1 00:00:01,814 --> 00:00:04,154 T.R. Eckler: I don't think I realized how much of a black cloud you were, 2 00:00:04,304 --> 00:00:07,574 but now the more you tell stories, the more I'm like, man, you have 3 00:00:07,574 --> 00:00:10,694 really had quite a black cloud run. 4 00:00:12,534 --> 00:00:15,624 Sam (2): Hi everyone, and welcome back to another episode of Amplify. 5 00:00:15,624 --> 00:00:19,284 I am one of your hosts, Sam Ashoo, and I wanna thank you for being a 6 00:00:19,284 --> 00:00:23,094 listener and encourage you to rate us in whatever podcast app you're 7 00:00:23,094 --> 00:00:26,394 listening in so that we can get the word out there to more listeners. 8 00:00:26,724 --> 00:00:29,904 And I also wanna share with you that this month, EB Medicine is 9 00:00:29,904 --> 00:00:35,724 running a special $1 for a seven day subscription to any or even all three 10 00:00:35,934 --> 00:00:38,004 of the journals on eb medicine.net. 11 00:00:38,274 --> 00:00:39,504 That's a great deal. 12 00:00:39,684 --> 00:00:42,414 If you're not already a subscriber, go there and take advantage of 13 00:00:42,414 --> 00:00:43,644 this special and check us out. 14 00:00:43,914 --> 00:00:48,324 You will not believe how many courses and how many issues and how many 15 00:00:48,324 --> 00:00:50,394 hours of CME you will have access to. 16 00:00:50,574 --> 00:00:54,594 It's an absolutely wonderful time saving and critical to 17 00:00:54,594 --> 00:00:56,484 your practice subscription. 18 00:00:56,799 --> 00:00:59,484 Do yourself a favor and take advantage of that special today. 19 00:00:59,754 --> 00:01:01,794 And now let's jump into this month's episode. 20 00:01:04,124 --> 00:01:07,884 Sam: Ladies and gentlemen, welcome back to another episode of EMPlify. 21 00:01:07,904 --> 00:01:11,804 I am one of your hosts, Sam Ashoo, and on the other side of the microphone. 22 00:01:12,393 --> 00:01:15,483 T.R. Eckler: Dr. TR Eckler back again, excited to make 23 00:01:15,573 --> 00:01:17,313 kids do a little less wiggling. 24 00:01:18,013 --> 00:01:20,593 Sam: Yes, I'm sure all of our pediatric emergency medicine 25 00:01:20,593 --> 00:01:22,363 colleagues appreciate that notion. 26 00:01:22,363 --> 00:01:27,343 No one wants to have to stand at the bedside and watch a child continuously 27 00:01:27,343 --> 00:01:30,493 seize, and that actually happens to be what we're talking about today. 28 00:01:30,493 --> 00:01:36,793 This is the July, 2025 issue of pediatric emergency medicine practice on the 29 00:01:36,793 --> 00:01:42,038 emergency department management of status epilepticus in pediatric patients, 30 00:01:42,428 --> 00:01:45,998 which is a frightening scenario for me. 31 00:01:45,998 --> 00:01:49,328 Something I don't enjoy watching or treating. 32 00:01:49,608 --> 00:01:53,208 But still a very, very important disease process. 33 00:01:53,208 --> 00:01:57,438 And if you happen to be the clinician standing at the bedside wondering 34 00:01:57,438 --> 00:02:01,098 what the next drug to push is, I highly recommend reading this article. 35 00:02:01,368 --> 00:02:06,198 The two authors, Dr. Bowen and Dr. Bolton did a really good job of summarizing all 36 00:02:06,198 --> 00:02:08,568 of the evidence and the guidelines for us. 37 00:02:08,968 --> 00:02:11,758 Especially the guidelines from the International League Against 38 00:02:11,758 --> 00:02:15,018 Epilepsy which I just love. 39 00:02:15,198 --> 00:02:18,798 I want a t-shirt with International League against Epilepsy on it. 40 00:02:18,958 --> 00:02:21,328 If you're listening to this podcast and you're a member of 41 00:02:21,328 --> 00:02:24,148 the International League Against Epilepsy, send me a t-shirt. 42 00:02:24,208 --> 00:02:24,628 I'll wear it. 43 00:02:25,328 --> 00:02:25,718 T.R. Eckler: Same. 44 00:02:25,808 --> 00:02:26,738 I would wear that t-shirt. 