T.R.

Eckler: I don't think I realized how much of a black cloud you were, but now the more you tell stories, the more I'm like, man, you have really had quite a black cloud run.

Sam (2): Hi everyone, and welcome back to another episode of Amplify.

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If you're not already a subscriber, go there and take advantage of this special and check us out.

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And now let's jump into this month's episode.

Sam: Ladies and gentlemen, welcome back to another episode of EMPlify.

I am one of your hosts, Sam Ashoo, and on the other side of the microphone.

T.R.

Eckler: Dr.

TR Eckler back again, excited to make kids do a little less wiggling.

Sam: Yes, I'm sure all of our pediatric emergency medicine colleagues appreciate that notion.

No one wants to have to stand at the bedside and watch a child continuously seize, and that actually happens to be what we're talking about today.

This is the July, 2025 issue of pediatric emergency medicine practice on the emergency department management of status epilepticus in pediatric patients, which is a frightening scenario for me.

Something I don't enjoy watching or treating.

But still a very, very important disease process.

And if you happen to be the clinician standing at the bedside wondering what the next drug to push is, I highly recommend reading this article.

The two authors, Dr.

Bowen and Dr.

Bolton did a really good job of summarizing all of the evidence and the guidelines for us.

Especially the guidelines from the International League Against Epilepsy which I just love.

I want a t-shirt with International League against Epilepsy on it.

If you're listening to this podcast and you're a member of the International League Against Epilepsy, send me a t-shirt.

I'll wear it.

T.R.

Eckler: Same.

I would wear that t-shirt.

That'd be, that'd be rad.

Sam: cool.

It reminds me of the Justice League.

We are the epilepsy league.

We will stop seizures.

And I think that's the point of this issue really.

If you're wondering why status epilepticus in children.

Is it really a big deal?

The answer is yes, it is a big deal.

Seizures are like 1% of ED visits here in the us and 3% of pre-hospital transport.

So if you're listening to this and you're in pre-hospital medicine, it is a very important topic and we'll have some more information on that for you in just a few minutes.

But it is common, or at least it's not rare if you're in the emergency department.

And , the crux of the historical aspect of it is, I remember the days, again, I'm just dating myself, but I remember when the status Epilepticus definition was 30 minutes of continual seizing.

And I will tell you in clinical practice before the guidelines changed, I never waited 30 minutes to call it status epilepticus.

Even then, I thought that was a ridiculous definition.

But I'm happy to see that the International League against Epilepsy, check my t-shirt, did change that definition in 2015.

And for convulsive status epilepticus, it's now five minutes, which seems a much more reasonable timeframe.

Something I'm far more comfortable with and something that's really far more in step with clinical practice, I think for most of us.

We don't like to just stand by and watch somebody seize for 20 to 30 minutes.

T.R.

Eckler: I really liked their, attempt to break that down too, where they basically, instead of it being like, after this time period, you must do something or This is the danger zone, and I thought it was great how they started to tease out more of the kind of nuance here by having a T one and a T two for each classification of seizures, meaning like after this amount of time with this kind of seizures, you know, you should treat, and after this amount of time with this amount of seizures, your T two, then it starts to have a risk of damage.

I felt like that was a helpful idea.

And I think that was maybe one of the only things I wanted to enhance with the article was having more of a sense of what those T one and T two times are.

But I think that those even tend to vary based on age and the condition that you're dealing with.

But it still gave me a clearer idea of like, I want to treat sooner so I don't get to that T two time.

Sam: Yeah, and you know, if you're listing and wondering what we're talking about, in the article, there is the definition from the International League against Epilepsy about, the time at which point it becomes status and the time at which you're starting to have neurological damage.

And it varies by the type of seizure.

So you know, you might have noticed that I called it convulsive status epilepticus.

And that's because there are non convulsive focal motor and myoclonic seizure types as well, all of which come with different timeframes.

But if you're obviously seeing seizure activity and it's convulsive, then five minutes is the number you gotta remember there.

And like I said, I just think that's a much better definition than what we used to have, and I'm happy to see that we're moving in that direction.

The authors as usual did a great job with the literature search and looked at a number of guidelines, and I thought it was important to point out that, you know, this particular issue is on pediatric status epilepticus, and much of the literature comes from national guidelines and studies performed outside of the ED.

So, it's helpful to have the summary and I like that they focused it on the initial management for us.

That was very good.

And as always, before we dive into anything, I like to pimp you with questions.

So let's just jump into one for the sake of talking.

That's how we go.

So, which of the following is among the leading causes of pediatric status epilepticus, according to the article.

Asthma, structural CNS abnormalities, diabetes, and hyperlipidemia.

T.R.

Eckler: Oh B, structural neurologic abnormalities

Sam: of course.

