Status Epilepticus in Critically Ill Children

Introduction: Status epilepticus (SE) is a neurological emergency that requires rapid and accurate management. SE is a condition in which the mechanisms that terminate seizures fail or the mechanisms that lead to abnormally prolonged seizures are activated. Refractory SE (RSE) refers to ongoing seizure activity despite adequate treatment with benzodiazepines and at least one non-benzodiazepine anticonvulsant. Super-RSE is defined as SE that continues for 24 hours or longer. Methods: This review outlines the current clinical definitions, management protocols, and therapeutic strategies for SE, with a focus on pediatric patients. Initial assessment and stabilization should be performed promptly, including mandatory evaluation of the patient’s blood glucose and other electrolite levels. Appropriate dextrose treatment should be administered to patients with hypoglycemia. Following the initial assessment, first-line treatments-such as intravenous diazepam, intramuscular midazolam, or rectal diazepam-should be administered based on vascular access and body weight. If the patient does not respond to first-line treatments and the seizures persist, second-line treatments-such as levetiracetam, phenytoin, valproic acid, or phenobarbital-should be selected and administered by the physician. Patients unresponsive to second-line therapy should be managed in a pediatric intensive care unit in collaboration with a pediatric neurologist. For patients unresponsive to second-line therapies, third-line treatments may include continuous infusions of midazolam, ketamine, thiopental, or propofol. There is no standardized protocol for transitioning from continuous infusion therapy to intermittent therapy. Results: In cases of RSE where autoinflammatory or autoimmune processes, or cryptogenic new-onset RSE are suspected, immunomodulatory therapies (such as corticosteroids, intravenous immunoglobulin, plasmapheresis, etc.) should be considered. Other therapies like ketogenic diet, hypothermia, and neurosurgery may be applied in selected patients. Continuous electroencephalography monitoring should be used in the management of status epilepticus. Conclusion: Mortality due to status epilepticus can be as high as 3%, because of these patients to be followed up jointly by pediatric neurologist and pediatric intensivist and to be monitored in the pediatric intensive care unit.