45 00:02:27,038 --> 00:02:28,028 That'd be, that'd be rad. 46 00:02:28,189 --> 00:02:28,489 Sam: cool. 47 00:02:28,699 --> 00:02:30,079 It reminds me of the Justice League. 48 00:02:30,139 --> 00:02:31,309 We are the epilepsy league. 49 00:02:32,009 --> 00:02:33,119 We will stop seizures. 50 00:02:33,119 --> 00:02:35,369 And I think that's the point of this issue really. 51 00:02:35,639 --> 00:02:38,519 If you're wondering why status epilepticus in children. 52 00:02:38,519 --> 00:02:39,569 Is it really a big deal? 53 00:02:39,569 --> 00:02:41,669 The answer is yes, it is a big deal. 54 00:02:41,669 --> 00:02:47,829 Seizures are like 1% of ED visits here in the us and 3% of pre-hospital transport. 55 00:02:47,829 --> 00:02:50,619 So if you're listening to this and you're in pre-hospital medicine, 56 00:02:50,799 --> 00:02:53,789 it is a very important topic and we'll have some more information on 57 00:02:53,789 --> 00:02:55,529 that for you in just a few minutes. 58 00:02:55,839 --> 00:03:00,265 But it is common, or at least it's not rare if you're in 59 00:03:00,265 --> 00:03:01,285 the emergency department. 60 00:03:01,495 --> 00:03:07,205 And , the crux of the historical aspect of it is, I remember the days, again, 61 00:03:07,205 --> 00:03:11,820 I'm just dating myself, but I remember when the status Epilepticus definition 62 00:03:11,820 --> 00:03:15,150 was 30 minutes of continual seizing. 63 00:03:15,510 --> 00:03:19,230 And I will tell you in clinical practice before the guidelines 64 00:03:19,230 --> 00:03:23,070 changed, I never waited 30 minutes to call it status epilepticus. 65 00:03:23,070 --> 00:03:25,590 Even then, I thought that was a ridiculous definition. 66 00:03:25,840 --> 00:03:29,470 But I'm happy to see that the International League against 67 00:03:29,470 --> 00:03:34,755 Epilepsy, check my t-shirt, did change that definition in 2015. 68 00:03:34,965 --> 00:03:40,215 And for convulsive status epilepticus, it's now five minutes, which seems 69 00:03:40,275 --> 00:03:42,975 a much more reasonable timeframe. 70 00:03:43,755 --> 00:03:47,175 Something I'm far more comfortable with and something that's really 71 00:03:47,175 --> 00:03:50,755 far more in step with clinical practice, I think for most of us. 72 00:03:51,025 --> 00:03:54,685 We don't like to just stand by and watch somebody seize for 20 to 30 minutes. 73 00:03:55,435 --> 00:03:58,499 T.R. Eckler: I really liked their, attempt to break that down too, where 74 00:03:58,499 --> 00:04:03,029 they basically, instead of it being like, after this time period, you must do 75 00:04:03,029 --> 00:04:06,749 something or This is the danger zone, and I thought it was great how they started 76 00:04:06,749 --> 00:04:12,389 to tease out more of the kind of nuance here by having a T one and a T two for 77 00:04:12,389 --> 00:04:16,079 each classification of seizures, meaning like after this amount of time with this 78 00:04:16,079 --> 00:04:19,259 kind of seizures, you know, you should treat, and after this amount of time 79 00:04:19,259 --> 00:04:22,799 with this amount of seizures, your T two, then it starts to have a risk of damage. 80 00:04:23,069 --> 00:04:25,594 I felt like that was a helpful idea. 81 00:04:25,594 --> 00:04:28,354 And I think that was maybe one of the only things I wanted to enhance with the 82 00:04:28,354 --> 00:04:31,954 article was having more of a sense of what those T one and T two times are. 83 00:04:32,224 --> 00:04:35,644 But I think that those even tend to vary based on age and the 84 00:04:35,644 --> 00:04:36,754 condition that you're dealing with. 85 00:04:36,934 --> 00:04:40,084 But it still gave me a clearer idea of like, I want to treat sooner 86 00:04:40,084 --> 00:04:41,884 so I don't get to that T two time. 87 00:04:42,584 --> 00:04:45,224 Sam: Yeah, and you know, if you're listing and wondering what we're talking about, in 88 00:04:45,224 --> 00:04:49,094 the article, there is the definition from the International League against Epilepsy 89 00:04:49,094 --> 00:04:53,274 about, the time at which point it becomes status and the time at which you're 90 00:04:53,274 --> 00:04:55,344 starting to have neurological damage. 