Right.

T.R.

Eckler: Have you had an MRI yet is my favorite question for kids that come in with seizures, has someone put your child inside the magical magnet?

The tunnel of truth, as I call it, to show us if there's something structural there or not.

Sam: Yeah, and that's a really good question because the leading causes for status epilepticus are the ones you would think of most commonly fever and infections, some kind of central nervous system abnormality, accidental ingestions, and then the genetic and metabolic disorders.

Those are kind of like the top four categories for causes of pediatric status, epilepticus, and again, it can be multifactorial.

And what we're gonna talk about today is trying to differentiate these causes and how your initial therapy might change.

But the finger member is those four categories because you've gotta run through 'em super fast in your head if you've got somebody who's actively seizing in front of you.

T.R.

Eckler: I really liked just the quick summary they had in this, that 10% of seizure patients are gonna come in in status.

And I think that that kind of helped me like feel better about the sense that like nine outta 10 of these patients are gonna be okay.

They'll have a seizure, but they're gonna stop.

But I need to be on my guard for that one out 10 that isn't gonna stop and be ready.

So, you know, not that I'm necessarily medicating every one of these patients when they come in, but I'm ready for the ones that aren't stopping or the ones that start up again, that I have a plan of where I'm gonna go.

And then I really liked how they gave you that sense that, yeah, 33% of these, it's due to subtherapeutic levels of their medicines, but 6% are gonna be their electrolytes or their glucose, and 3.6% is toxic ingestions.

So that same kind of thing.

I'm ready for the common things, but I have those zebras in the back of my head of, alright, do I need to give, you know, glucose?

Do I need to fix an electrolyte?

Do I need to worry about some toxic congestion?

Do I need to start broadening my sense of what I'm gonna do to fix this patient?

Because what I'm doing isn't working?

Sam: Yeah.

Yeah.

I did, I mean, I'm a numbers guy, so I enjoy the numbers.

And I did also find it interesting that 70% of children who are diagnosed with epilepsy before the age of one will experience status epilepticus.

That's a l ot.

And if they didn't experience it on diagnosis, then it's going to happen at some point.

And that's an important thing to share with parents.

And it also will tell you that those parents are probably well educated and may have already given a therapy or two before the person even gets to the emergency department.

So history, history and more history.

And in this scenario, luckily there's a parent who hopefully knows quite a bit about this patient right in front of you if it's someone with a diagnosis of epilepsy already.

Table one is an interesting table from the International League against Epilepsy classification of convulsive status epilepticus to kind of break down the different types, and if you have the time to try and differentiate these, this is great.

Sometimes it can help with the conversation with the neurologist or if the parent already knows.

It can make a difference if it's impending convulsive status epilepticus versus established versus refractory, and at what point you're gonna use what term, but just know that five minutes is your timeframe there.

If it lasts five minutes or more, you're into that status.

And once you get into that area, then you're starting to break down things like the differential diagnosis and what it is we're supposed to be doing for the patient.

And table two does a great job of breaking it down by age because the causes can vary depending on the size and age of the patient.

If they're anywhere from birth to six years old, you're thinking things like febrile seizures, chromosomal and genetic abnormalities, inborn errors of metabolism, breath holding spells, and non-accidental head trauma.

The big key there.

Don't miss that.

If they're school age, then autoimmune disorders become the most common.

If they're adolescents, now you're thinking things like eclampsia.

You can't forget about the possibility of pregnancy.

Hypertensive crisis, autoimmune disorders, and functional neurologic disorder.

And then for all ages, you also have to keep in mind things like cerebral vascular accidents, infections, tumors, cortical dysplasia, head trauma, medication exposures or overdoses, metabolic disturbances, et cetera.

So lots and lots of things to keep in mind in the differential.

Table two does a really good job of breaking it down by age.

T.R.

Eckler: And it's really the common things that were there at the finish.

I found that table confusing because I felt like they led with the rare things, but then once you get to the bottom, it's really the cerebrovascular diseases, the CNS infections, the tumors, head trauma, intoxication, overdose.

Those are really the things that are causing most of these.

But I felt like it was great to have that even broader sense that occasionally you're gonna get some of these unusual kids with autoimmune disorders or you know, some other unusual inborn error metabolism.

And it's great to look for help early from your specialists when you realize that you're getting into something like that.

Sam: Yeah.

Yeah.

Great point.

Alright.

When it comes to pre-hospital treatments, there are some significant things that our pre-hospital personnel can do which leads me to our next question, which pre-hospital intervention improves seizure control before ED arrival?

Number one, rectal acetaminophen.

Number two, oral lorazepam.

Number three, intramuscular midazolam, or number four hypertonic saline.

T.R.

