The first priority of treatment is to ensure an adequateairway, breathing, and circulation (Chapter 38). Vital signsshould be obtained and oxygen administered if needed.If respirations are inadequate, positive-pressure ventilation may be required. Intravenous (IV) access should beobtained. In patients with no history of seizures, laboratory evaluation should be undertaken (see below). Severalpharmacologic options exist for management of status epilepticus (Table 181-5). Initial management is usually witha benzodiazepine. Lorazepam, diazepam, and midazolamall are effective agents. Diazepam distributes rapidly to the brain but has a short duration of action. If IV access is not available, liquid preparations may be administered per rectum. If the seizure does not resolve after two dosesof benzodiazepine, a second-line agent must be administered. Either IV phenytoin or fosphenytoin is effective, butcardiac monitoring is required to evaluate for arrhythmia.If the seizures persist, a loading dose of phenobarbital orvalproic acid is appropriate (see Table 181-5). Alternatively,continuous infusions, such as midazolam or pentobarbital,can be employed as third-line agents (with appropriate airway protection, blood pressure support, and strong consideration of continuous video-EEG monitoring to evaluate for ongoing subclinical seizures). If this approach is ineffective, preparations for general anesthesia are undertaken.When status epilepticus stops, maintenance therapy is initiated with the appropriate anticonvulsant.
For an otherwise healthy child with an unprovoked seizure anda normal physical and neurological examination, no laboratoryevaluation is required. Children with simple febrile seizures who have recovered completely require little or no laboratory evaluation other than studies necessary to evaluate the sourceof the fever. If the clinical presentation does not meet thesecriteria and acute symptomatic seizures are suspected, potentially life-threatening causes such as meningitis, sepsis, headtrauma, and toxins should be pursued. A complete laboratoryevaluation for new onset of seizures includes a complete bloodcount and measurement of glucose, calcium, sodium, potassium, chloride, bicarbonate, urea nitrogen, creatinine, magnesium, and phosphorus, as well as blood or urine toxicology
ABCs (airway, breathing, circulation)
Basic metabolic panel—sodium, calcium, magnesium
Toxicology studies as appropriate
Complete blood counts, platelets, and differential
Benzodiazepine (max rate of administration = 1 mg/min) Lorazepam 0.05–0.1 mg/kg (maximum 2–4mg per dose) Diazepam 0.2–0.5 mg/kg Midazolam 0.1–0.2 mg/kg screening. Children with clinical signs and symptoms of meningitis (neck stiffness, Kernig sign, Brudzinski sign), or historyor physical examination suggestive of intracranial infection,should undergo a lumbar puncture. Cerebrospinal fluid (CSF)should be analyzed for cell counts, culture, protein, and glucose levels. In children less than 18 months old, particularlyyoung infants, the clinical symptoms of meningitis may besubtle. Neonates also may require testing for inborn errors ofmetabolism; blood ammonia; CSF glycine and lactate, as wellas herpes simplex polymerase chain reaction; urine and stoolculture (cytomegalovirus and enterovirus); and a clinical trial of pyridoxine.