91 00:04:55,624 --> 00:04:57,879 And it varies by the type of seizure. 92 00:04:57,879 --> 00:05:01,839 So you know, you might have noticed that I called it convulsive status epilepticus. 93 00:05:01,839 --> 00:05:06,039 And that's because there are non convulsive focal motor and myoclonic 94 00:05:06,039 --> 00:05:09,009 seizure types as well, all of which come with different timeframes. 95 00:05:09,009 --> 00:05:11,889 But if you're obviously seeing seizure activity and it's 96 00:05:11,889 --> 00:05:16,149 convulsive, then five minutes is the number you gotta remember there. 97 00:05:16,419 --> 00:05:19,708 And like I said, I just think that's a much better definition than what 98 00:05:19,708 --> 00:05:23,478 we used to have, and I'm happy to see that we're moving in that direction. 99 00:05:24,178 --> 00:05:28,668 The authors as usual did a great job with the literature search and looked at a 100 00:05:28,668 --> 00:05:32,088 number of guidelines, and I thought it was important to point out that, you know, 101 00:05:32,088 --> 00:05:36,468 this particular issue is on pediatric status epilepticus, and much of the 102 00:05:36,468 --> 00:05:41,808 literature comes from national guidelines and studies performed outside of the ED. 103 00:05:41,838 --> 00:05:45,668 So, it's helpful to have the summary and I like that they focused it 104 00:05:45,668 --> 00:05:47,678 on the initial management for us. 105 00:05:47,678 --> 00:05:48,488 That was very good. 106 00:05:49,188 --> 00:05:52,458 And as always, before we dive into anything, I like 107 00:05:52,458 --> 00:05:53,448 to pimp you with questions. 108 00:05:53,448 --> 00:05:56,458 So let's just jump into one for the sake of talking. 109 00:05:56,758 --> 00:05:57,418 That's how we go. 110 00:05:57,568 --> 00:06:02,793 So, which of the following is among the leading causes of pediatric status 111 00:06:02,793 --> 00:06:05,393 epilepticus, according to the article. 112 00:06:05,483 --> 00:06:11,676 Asthma, structural CNS abnormalities, diabetes, and hyperlipidemia. 113 00:06:12,376 --> 00:06:15,136 T.R. Eckler: Oh B, structural neurologic abnormalities 114 00:06:15,562 --> 00:06:16,042 Sam: of course. 115 00:06:16,102 --> 00:06:16,372 Right. 116 00:06:16,441 --> 00:06:20,791 T.R. Eckler: Have you had an MRI yet is my favorite question for kids that 117 00:06:20,791 --> 00:06:25,021 come in with seizures, has someone put your child inside the magical magnet? 118 00:06:25,021 --> 00:06:27,581 The tunnel of truth, as I call it, to show us if there's 119 00:06:27,581 --> 00:06:28,781 something structural there or not. 120 00:06:29,481 --> 00:06:32,571 Sam: Yeah, and that's a really good question because the leading causes 121 00:06:32,571 --> 00:06:36,441 for status epilepticus are the ones you would think of most commonly 122 00:06:36,441 --> 00:06:41,111 fever and infections, some kind of central nervous system abnormality, 123 00:06:41,341 --> 00:06:46,486 accidental ingestions, and then the genetic and metabolic disorders. 124 00:06:46,486 --> 00:06:50,356 Those are kind of like the top four categories for causes of 125 00:06:50,356 --> 00:06:54,416 pediatric status, epilepticus, and again, it can be multifactorial. 126 00:06:54,566 --> 00:06:57,956 And what we're gonna talk about today is trying to differentiate these causes and 127 00:06:57,956 --> 00:06:59,966 how your initial therapy might change. 