Eckler: I am gonna go with number three, intramuscular Midazolam, because I just love that medicine because I know intramuscular is gonna stay in the patient.

I know that the other stuff is gonna help, but not necessarily like.

really like give that improvement in control.

And I found that the, the RAMPART study they referred to here, which talked about how if they got IM Midazolam or IV lorazepam in adults and children, they were more likely to not need to go to the ICU, more likely to have their seizures terminated prior to the arrival of the ER.

And I felt like that boosted my own practice, like what I recommend for EMS in the field.

And I like how Midazolam wears off so I can kind of have a sense of what I'm doing next, or I can plan for it as opposed to the longer term of Lorazepam if you're getting it in pre-hospital settings.

So I feel like I get more chances to adjust once I know more about the patient.

If they're in the ER, then I'm more interested in giving them a longer acting medicine if I have that chance.

Sam: Yeah.

Yeah, and that's a perfect answer.

So the, the pre-hospital treatment is all about targeting seizure control, and there is good evidence from that rapid anti-convulsant medication prior to arrival trial, or RAMPART, that involvement of pre-hospital personnel in treating seizures is critically important and does actually improve outcomes.

So definitely IM midazolam and it's really great actually that our EMS personnel now have multiple options.

It used to be you struggle to get the IV in someone who's actively seizing, and maybe you get it and maybe you don't.

And then your only other option was an IO.

But now we have intranasal, we have IM, and we have rectal forms.

Again, if the person has a diagnosis of epilepsy and the parent has rectal diazepam, it's okay to give it, you know, just because you're the pre-hospital personnel doesn't mean you can't give them their home diazepam.

So you've got lots of options and lots of delivery mechanisms to try and get that benzodiazepine on board as fast as you can.

Use whatever you have at your disposal.

T.R.

Eckler: And having, said that, I think the, key that I, having read this article that I took away was to remember how flexible you need to be, because EMS isn't gonna have all the medicines that you want.

There's so many often drug shortages.

So things that you're used to using are not gonna be there.

So being ready to adjust your practice and, you know, adjust to what's available.

And as you said, the medicines now that the patients are having at home are becoming more common.

An intranasal Valium or intranasal diazepam is now much more of a common thing that's going home with these patients.

So you can ask EMS in the field, Hey, do they have their intranasal Valium?

Have they given it?

Okay.

Then if you want, you can give that if you don't have another option, if you don't have midazolam or something else.

But really just figuring out quickly what your options are, and then making the best decision you can or helping your EMS crews make the best decision from what they have.

Sam: Yeah.

And then once that's been done, then you turn to your routine ABCs.

So making sure their airway is controlled or patent, making sure they have adequate ventilation, especially if you've just given them a benzodiazepine.

And whether or not that seizure has terminated, they're gonna need some supplemental oxygen and perhaps some bag valve mask assistance until you get to the hospital, especially if the benzos are causing a little bit of respiratory depression.

Circulation.

Certainly if they are getting hypotensive or having instability, then they need that IV access and the IV fluid boluses.

And lastly glucose levels.

So point of care glucose, gotta check that sugar to make sure, especially the younger they are, the more likely they are to be just hypoglycemic.

And so that's an important piece that you need to add to your investigation when you're in the pre-hospital arena.

And hopefully by then you are at the hospital.

'cause these can be very anxiety provoking cases and getting to the nearest emergency department is important.

You know, hopefully it's a peds emergency department, but if not, that's still okay.

The ABCs and initial resuscitation should be the same regardless of wherever you land.

Once you're in the emergency department, our initial evaluation begins and leads to our next question.

What is the most important first step in the ED management of pediatric status epilepticus?

Here we go.

A, obtain a head, CT.

B, secure airway breathing, and circulation.

C.

Start valproic acid or D order.

An EEG

T.R.

Eckler: I would tell you that I think the answer to that question is A, B, C, and a second C.

'cause I liked how they added consciousness to their ABCs.

'cause I do think sometimes a kid looks okay but is not actually conscious.

Like, you could look at a kid quickly and be like, all right, they're not having status epilepticus.

It's not convulsive.

But if that kid's not there, they might be a non convulsive status.

And I liked how they put that little nuance to it.

Sam: Yeah.

Yes.

Well, first of all, you are correct.

So it is the ABCs.

And second, you know, I recall we talked about seizures when we talked about geriatric emergencies some time ago on a different podcast, and we talked about alterations in mental status in the geriatric population, maybe being something like non convulsive status.

And so similarly in children, as you said, if they're not actively convulsing, but they haven't returned to their normal baseline, it's something you need to keep in mind in your differential and it can be very challenging to try and make that diagnosis and figure out, okay, what is it exactly that is now causing this alteration?

