WAHT-PAE-045

This guideline has been printed from the Worcestershire Acute Hospitals NHS Trust intranet on
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GUIDELINES FOR STATUS EPILEPTICUS IN CHILDREN

This guidance does not override the individual responsibility of health professionals to make
appropriate decision according to the circumstances of the individual patient in consultation
with the patient and /or carer. Health care professionals must be prepared to justify any
deviation from this guidance.

INTRODUCTION
Generalised convulsive (tonicclonic) status epilepticus is defined as a generalised
convulsion lasting 30 minutes or longer, or repeated tonicclonic convulsions occurring over
a 30 minutes period without recovery of consciousness between each convulsion. However,
the guideline stated that 'for practical purposes, the approach to the child who
presents with a tonicclonic convulsion lasting more than 5 minutes should be the
same as the child who is in "established" status to stop the seizure and to prevent
the development of status epilepticus'
With the exclusion of neonates, the guideline covers all children from 1 month to 16 years of
age who fits the definition of status epilepticus. If individual patients have had a previous
adverse experience e.g. with Benzodiazepines, or for other reasons have their own tailor
made individual emergency plan, this should be used in preference to the generic default
guideline.

THIS GUIDELINE IS FOR USE BY THE FOLLOWING STAFF GROUPS:

Personnel who are trained and competent in Basic Life Support, Intravenous Cannulation
and Intraosseous Cannulation.
Paediatricians trained in APLS/EPLS & Anaesthetists competent in paediatric airway
management.
Qualified paediatric nurses assesses in the administration of intravenous medication as per
guidelines and administration of rectal and buccal medication.

Lead Clinician(s)
Dr M Hanlon Paediatric Consultant WRH
Dr Sujatha Chinnappan ST6 Paediatrics

Approved by C Doherty on behalf of Clinical 1 February 2006

Effectiveness Committee on: 17 April 2012

Approved by Medical Safety Committee on 18 January 2006

9 May 2012
Extension approved:
This guideline should not be used after end of: 28th March 2017

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Guidelines for Status Epilepticus in children
WAHT-PAE-045
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Key amendments to this guideline

Date Amendment By:
17.02.12 Amended definition of convulsive status epilepticus to seizure Dr M Hanlon
lasting for 5 minutes or longer, or two or more seizures
occurring without regain of consciousness between them, and
changes to the drug regime used for emergency convulsive
treatment.
Agreed Paediatric Clinical Governance Committee and MSC
17.04.12 Further amendments made regarding: Dr M Hanlon
In a child with tonic-clonic convulsion lasting more than 5
minutes the approach should be the same as for a child who
is in established status to stop the seizure and to prevent
the development of status epilepticus
Administration of medications.
May 2016 Document extended for 12 months as per TMC paper TMC
approved on 22nd July 2015

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Guidelines for Status Epilepticus in children
WAHT-PAE-045
This guideline has been printed from the Worcestershire Acute Hospitals NHS Trust intranet on
05/05/2016, 09:59
It is the responsibility of every individual to check that this is the latest version/copy of this document

GUIDELINES FOR STATUS EPILEPTICUS

INTRODUCTION
Definition
Generalised convulsive (tonicclonic) status epilepticus is defined as a generalised convulsion
lasting 30 minutes or longer, or repeated tonicclonic convulsions occurring over a 30 minutes
period without recovery of consciousness between each convulsion. However, the guideline
stated that 'for practical purposes, the approach to the child who presents with a tonic
clonic convulsion lasting more than 5 minutes should be the same as the child who is in
"established" status to stop the seizure and to prevent the development of status
epilepticus'
Any type of seizure may develop into status epilepticus; generalised tonic clonic is the most
common and most serious type.