128 00:07:00,186 --> 00:07:03,186 But the finger member is those four categories because you've gotta 129 00:07:03,186 --> 00:07:06,126 run through 'em super fast in your head if you've got somebody who's 130 00:07:06,126 --> 00:07:07,656 actively seizing in front of you. 131 00:07:08,056 --> 00:07:10,716 T.R. Eckler: I really liked just the quick summary they had in 132 00:07:10,716 --> 00:07:16,026 this, that 10% of seizure patients are gonna come in in status. 133 00:07:16,611 --> 00:07:19,821 And I think that that kind of helped me like feel better about 134 00:07:19,821 --> 00:07:22,851 the sense that like nine outta 10 of these patients are gonna be okay. 135 00:07:22,851 --> 00:07:24,201 They'll have a seizure, but they're gonna stop. 136 00:07:24,351 --> 00:07:29,481 But I need to be on my guard for that one out 10 that isn't gonna stop and be ready. 137 00:07:29,691 --> 00:07:32,961 So, you know, not that I'm necessarily medicating every one of these patients 138 00:07:32,961 --> 00:07:35,511 when they come in, but I'm ready for the ones that aren't stopping or 139 00:07:35,511 --> 00:07:38,601 the ones that start up again, that I have a plan of where I'm gonna go. 140 00:07:38,721 --> 00:07:43,001 And then I really liked how they gave you that sense that, yeah, 33% 141 00:07:43,001 --> 00:07:47,441 of these, it's due to subtherapeutic levels of their medicines, but 6% are 142 00:07:47,441 --> 00:07:51,851 gonna be their electrolytes or their glucose, and 3.6% is toxic ingestions. 143 00:07:52,001 --> 00:07:53,201 So that same kind of thing. 144 00:07:53,381 --> 00:07:56,501 I'm ready for the common things, but I have those zebras in the 145 00:07:56,501 --> 00:07:59,891 back of my head of, alright, do I need to give, you know, glucose? 146 00:07:59,951 --> 00:08:01,121 Do I need to fix an electrolyte? 147 00:08:01,331 --> 00:08:03,371 Do I need to worry about some toxic congestion? 148 00:08:03,521 --> 00:08:07,511 Do I need to start broadening my sense of what I'm gonna do to fix this patient? 149 00:08:07,661 --> 00:08:08,606 Because what I'm doing isn't working? 150 00:08:09,306 --> 00:08:09,576 Sam: Yeah. 151 00:08:10,056 --> 00:08:10,356 Yeah. 152 00:08:10,706 --> 00:08:13,556 I did, I mean, I'm a numbers guy, so I enjoy the numbers. 153 00:08:13,556 --> 00:08:17,906 And I did also find it interesting that 70% of children who are diagnosed 154 00:08:17,906 --> 00:08:21,936 with epilepsy before the age of one will experience status epilepticus. 155 00:08:21,936 --> 00:08:23,245 That's a l ot. 156 00:08:23,268 --> 00:08:26,618 And if they didn't experience it on diagnosis, then it's 157 00:08:26,618 --> 00:08:28,238 going to happen at some point. 158 00:08:28,598 --> 00:08:31,088 And that's an important thing to share with parents. 159 00:08:31,088 --> 00:08:35,508 And it also will tell you that those parents are probably well educated 160 00:08:35,508 --> 00:08:39,288 and may have already given a therapy or two before the person even 161 00:08:39,288 --> 00:08:40,788 gets to the emergency department. 162 00:08:40,788 --> 00:08:43,088 So history, history and more history. 163 00:08:43,088 --> 00:08:45,878 And in this scenario, luckily there's a parent who hopefully knows quite 164 00:08:45,878 --> 00:08:49,478 a bit about this patient right in front of you if it's someone with 165 00:08:49,478 --> 00:08:51,098 a diagnosis of epilepsy already. 166 00:08:51,458 --> 00:08:54,228 Table one is an interesting table from the International League 167 00:08:54,228 --> 00:08:58,028 against Epilepsy classification of convulsive status epilepticus to kind 168 00:08:58,028 --> 00:09:02,088 of break down the different types, and if you have the time to try and 169 00:09:02,088 --> 00:09:03,498 differentiate these, this is great. 170 00:09:03,498 --> 00:09:05,988 Sometimes it can help with the conversation with the neurologist 171 00:09:05,988 --> 00:09:07,458 or if the parent already knows. 