Especially if they had a dose of benzodiazepines already.

So it can certainly be a challenge.

But yes, you are correct airway is a lways the first priority, especially if they've already had some benzodiazepine.

So positioning suctioning, oxygen administration for the hypoxia because you're trying to reduce the neuronal injury.

Second is making sure they're not apnic.

Third is checking, breathing and circulation and hooking up the monitor.

And if you have end tidal CO2, this is an ideal time to use it because not only are you interested in preventing hypoxia, but you also want to know if they've got hypoventilation and they need some assistance with ventilation.

Bag valve mask ventilation is okay to use even briefly after administration of benzodiazepines.

So they may need that for a few minutes until they start to adequately ventilate on their own.

And then that'll start hopefully, your brain going down the pathway of, you know, at one point, do I need to decide about intubating this patient now?

But if you're doing well with bag valve mask ventilation, that's okay.

You got time.

Establishing IV access or IO access.

So if the pre-hospital personnel were unable to do so, then this is a good time to do it.

And then gathering history, right?

Talking to mom or dad about previous history, medication exposures, recent illnesses and if they're in the neonatal period or infant period, formula mixing is a big deal because you're trying to also exclude hypoglycemia and hyponatremia your differential diagnosis.

And then lastly, trauma.

Non-accidental trauma.

I recall having a neonate come through the emergency department who had some abnormal movements.

We weren't really sure if they were seizing.

We gave some benzos.

It didn't really change much, but it did cause respiratory depression.

And at that point I was calling the ICU and we had gathered a bunch of labs and we weren't really sure if this was infectious.

There was no fever.

Ended up doing a lumbar puncture and as soon as I walked out of the room my ICU colleague was there and I said, gosh, you know, I'm really sorry.

Like I got CSF.

This was a really tiny neonate.

I got CSF, but I think it was a traumatic tap because it was all just bloody.

And he kinda looked at me and went, Hmm.

Okay, well we're gonna send it anyway.

And I said, oh yeah, we'll send it for fluid analysis.

And we started the antibiotics and sure enough, the next day, now we'd already obtained a head CT, which was normal.

And the next day the MRI showed, you know, bilateral subdural hemorrhages.

And so it was not a traumatic lumbar puncture.

It was trauma that was the cause of the blood in the CSF.

And so, uh with a normal head CT

T.R.

Eckler: Oh, that's so.

Sam: because there were like subacute, bilateral subdural hematomas.

So trauma, trauma, trauma.

Don't forget the non-accidental trauma in your differential.

And then when we start, talking about initial management, so what are we gonna give first, first line therapy

T.R.

Eckler: Can I stop us for one second because I think this is a question I ask med students and residents all the time, and I thought they did a great job, is when do you intubate the seizure patient?

Like what are your indications for rapid sequence intubation and mechanical ventilation.

I like how they put that together.

You gotta plan for both.

It's inability to maintain their airway.

Meaning they're not able to hold their airway open despite what other things you're gonna do.

Hypoxemia, inadequate ventilation, apnea, and refractory status lasting longer than 30 minutes.

So I think if you don't feel comfortable with any of those things, take that airway, it's time.

I thought that was a nice line in the sand in a very gray world that we live in.

I thought that was a nice, clear thing of you can feel comfortable if this is what you're looking at, then that's when you should take that airway.

Sam: Yeah, they did actually mention under circulation as well that bradycardia can be the harbinger of impending badness.

If it's not from hypoxia then it can be the potential clue that this person needs invasive ventilation as well.

So lots of physical examination clues there, or if their seizure is persisting and you're not able to control it.

Once we've passed through the ABCs the authors then had a little discussion here about diagnostic studies and what you should be ordering in the emergency department.

And we you know, are pretty good about this.

Really, most of these are protocoled or fit in line with the things that we're trying to eliminate from our differential diagnosis.

So obviously we're going to get a point of care glucose if that wasn't already done by EMS, and then you're gonna get your comprehensive metabolic panels in order to exclude metabolic inborn errors, calcium, magnesium, and phosphorus.

So your calcium may be part of your CMP.

Your magnesium and phosphorus are usually not, so you gotta remember to order those.

A lactic acid can be helpful.

A serum pH, even if it's a venous pH, can be helpful.

If they're already on seizure medications, you might be interested in getting levels for those to see if they're therapeutic.

If you know that they've had a toxic ingestion, you may be able to send levels for those if that comes across in the history from the parent.

If they're of age, you need a pregnancy test.

Again, not to be the harbinger of terrible stories, but , I recall being in the emergency department and having a 15-year-old obese female come in with a seizure first time.

No past medical history.

EMS had given a dose of Lorazepam IV prior to arrival and the seizure stopped and she arrived appropriately postictal and sedated from the Lorazepam.