Aetiology
Remote symptomatic (where there is a chronic non-progressive or progressive disturbance
of brain function including epilepsy, metabolic diseases)
Acute symptomatic (acute neurological or systemic disorder, including infections i.e.
meningitis and encephalitis, head injury, accidental or deliberate ingestion)
Febrile (occurring in febrile children with no previous history of non-febrile seizures and no
evidence of meningitis/encephalitis)
Idiopathic

Significance of Status Epilepticus

Convulsive status epilepticus in childhood is a life threatening condition with serious risk of
neurological sequelae and constitutes medical emergency.
Commence emergency treatment if convulsive epileptic seizure has persisted more than
5 minutes. Focal motor seizures with preserved consciousness / responsiveness are
generally less noxious and should be tolerated for a longer period before giving
emergency treatment.

Pathophysiology
Prolonged convulsive status cause irreversible damage within hippocampus, amygdala,
cerebellum, thalamus and cerebral cortex.
This damage results from a cytotoxic chain reaction involving excitatory amino acids (e.g.
glutamate), free radical release, mitochondrial dysfunction, cerebral oedema and cerebral
ischaemia.
Persisting status epilepticus leads to a loss of physiological compensatory mechanisms, with
consequent biochemical, renal, hepatic and cardiac failure, and ultimately death.

COMPETENCIES REQUIRED
Training in Basic Life Support
Intravenous Cannulation
Intraosseous Cannulation
Resuscitation Team - Trained in APLS/EPLS
Administering intravenous medication as per guideline.
Training in the administration of Buccolam (buccal midazolam)

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Guidelines for Status Epilepticus in children
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PATIENTS COVERED
With the exclusion of neonates, the guideline covers all children from 1 month to 16 years of
age who fits the definition of status epilepticus. If individual patients have had a previous
adverse experience e.g. with Benzodiazepines, or for other reasons have their own tailor
made individual emergency plan, this should be used in preference to the generic default
guideline.

GUIDELINE:
Primary Assessment
AIRWAY
Assess airway patency by look, listen, and feel method. If no air entry, chin lift-jaw
thrust manoeuvres should be carried out and reassessed. If no improvement, rescue
breaths to be given.
BREATHING Assess adequacy of breathing
Effort of breathing: recession, respiratory rate grunting
Efficacy of breathing: breath sounds, chest expansion
Effects of breathing: heart rate, skin colour
Monitor oxygen saturation with pulse oximeter

CIRCULATION Assess adequacy of circulation

Cardiovascular status: heart rate (presence of inappropriate bradycardia suggest
raised intracranial pressure), pulse, capillary refill, blood pressure (significant
hypertension >97th percentile for age indicates possible aetiology)
Monitor heart rate, rhythm, blood pressure, and core/toe temperature difference

DISABILITY Assess neurological function.

Pupillary size and reaction (very small pupils suggest opiate poisoning, dilated pupils
seen in amphetamine, atropine, tricyclic antidepressant poisoning)
Note childs posture. (Decorticate, decerebrate posture suggests raised ICP)
Look for neck stiffness and full fontanelle which suggest meningitis
Focal neurological signs.

EXPOSURE
Take childs temperature (hyperthermia suggest infective cause, hypothermia suggests
poisoning with barbiturates, ethanol.)
Look for rash to rule out meningococcal disease.

RESUSCITATION
Maintain patent airway and left lateral position (unless needs intubation)
Clear secretion by gentle suction
High flow oxygen through face mask
Gain intravenous/intraosseous access - check blood glucose, correct hypoglycaemia if
present.
Give 20ml/kg bolus of crystalloid (e.g. 0.9% sodium chloride (normal saline)) only if
signs of shock present.
Antibiotic to any child in whom diagnosis of meningitis is made after taking blood for
culture.

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Obtain full history from parents/carers/ambulance crew to ascertain underlying diagnosis.

FULL HISTORY AND EXAMINATION.

INVESTIGATIONS

Bloods: FBC, U&E, LFT, CRP, Blood Gas, Blood Culture, glucose.
Consider Plasma Ammonia, Lactate, Serum amino acid, Urine amino and
organic acids to rule out inborn errors of metabolism.
Anticonvulsant levels if a known epileptic on anticonvulsants.
Save serum.

Urine : MC&S, reducing substance, toxicology, amino acids & organic acids.