172 00:09:07,708 --> 00:09:11,843 It can make a difference if it's impending convulsive status epilepticus 173 00:09:11,843 --> 00:09:15,443 versus established versus refractory, and at what point you're gonna use 174 00:09:15,443 --> 00:09:18,953 what term, but just know that five minutes is your timeframe there. 175 00:09:19,133 --> 00:09:22,763 If it lasts five minutes or more, you're into that status. 176 00:09:23,443 --> 00:09:26,623 And once you get into that area, then you're starting to break 177 00:09:26,623 --> 00:09:29,503 down things like the differential diagnosis and what it is we're 178 00:09:29,503 --> 00:09:31,033 supposed to be doing for the patient. 179 00:09:31,333 --> 00:09:36,643 And table two does a great job of breaking it down by age because 180 00:09:36,643 --> 00:09:41,473 the causes can vary depending on the size and age of the patient. 181 00:09:41,813 --> 00:09:45,473 If they're anywhere from birth to six years old, you're thinking things 182 00:09:45,473 --> 00:09:49,933 like febrile seizures, chromosomal and genetic abnormalities, inborn 183 00:09:49,933 --> 00:09:54,823 errors of metabolism, breath holding spells, and non-accidental head trauma. 184 00:09:54,823 --> 00:09:55,813 The big key there. 185 00:09:55,903 --> 00:09:56,653 Don't miss that. 186 00:09:56,993 --> 00:10:00,743 If they're school age, then autoimmune disorders become the most common. 187 00:10:00,893 --> 00:10:04,913 If they're adolescents, now you're thinking things like eclampsia. 188 00:10:05,153 --> 00:10:07,103 You can't forget about the possibility of pregnancy. 189 00:10:07,443 --> 00:10:11,618 Hypertensive crisis, autoimmune disorders, and functional neurologic disorder. 190 00:10:11,978 --> 00:10:16,628 And then for all ages, you also have to keep in mind things like cerebral 191 00:10:16,628 --> 00:10:22,008 vascular accidents, infections, tumors, cortical dysplasia, head trauma, 192 00:10:22,338 --> 00:10:26,298 medication exposures or overdoses, metabolic disturbances, et cetera. 193 00:10:26,298 --> 00:10:29,238 So lots and lots of things to keep in mind in the differential. 194 00:10:29,238 --> 00:10:32,628 Table two does a really good job of breaking it down by age. 195 00:10:33,102 --> 00:10:36,012 T.R. Eckler: And it's really the common things that were there at the finish. 196 00:10:36,162 --> 00:10:39,372 I found that table confusing because I felt like they led with the rare 197 00:10:39,372 --> 00:10:43,002 things, but then once you get to the bottom, it's really the cerebrovascular 198 00:10:43,002 --> 00:10:48,192 diseases, the CNS infections, the tumors, head trauma, intoxication, overdose. 199 00:10:48,282 --> 00:10:50,472 Those are really the things that are causing most of these. 200 00:10:50,652 --> 00:10:53,862 But I felt like it was great to have that even broader sense that 201 00:10:53,982 --> 00:10:57,222 occasionally you're gonna get some of these unusual kids with autoimmune 202 00:10:57,222 --> 00:11:01,872 disorders or you know, some other unusual inborn error metabolism. 203 00:11:01,962 --> 00:11:06,612 And it's great to look for help early from your specialists when you realize that 204 00:11:06,792 --> 00:11:08,052 you're getting into something like that. 205 00:11:08,752 --> 00:11:09,082 Sam: Yeah. 206 00:11:09,172 --> 00:11:09,352 Yeah. 207 00:11:09,352 --> 00:11:09,862 Great point. 208 00:11:10,562 --> 00:11:10,832 Alright. 209 00:11:10,832 --> 00:11:15,632 When it comes to pre-hospital treatments, there are some significant things that 210 00:11:15,632 --> 00:11:19,842 our pre-hospital personnel can do which leads me to our next question, which 211 00:11:20,232 --> 00:11:25,842 pre-hospital intervention improves seizure control before ED arrival? 212 00:11:26,542 --> 00:11:28,612 Number one, rectal acetaminophen. 213 00:11:29,312 --> 00:11:31,652 Number two, oral lorazepam. 214 00:11:32,352 --> 00:11:37,482 Number three, intramuscular midazolam, or number four hypertonic saline. 