And I was waiting for a parent to show up and a second seizure ensued.

And so we gave another dose of Lorazepam and off went to CT because the rest of the vitals were normal.

And while she was in CT, a parent showed up and confirmed, Hey, there's no history of this.

And while she was in CT, she had a third seizure and got a third dose of Lorazepam, and then as soon as she came back from CT she gave birth.

T.R.

Eckler: Wow.

Sam: no one knew that she was pregnant, she was obese.

And unfortunately she gave birth to a fetal demise that was probably somewhere in the second trimester, so she hadn't even made it to the third trimester.

And then now we were in the midst of trying to resuscitate what we thought were two patients.

And so we've got the neonate born still, and then the 15-year-old who has received a bunch of Lorazepam who is now excessively sedated and still having seizures and now moving down a different differential and diagnosis and treatment modality.

So don't forget to get the pregnancy test, and don't forget to consider that in anyone who is of the age

T.R.

Eckler: Also a patient like that is gonna be challenging To get a urine out of.

But I like to remind people most of the rapid urine pregnancy cartridges that we use in the United States are dual certified for blood, like whole blood and urine.

So you can drop whole blood onto those cartridges and then wait a few minutes.

And just like a urine pregnancy test, it will show you if the patient is pregnant or not.

Just from their whole blood.

So if your lab tells you, oh, we can't run this, we have to run the quant, or it has to be a urine, you can basically just have them send you a cartridge and you can put blood on that cartridge.

If the cartridge says it's okay, and you will know very, very quickly if your patient is pregnant or not.

And you don't need to wait a couple hours for somebody to cath the patient for urine while they're altered and confused.

Sam: Yeah.

Yeah, great point.

And sometimes, you know, it seems strange that we even have to say things like this, but sometimes it does take the physician to just say.

Send me the cartridge, send me whatever it is that I have to put the drop on.

I'll just do it myself because the lab technician is constrained by lab policies or rules or whatever it is from somebody who's nonclinical.

Then you, you just have to say, okay, look, I'll do it and I'll take the heat for it, but I gotta save this person's life.

T.R.

Eckler: I gotta save this person.

Yep.

Sam: so diagnostic imaging, if you're suspecting some kind of intracranial lesion or they got a history of it, or if they come with a history of a VP shunt and you're worried about a VP shunt failure then yes, you have to obtain the CT imaging of the brain.

And then there's other ancillary testing, ECG EEG, et cetera, that comes later down the line if you have the time.

If they have a history of VP shunt or if they have a focal seizure or if you're worried about head trauma, you need to order the head CT.

Now we are usually radiation sparing, especially in our children and pediatric populations.

But in this scenario, this is not the time to be radiation sparing.

If they have a history of anything intracranial or if you're suspecting even mildly suspecting something traumatic, you need to get that head CT.

You know, reducing radiation exposure is not the appropriate step in this scenario.

T.R.

Eckler: I think the key to that is we're not talking about all seizure patients that come into the ER.

We're not talking about your febrile seizure children.

We're talking about patients in status that are not returning to their baseline, that you're having trouble controlling their seizures.

You want to get the CT in that patient because it's often gonna change management.

I remember I had a well-known seizure patient that came in in rural Colorado, and I just couldn't get his seizures to stop.

And I finally, after like three different medications, got his seizures under control and got him intubated and got him to CT and he had a huge brain bleed.

and that was just something that stuck with me.

That if you can't control the seizures, take pictures, do more things because there's something there that, that you just need to get there and you'll find it.

Sam: Yeah.

And really that brings us to first line treatment.

So again, we're in the emergency department.

We're going to give something regardless of what EMS has given so far.

Which leads me to the next question.

Which benzodiazepine is preferred?

If IV access is available, is it diazepam, midazolam, or clonazepam?

T.R.

Eckler: So I will tell you that I know the right answer to this question is Lorazepam.

And I will tell you that I firmly disagree with the authors and I would like someone to check my record because I have a long track record of being appreciative and supportive of the authors.

But I find in clinical practice it is so much easier to dose stack Lorazepam where you give some, nothing happens, and then you give more and then they get respiratory depression and get intubated.

I think that in my practice I have seen better results from Diazepam, but I do like how they focused clearly on a weight-based dosing where Lorazepam should be 0.1 mg per kilos.

But then diazepam can be 0.1 to 0.3, and I think that Lorazepam is a significantly stronger medication.

So I would be more inclined to go 0.1 of Lorazepam, 0.2 of Midazolam, or 0.3 of Diazepam if I was treating patients.

And I think that as we talked about earlier, you need to be ready to use any of these medications because your favorites aren't always gonna be there.