Imaging: CT Scan of brain if suspect NAI or Space occupying lesion or raised

intracranial pressure. (MRI may be needed later to evaluate other
neurodevelopmental causes of Epilepsy)

TREATMENT OF UNDERLYING CAUSES e.g. antibiotics, antiviral, antiepileptic etc.

LIAISE WITH POISONS CENTRE (if suspecting ingestion)

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Guidelines for Status Epilepticus in children
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Algorithm to emergency convulsive treatment

Airway
High flow oxygen
Dont ever forget glucose

Check what medication the

Vascular access? patient received before coming
Yes No into the hospital

Lorazepam 0.1mg/kg IV/IO over 60 Buccolam (dose is age specific please

seconds refer to table 3)
(max 4mg) or
Or or
Rectal Diazepam 0.5mg/kg
Diazepam 0.25mg/Kg IV/IO If midazolam not available
(maximum 10 mg)

10 mins
Vascular access?
Yes No

Lorazepam 0.1mg/kg IV/IO over 60 seconds Buccolam (dose is age specific please refer to
(max 4mg) table 3)
or or
Diazepam 0.25mg/Kg IV/IO (maximum 10 mg) Rectal Diazepam 0.5mg/kg
(Get phenytoin ready) If midazolam not available
10 mins 10 mins

Phenytoin Paraldehyde (undiluted) 0.4ml/kg PR and dilute with

18 mg/kg IV/IO over 20 min an equal volume of olive oil
Or OR Get phenytoin
if already on Phenytoin, give Phenobarbitone Paraldehyde 0.8ml/kg PR of ready ready
15-20mg/kg IV/IO over 10 min (mixed paraldehyde/oliveoil50%v/v)

Call anaesthetist
20 mins

RSI with Thiopentone

4mg/kg IV/IO

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Diazepam dose I.V.

For patients weighing less than 10kg:
Volume to administer I.V. Doses are rounded to nearest ml:
Dilute 10mg (i.e. 2ml) of diazepam with 8 ml of
0.9% sodium chloride to give a solution of 10mg/10ml = 1mg/ml.
Dose of 0.25mg/Kg = 0.25ml/Kg
Table 1
2.5kg 0.6ml (0.6mg) total dose
5kg 1.2ml (1.2mg) total dose
7.5kg 1.8ml (1.8mg) total dose
10kg 2.5ml ( 2.5mg) total dose

For patients more than 10kg:

Weight Volume to administer I.V:
Give undiluted 10mg/2ml
Dose of 0.25mg/Kg = 0.05ml/Kg
Table 2
12.5kg 0.6ml (3mg) total dose
15kg 0.75ml (3.75mg) total dose
17.5kg 0.9ml (4.5mg) total dose
20-30kg 1.2ml (6mg) total dose
30-40kg 1.8ml (9mg) total dose
>40kg 2ml (10mg) total dose
Buccolam is the only licensed oromucosal midazolam for the treatment of prolonged, acute,
convulsive seizures in infants, children and adolescents (from 3 months to <18 yrs of age).
Available in age specific, pre-filled, plastic, colour-coded oromucosal-dosing syringes. Has a
shelf life of 18 months. (The doses below are equivalent to about 0.3mg/Kg.)

Buccolam unit dose preparations:

Table 3
Label colour Age range Midazolam dose
Yellow 1-3 months 1.25mg (half 2.5 syringe)
Yellow 3 to 6 months 2.5 mg
Yellow >6 months< 1 year 2.5mg
Blue 1 to <5 years 5mg
Purple 5 to <10years 7.5mg
Orange 10 to <18years 10mg

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Guidelines for Status Epilepticus in children
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MONITORING TOOL

How will monitoring be carried out? Clinical Audit

Who will monitor compliance with the guideline? Paediatric Clinical Governance Committee

STANDARDS % CLINICAL EXCEPTIONS

Correct dose of medication administered by weight/age 100%
as appropriate
Correct timing between doses of medication 100%
Document medication given before hospital admission 100%
If failed cannulation how long to alternative route of 100%
administration of medication should be less than 3
minutes
APLS ABCD and glucose 100%

