Seizures and Status Epilepticus
Definitions and recognition
Status epilepticus is a seizure lasting about 5 minutes or recurrent seizures without recovery of consciousness. Recognize that critically ill children often have nonconvulsive seizures, detectable only by EEG, especially after cardiac arrest, in encephalitis, or with unexplained persistent coma. Seizure semiology varies with age: neonates may show subtle eye deviation, cycling, or apnea rather than tonic-clonic movements.
Treatment sequence
Know the time-based algorithm: stabilize airway, breathing, circulation and check glucose first, then a benzodiazepine (lorazepam or midazolam, weight-based, may repeat once), then a second-line antiseizure medication (levetiracetam, fosphenytoin, or valproate), then refractory management with continuous infusion (midazolam, propofol with caution, or pentobarbital) under EEG and hemodynamic monitoring. Anticipate respiratory depression after benzodiazepines and have airway support ready.
Safety and monitoring
Protect the child from injury, do not restrain forcibly, position for airway, monitor glucose, electrolytes, and temperature, and look for the cause (hypoglycemia, hyponatremia, infection, toxin, structural lesion). Post-ictal confusion is expected; a prolonged or atypical recovery warrants EEG.
Traps
Questions test that you never delay benzodiazepines to obtain imaging, that you check glucose before or alongside the first drug, and that propofol infusion syndrome (acidosis, rhabdomyolysis, arrhythmia) limits prolonged propofol use.
Rule of thumb
Time equals neurons: at 5 minutes treat as status; give a weight-based benzodiazepine after glucose check, then escalate.