So I think you need to have a sense of that dosing, or you need to have a sense that I know the medicines I need, but I can't keep these doses in my head.

So you need to either have support from an ER pharmacist to help you dose, or you need to be your own ER pharmacist and have an application like PD stat.

I love PD stat for basically making sure when I'm running a complex pediatric resuscitation that I know exactly the doses I'm giving.

'cause I put in the child's Braslow or their weight, and then I hand the phone to the nurses and say, I'm gonna give you drugs.

You just look down and tell me what the doses are from that .

Sam: Yeah.

Perfect.

and I will say, page seven of the article table four medications for status epilepticus first line anti-seizure medications lists all three of those as an option, right?

Lorazepam midazolam and diazepam.

Now, they do have a preference for Lorazepam, but it's not to the exclusion of the other two.

So whatever of the three that you have they do recommend Lorazepam because of its reliable onset and its duration.

But if you don't have, or if you have a preference, it's okay.

, You've got some flexibility there.

Midazolam does come with the other delivery options too, so IO, intranasal, intramuscular and has had efficacy in all of those areas.

So if you don't have an IV in place, that's probably the better choice.

T.R.

Eckler: To clarify, you can use any of those through an IV or an IO, but if you need to give them IN like nasally or muscularly, then you have to use Midazolam.

But I think that to be clear, midazolam is a significantly shorter acting drug.

So you need to know if you're giving Midazolam that you need to be ready to catch that patient an hour or two, either by starting them on infusion or giving them other medications that are gonna gain control of that seizure.

'cause the, solution you've provided is a shorter term one than the four to six hours you'll get out of Diazepam or Lorazepam.

Sam: Yeah.

Which brings us to second and third line medications.

The authors cited the ECET study, which is efficacy of levetiracetam, fosphenytoin, and valproate for established status epilepticus by age group.

And that study looked at which of these agents has the best efficacy as a second and third line anti-seizure medication.

The point being that  levetiracetam, fosphenytoin, and valproate were all shown to have similar efficacy.

But there are some specific scenarios where you might wanna give one instead of the other.

T.R.

Eckler: my takeaway from this was just that, you know, if you're worried about trauma, if you're worried about ingestion, there's a case to be made for  levetiracetam being the best first choice.

And I also think that it has such a high threshold for how high you can dose it in status, that even if they're on Keppra, you can give them another dose safely 'cause it's gonna take a lot to get them to 60 mgs per kilo.

And I think that that's the reason you're seeing so much of it given in clinical practices that there's such a better safety profile and such an ease of administration that's there as opposed to some of the other medicines in terms of like needing the pharmacy to be involved to get those other medications.

So I think that, that was my takeaway was just Keppra if I can get it and if I think it's safe to give another dose, great.

If not, if I need to use the other medicines, then I go to those because that's what I have available to me and that's where I'm at at the moment.

Sam: And, and honestly, I, I like Levetiracetam.

It is definitely my preferred agent, and I think the, our, really, our neurologists feel the same way.

You can give  fosphenytoin, even in the setting of trauma.

But you know, sometimes in the settings of drug or toxic ingestions, it's less effective.

And it has the potential for arrhythmia and hypotension, especially if you're exceeding certain doses.

Valproate is an option.

You do have to avoid it if there's any kind of history of mitochondrial disease.

And there used to be a stipulation that you couldn't give it to children under two years old, but recent studies have actually said that that's not true and that the side effects are similar to older children.

And so that is an option as well.

This might come up in a conversation with your peds neurologist, which hopefully you've already contacted at this point.

Phenobarbital is recommended by the American Epilepsy Society only if your usual first or second line medications are unavailable.

So just know that it's another option.

It's probably not the ideal second or third line option, but, if it's all you got, it's all you got.

And if you've tried others and they've failed, something to consider.

T.R.

Eckler: They listed under second, but they really want you to think about it in the third line.

Sam: Yeah, maybe even fourth.

T.R.

Eckler: Yeah.

Or, or refractory only.

Super, super refractory.

You're allowed to start at that point.

Sam: That's right, that's right.

And then when we're talking about the refractory category, so this is someone who's had two doses of benzodiazepines, has had a second and maybe third line agent, and is still seizing.

Now we're looking at infusions and at this point it is very likely that you've already controlled the airway or you're going to control the airway before you move on to one of these infusions, because these things are heavily sedating.

You're in the induction of coma kind of portion of the treatment protocol, and we're talking about things like Midazolam continuous infusion, pentobarbital continuous infusion, or Propofol continuous infusion.

And again, another clinical case.

I recall actually being in a brand new freestanding emergency department which unfortunately meant we were separate from the main hospital and had a limited pharmacy.

And in came a child in status, first line benzos by EMS unsuccessful.