References
1. Sofou K, Kristjnsdttir R et al,Management of prolonged seizures and status epilepticus
in childhood: a systematic review, J Child Neurol. 2009 Aug;24(8):918-26. Epub 2009 Mar
30
2. Appleton R, Macleod S, Martland T et al, Drug management for acute tonic-clonic
convulsions including convulsive status epilepticus in children, Cochrane Database Syst
Rev. 2008 Jul 16;(3):CD001905
3. Treatment of convulsive status epilepticus: recommendations of the Epilepsy Foundation
of Americas Working Group on Status Epilepticus. JAMA. 1993;270:854-859.
4. NICE Clinical Guidelines 2012: The diagnosis and management of the epilepsies in adults
and children in primary and secondary care October 2011.
5. Advanced Life Support Group. Convulsions. In: APLS - the practical approach, 4th edition
6. Abend NS, Marsh E. Convulsive and non-convulsive status epilepticus in children. Current
Treatment Options in Neurology. 2009; 11(4):262-272.
7. Scott RC,Besag FM,Nevellie BG. Buccal midazolam and rectal diazepam for treatment of
prolonged seizures in childhood and adolescents: a randomised trial.Lancet
1999;353(9153):623-626
8. Mpimbaza A,et al. Comparison of Buccal midazolam with rectal diazepam in the treatment
of prolonged seizures in Ugandan children: randomised clinical trial.Paediatrics
2008;121(!):e58-e64
9. McMullah J,et al. Midazolam versus rectal diazepam for the treatment of status epilepticus
in children and young adults:meta-analysis.Acad Emerg Med 2010;17(6):575-582
10. Mclntyre J,et al .Safety and efficacy of buccal midazolam versus rectal diazepam for
emergency treatment of seizures in children: a randomised controlled trial. Lancet
2005;366(9481):205-210

11. NHS National patient safety Agency 2012. Prevention of Harm with Buccal Midazolam
signal.

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CONTRIBUTION LIST
Key individuals involved in developing the document
Name Designation
Dr M Hanlon Consultant Paediatrician
Dr Sujatha Chinnappan ST6 Paediatrics
Circulated to the following individuals for comments
Name Designation
Dr N Ahmad Consultant Paediatrician
Dr M Ahmed Consultant Paediatrician
Dr T Bindal Consultant Paediatrician
Dr D Castling Consultant Paediatrician
Dr T C Dawson Consultant Paediatrician
Dr T El-Azzabi Consultant Paediatrician
Dr G Frost Consultant Paediatrician
Dr A Gallagher Consultant Paediatrician
Dr M Hanlon Consultant Paediatrician
Dr L Harry Consultant Paediatrician
Dr B Kamalarajan Consultant Paediatrician
Dr K Nathavitharana Consultant Paediatrician
Dr C Onyon Consultant Paediatrician
Dr J E Scanlon Consultant Paediatrician
Dr A Short Clinical Director/Consultant Paediatrician
Dr V Weckemann Consultant Paediatrician
Dr F Childs Consultant Paediatrician - Community
Dr J Crane Consultant Paediatrician - Community
Dr D Lewis Consultant Paediatrician - Community
Dr A Mills Consultant Paediatrician - Community
Sharon Dawe Epilepsy Nurse Specialist
Alex Borg Directorate Manager
Dana Picken Matron, Paediatrics
Nell Pegg Ward Manager, Riverbank
Lara Greenway Ward Manager, Ward 1
Stephanie Courts Orchard Services Manager
Melanie Chippendale Advanced Nurse Practitioner
Matt Kaye/Sarah Scott Lead Pharmacist for Paediatrics and Neonatal
Circulated to the following CDs/Heads of dept for comments from their directorates /
departments
Name Directorate / Department
C Doughty Senior Resuscitation Officer
C Hetherington Clinical Director Accident & Emergency
I Levett CG Lead Accident & Emergency WRH
Circulated to the chair of the following committees / groups for comments
Name Committee / group
Alison Smith Medicines Safety Committee

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Guidelines for Status Epilepticus in children