Status Epilepticus Clinical Pathway — ED, Inpatient and ICU
Status Epilepticus Clinical Pathway — ED, Inpatient and ICU
PICU Refractory Status Epilepticus Management
If the seizure continues after administration of a benzodiazepine and another appropriately dosed anti-seizure medication, then the patient meets criteria for refractory status epilepticus.
Upon arrival to the PICU
- Consult Neurology and establish a seizure action plan.
- Document seizure action plan (EPIC smart text tool: PICUSeizureActionPlan), including awareness of any pre-existing medications or ketogenic diet.
- Seizure action plan enactment will be led by Critical Care staff at the bedside.
- Initiate continuous EEG monitoring Intensive Care Pathway for EEG Monitoring
- Utilize ICU STATUS EPILEPTICUS order set.
- Evaluate need for:
- Airway support
- Central venous access and/or arterial access
- Vasoactive support
- Temperature control
- Any additional diagnostic testing or procedures, including but not limited to:
- Lumbar puncture
- Laboratory workup including blood glucose checks (every 2 hours for ketogenic diet patients)
- Neuro checks q 1 hour
- Imaging (CT or MRI)
Pharmacologic Coma Overview
The care plan is developed and modified jointly with Neurology ICU Consultation service, but implementation (initiation and titration of medication infusions) is primarily the responsibility of Critical Care Medicine.
Pharmacologic coma initiation and management:
- The first-line medication is generally Midazolam, and the second-line medication is generally Pentobarbital.
- Questions about treatment plans should involve direct dialogue between services.
- Documentation of the treatment plan:
- Neurology ICU Consultation service writes detailed Seizure Action Plan (EPIC smart text tool: PICUSeizureActionPlan).
- Critical Care Medicine provider implements Seizure Action Plan treatment plan.
Midazolam
- Utilize the Epic order set for ICU STATUS EPILEPTICUS.
- In patients age > 2 months utilize Midazolam titration bedside tracking sheets to escalate bolus doses and infusion, using the CHOP formulary for initiation doses.
- Midazolam Titration Excel Sheet - Convulsive Status Epilepticus — See Spreadsheet
- Midazolam Titration Excel Sheet - Non-convulsive Status Epilepticus — See Spreadsheet
- Continue frequent communication with ICU Neurology Consultation service. However, titration is per protocol, especially for convulsive seizures evident to the bedside practitioner.
- Consider additional infusions for coma in consultation with Neurology if status epilepticus is present at 4 hours after induction of Midazolam coma or at a continuous infusion ≥ 0.4 mg/kg/hr.
- Midazolam concentrations:
- Patients ≥ 10 kg: Choose Midazolam 5 mg/mL concentration which does not contain any diluent.
- Patients < 10 kg: Choose Midazolam 1 mg/mL concentration at the initiation of the titration protocol. After escalating over 4 hours, change the concentration to 5 mg/mL.
- For patients on the ketogenic diet, ensure that the diluent is normal saline.
Key Decisions Regarding RSE Management
- Duration of therapy: Pharmacologic coma duration should be determined and is often 24-48 hours, with exact determination made by considering seizure response, underlying etiology management, and time required to initiate or modify other anti-seizure medications. The wean time should be determined and is often 24-48 hours, with exact determination made by considering EEG monitoring data during wean and systemic adverse effects.
- Goals of therapy: Burst suppression vs. termination of status epilepticus vs. termination of all electrographic seizures. The goal depends on the patient-specific clinical factors as well as the drug being used (e.g. different for certain general anesthetics like Ketamine).
- Criteria for transitioning to or adding additional coma-inducing agents: If seizures persist after 4 hours, on high-infusion doses, or adverse effects occur, then transition to additional medications may be appropriate. If seizures are somewhat improved but persist or adverse effects are developing, then addition of an additional medication may be appropriate.
Additional Therapies
If seizures persist with the first pharmacologic coma induction medication or adverse effects occur, then transition to other options may be appropriate. During pharmacologic coma, developing a plan to reduce the likelihood of seizure recurrence during the wean is essential, and this may involve management of precipitant etiologies or modification of the anti-seizure medication regimen.
| Pharmacologic Coma Medications |
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|---|---|
| Anti-seizure Medications |
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| Metabolic Considerations |
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| Other therapies |
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