED Evaluation and Initial Management

• Prioritize ABCs: Airway, Breathing, Circulation, Consciousness
• Use end-tidal CO₂ to monitor ventilation if available
• Point-of-care glucose is essential
• Labs: CMP, Mg, Phos, lactate, drug levels, pregnancy test (when indicated)
• Imaging: Head CT if concern for trauma, shunt malfunction, or focal signs
• Case examples highlight pitfalls and diagnostic delays

First-Line Treatment

• Benzodiazepines remain the cornerstone
• Lorazepam preferred IV agent (0.1 mg/kg)
• Midazolam preferred if no IV access (IN, IM, or IO)
• Diazepam is also effective, especially rectally
• Be mindful of respiratory depression and the need for airway control

Second- and Third-Line Therapies

• Based on ESETT trial:
• Levetiracetam, fosphenytoin, and valproate have similar efficacy
• Levetiracetam favored for safety and ease of use
• Fosphenytoin may be avoided in trauma or toxicity
• Valproate not recommended in mitochondrial disease
• Phenobarbital reserved for refractory cases only

Refractory Status Epilepticus

• Definition: persistent seizures despite first- and second-line agents
• Requires sedation and likely intubation
• Infusion options:
• Midazolam (preferred for flexibility)
• Propofol (short-term use only due to risk of infusion syndrome)
• Pentobarbital (rare, ICU-level care)
• Need for continuous EEG to assess seizure activity

Special Scenarios

• Neonates:
• Watch for subtle signs (lip smacking, bicycling, tongue thrusting)
• Broad differential includes asphyxia, infection, metabolic errors
• Febrile Status Epilepticus:
• Higher risk of CNS infections, especially if unvaccinated
• Consider lumbar puncture if indicated
• Electrolyte/Metabolic Triggers:
• Treat hypoglycemia, hyponatremia, and hypocalcemia directly
• Use 3% saline or dextrose as appropriate

Disposition and Discharge Considerations

• Many children will require ICU-level care
• Some known epilepsy patients may go home if back to baseline
• Ensure rescue medications are up to date (rectal/intranasal benzos)
• Consider “clonazepam bridge” for short-term seizure prevention
• Collaborate with neurology for medication adjustment and follow-up

Final Thoughts

• Keep treatment tables and dosing references accessible
• Early, aggressive treatment can prevent long-term harm
• Episode closes with gratitude to article authors and a reminder to visit EBMedicine.net

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