Peds Status Epilepticus

Pediatric status epilepticus is a time-critical neurologic emergency where early benzodiazepines matter and drug effectiveness shifts as seizures persist. Neonatal seizures are often subtle rather than convulsive, with electrolyte derangements and HSV sitting high on the differential.

Pediatric Status Epilepticus Approach

• Early stabilization priorities: Initial management mirrors adult status care: ABCs, monitors, pulse oximetry, bedside glucose, and rapid IV access while treatment starts without waiting for the full workup.
• First-line benzodiazepine therapy: Benzodiazepines are the clear first-line treatment, with IV lorazepam or diazepam preferred and intranasal or IM midazolam strong options when access is delayed.
• Receptor shift over time: Ongoing seizures become harder to break because GABA receptors internalize while NMDA activity rises, which is why repeated benzodiazepines lose punch as time passes.
• Second-line agent choices: Guidelines do not endorse a single best second-line drug; levetiracetam and fosphenytoin are both reasonable, and we get into why many clinicians lean levetiracetam in the episode.
• Airway and refractory care: Intubation is not treatment failure in prolonged seizures; propofol or thiopental are suggested third-line anesthetic options, with additional rescue nuances discussed in the chapter.
• Seizure mimic red flags: Dissociative seizures can look dramatic and prolonged, often with flopping movements and vocalization, especially in teenagers with a psychiatric history.

Neonates and Special Populations

• Subtle neonatal seizure signs: Neonatal seizures often lack generalized tonic-clonic activity and instead show eye winking, lip-smacking, or bicycling leg movements that are easy to miss.
• Electrolyte-driven neonatal causes: In neonates, check glucose plus sodium and calcium early because correctable metabolic problems are common triggers, including hyponatremia from improperly mixed formula.
• Neonatal first-line therapy: Phenobarbital is first-line for prolonged neonatal seizure, since benzodiazepines are less reliable when neonatal GABA signaling remains relatively excitatory.
• HSV and structural workup: Head CT matters in neonatal seizure evaluation because vertical HSV and other intracranial pathology belong on the early differential.
• Genetic epilepsy medication trap: Dravet syndrome and other sodium-channel epilepsies can worsen with fosphenytoin, carbamazepine, or lacosamide, making levetiracetam the safer second-line direction.
• Infantile spasms clue: Infantile spasms often present as a forward head bob with simultaneous arm flexion and carry a distinctive EEG pattern. We highlight the bedside recognition clue in the episode.

References:

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