Second dose of benzo given in the emergency department and seizure stopped and then came the clinical examination.

And the nurse and I are undressing the child and she's looking at the skin and then looks up at me with these big, glaring eyes as we're looking at bruises.

And she's thinking is this child getting beaten?

Is there some non-accidental trauma?

Mom is there and I'm looking at the child and thinking something completely different because the bruises have no pattern whatsoever.

There's small little petechial hemorrhages all over this patient's body.

There's some larger confluent ecchymosis, but mostly on the back and the buttocks.

And I'm thinking, yes, this is definitely a problem.

But this doesn't look like non-accidental trauma.

And then the third seizure ensued.

And in that case, we were pretty limited.

We did not have levetiracetam or fosphenytoin at the time was a brand new freestanding emergency department.

It was benzos or propofol, and I think we had one vial of propofol.

So it was okay get the propofol.

Here we go.

So we gave the third dose of benzodiazepine.

It didn't work.

And I ended up having to intubate this child.

And unfortunately the child did have what looked like new onset leukemia, had severe thrombocytopenia, CT scan of the head showed petechial hemorrhages.

And so there we were trying to stabilize this patient and send them out somewhere where they could take care of them to a pediatric tertiary center.

But the point being that sometimes you have to go to this third infusion state, and when you do, you really need to control the airway at this point because you're inducing a coma.

And again, I thought the authors did a good job of reminding us that at some point, an EEG needs to enter this pathway because even after you induce a coma or intubate this person and sedate them with a continuous infusion, now they're just no longer moving.

But you don't know if they're no longer seizing, and that's really where you need the EEG.

T.R.

Eckler: I think excellent.

Super well said.

I don't think I realized how much of a black cloud you were, but now the more you tell stories, the more I'm like, man, you have really had quite a black cloud run.

I think that when you're dealing with such a challenging patient like this, I like that midazolam infusion because of its short acting nature that, you know, you can back out of it if you need to, but I just think that that's a nice thing to gain short term control as you're figuring out what's going on.

And I think if you only have propofol, that's okay short term, but you need to be aware that that can't continue long term because of the potential for  propofol infusion syndrome.

So I think that's something where you need to quickly have a plan for how am I gonna get this kid somewhere else?

Or to someone else that has other kinds of medications they can try.

Sam: Yes, and that propofol infusion syndrome specifically is characterized by rhabdomyolysis, ECG changes, severe metabolic acidosis, renal failure, transaminitis, and sometimes cardiovascular decompensation.

So it's a big deal.

And the primary risk factor there being a history of a ketogenic diet or high infusion rates of your propofol.

So if they have epilepsy and they're on a special diet, or if you're having to crank up the propofol to stop the seizures, both of those are reasons to keep that infusion syndrome in your mind and maybe get them off the propofol as soon as possible after they reach, for example, the PICU.

And another thing to keep in mind is that about 14 to 20% of these patients will continue to seize after being placed on this infusion for persistent status epilepticus.

So even though you can't see it, this is just driving home that point.

Again, they need that EEG.

And then just to touch on some special scenarios.

So if you happen to do a point of care glucose, especially in the neonate, and they're hypoglycemic, you treat that to stop the seizure, right?

Benzos are not the ideal choice in this scenario.

You're gonna be giving them the D 10 or if they're a young child, the D 25.

And if they are in the neonatal period and they're on the formula and it's being inappropriately mixed and they're hyponatremic and their sodium is less than 120, then you're gonna treat the hyponatremia with 3% saline.

Give them that three to five milliliter per kilogram dose over 20 minutes to try and stop the seizures, and then you stop that infusion as soon as the seizures end.

And then the rest is slowly treated over time.

And the same with hypocalcemia.

So if they're hypocalcemic and you're gonna treat that, then calcium gluconate, or if they have a central line, the calcium chloride and all of those doses are there for you in the issue.

Neonatal seizures was another one of those special populations that the authors brought up.

And just as a reminder, some of the things you may see on clinical exam include the automatisms like blinking, chewing, lip smacking, tongue thrusting, or the bicycling of the lower extremities.

Those are the kinds of symptoms that you might pick up on physical exam for a child that's persistently seizing in this neonatal period and that they might have jitteriness and kind of an exaggerated Moro reflex that sometimes can be misconstrued as seizing.

So you just gotta be careful.

Do your own exam, be thorough.

And then the etiology there is very broad.

It does include trauma, but includes things like asphyxia, maternal medication use, especially if they're breastfeeding, maternal substance abuse, maternal infections, the neonatal infections, the inborn errors.

And this is where, you know, if they were born at your hospital, you might be able to look up their birth history and see if they had a genetic screening at birth.

And if not, then, you know, maybe ask Mom about those kinds of things.

And then keep in mind that CNS infections, especially with herpes simplex virus, can also cause seizures in this population.

So lots of special considerations for the neonatal seizures.

T.R.

Eckler: I think febrile status epilepticus is something you need to be a little more cautious about just because those kids that are not your common febrile seizures, that like they have one and they stop.

Or even if they're, you know, like the complex ones where they have one or two and then they stop.

The ones that are really truly febrile and in status, you need to be more cautious and especially ask about vaccine status because you need to be more aggressive about considering an LP in these kids and basically making sure that you talk to the parents about your recommendation to do that LP.

'cause I don't think I would want in practice to admit a child with febrile status and not have recommended in my chart that I wanted to get an LP and let the parents make that decision.

Sam: I think that's well said.

So febrile status epilepticus is very different than just a simple febrile seizure.

Those two entities do have the word febrile in them, but otherwise there's really very little overlap there.

So just be sure that you're making that distinction and understanding that you really need to rule out the infectious causes there for sure.

And that your first line treatment in those is going to include benzodiazepines, but also can include things to treat fever.

You know, the fever does lower seizure threshold and you want to address that as well.

T.R.

Eckler: to clarify my point, the authors said basically that if there's signs of meningitis, you need to consider a lumbar puncture.

But I think in the unvaccinated child, making sure that you were clear, that you were really concerned and really wanted to make sure you worked them up thoroughly.

I think you wanna be really cautious about making sure that you think carefully about, does this child need an LP If they're in febrile status.

Sam: Yeah, I mean, honestly again, it is just a reflection of my age.

I tend to be pretty aggressive with lumbar punctures.

You know, having treated patients at the very cusp or the beginning of the, super effective vaccine era.

We were lumbar puncturing all of these infants and, honestly, it's a relatively benign procedure.

Now, it may be difficult for you to get CSF out of a neonate, but still I have a very low threshold for just saying, yeah, we're gonna do the lumbar puncture, and this is why and there's no other way to really make this diagnosis if they have something infectious, especially if they're at risk for HSV.

It's something you don't wanna miss and can certainly be catastrophic for the patient.

The authors did do a good job of talking about some of the other newer medications, and we won't get into those today.

But I do wanna just touch on ketamine.

We have used ketamine significantly in the adult population for treatment of seizures, and there are case reports in the pediatric literature but still limited case reports so wasn't a strong recommendation for ketamine in status epilepticus.

It doesn't mean your pediatric neurologist might not recommend it.

But there are some others.

things like lacosamide and brivaracetam uh, like a longer more potent acting version of levetiracetam that binds to the same receptor but has a higher affinity.

So lots of other things that your pediatric neurologist might recommend if you get to the point where you've thrown everything in the kitchen sink at the patient.

But hopefully by then they're in the pediatric ICU.

T.R.

Eckler: I think the last thing I would wanna say is I really like their note about disposition, and I think some of these patients are gonna come in with seizures that are, you know, epilepsy patients that are on their medications.

You give them medications, things calm down, they go back to the baseline.

And if you talk to their neurologist, a lot of times these kids can go home.

But I think especially if they have a concern that they've outgrown their seizure coverage.

You wanna ask their neurologist if you want to adjust their medications.

Or if they need refills of their rectal diazepam, their intranasal midazolam, or diazepam, or even what's called a klonopin bridge or clonazepam bridge, to get them through a period of time, let's say if they have an infection, that they're gonna be more prone to seizures and you can give them an additional layer of seizure coverage.

I've seen a few neurologists do this where the patient goes home with a short course of Clonazepam, and I think it works really great for helping educated parents that do a great job of managing their kids have the tools to keep them outta the emergency department again.

Sam: Fantastic.

Well said.

And that brings us to the end of the episode.

Thanks again to Dr.

Bowen and Dr.

Bolton, our two authors for this July 2025 pediatric emergency medicine practice article on the treatment of peds status epilepticus in the ED and keep this in mind.

Keep those tables in your pocket.

It's a great reference, especially when you're standing there at the bedside treating this critical patient.

And until next time, everyone, be safe.

I am one of your hosts , Sam Ashoo.

T.R.

Eckler: Dr.

TR Eckler, stay safe out there.

Good luck.

Try to deal with your newfound celebrity from the pit.

Sam: and that's a wrap.

Thanks for joining us for this episode of EMPlify.

I hope you found it informative, and I want to remind you that ebmedicine.net is your one stop shop for all of your CME needs, whether that be for emergency medicine or urgent care medicine.

There are three journals, there's tons of CME, there's lots of courses, there's so many clinical pathways, all this information at your fingertips at ebmedicine.net.

Until next time, everyone, I'm your host, Sam Ashoo.

Be safe.