215 00:11:37,832 --> 00:11:41,222 T.R. Eckler: I am gonna go with number three, intramuscular Midazolam, 216 00:11:41,222 --> 00:11:45,902 because I just love that medicine because I know intramuscular 217 00:11:45,902 --> 00:11:47,132 is gonna stay in the patient. 218 00:11:47,342 --> 00:11:51,742 I know that the other stuff is gonna help, but not necessarily like. 219 00:11:51,826 --> 00:11:54,976 really like give that improvement in control. 220 00:11:55,276 --> 00:11:59,296 And I found that the, the RAMPART study they referred to here, which talked 221 00:11:59,296 --> 00:12:04,456 about how if they got IM Midazolam or IV lorazepam in adults and children, they 222 00:12:04,456 --> 00:12:08,506 were more likely to not need to go to the ICU, more likely to have their seizures 223 00:12:08,656 --> 00:12:10,516 terminated prior to the arrival of the ER. 224 00:12:10,726 --> 00:12:14,151 And I felt like that boosted my own practice, like what I 225 00:12:14,151 --> 00:12:15,501 recommend for EMS in the field. 226 00:12:15,651 --> 00:12:21,021 And I like how Midazolam wears off so I can kind of have a sense of what I'm doing 227 00:12:21,021 --> 00:12:25,101 next, or I can plan for it as opposed to the longer term of Lorazepam if you're 228 00:12:25,101 --> 00:12:26,871 getting it in pre-hospital settings. 229 00:12:27,021 --> 00:12:30,741 So I feel like I get more chances to adjust once I know more about the patient. 230 00:12:30,891 --> 00:12:33,441 If they're in the ER, then I'm more interested in giving them a longer 231 00:12:33,441 --> 00:12:34,641 acting medicine if I have that chance. 232 00:12:35,341 --> 00:12:35,521 Sam: Yeah. 233 00:12:35,851 --> 00:12:37,231 Yeah, and that's a perfect answer. 234 00:12:37,231 --> 00:12:42,501 So the, the pre-hospital treatment is all about targeting seizure control, 235 00:12:42,501 --> 00:12:47,451 and there is good evidence from that rapid anti-convulsant medication prior 236 00:12:47,451 --> 00:12:52,041 to arrival trial, or RAMPART, that involvement of pre-hospital personnel in 237 00:12:52,041 --> 00:12:56,361 treating seizures is critically important and does actually improve outcomes. 238 00:12:56,661 --> 00:13:01,381 So definitely IM midazolam and it's really great actually that our EMS 239 00:13:01,471 --> 00:13:03,811 personnel now have multiple options. 240 00:13:03,811 --> 00:13:08,491 It used to be you struggle to get the IV in someone who's actively seizing, and 241 00:13:08,491 --> 00:13:10,291 maybe you get it and maybe you don't. 242 00:13:10,291 --> 00:13:12,481 And then your only other option was an IO. 243 00:13:12,481 --> 00:13:17,311 But now we have intranasal, we have IM, and we have rectal forms. 244 00:13:17,341 --> 00:13:21,816 Again, if the person has a diagnosis of epilepsy and the parent has rectal 245 00:13:21,816 --> 00:13:24,546 diazepam, it's okay to give it, you know, just because you're the 246 00:13:24,546 --> 00:13:27,396 pre-hospital personnel doesn't mean you can't give them their home diazepam. 247 00:13:27,816 --> 00:13:31,626 So you've got lots of options and lots of delivery mechanisms to 248 00:13:31,626 --> 00:13:34,686 try and get that benzodiazepine on board as fast as you can. 249 00:13:34,896 --> 00:13:36,906 Use whatever you have at your disposal. 250 00:13:37,606 --> 00:13:40,816 T.R. Eckler: And having, said that, I think the, key that I, having read 251 00:13:40,816 --> 00:13:43,996 this article that I took away was to remember how flexible you need 252 00:13:43,996 --> 00:13:48,046 to be, because EMS isn't gonna have all the medicines that you want. 253 00:13:48,356 --> 00:13:50,576 There's so many often drug shortages. 254 00:13:50,696 --> 00:13:53,096 So things that you're used to using are not gonna be there. 255 00:13:53,246 --> 00:13:57,206 So being ready to adjust your practice and, you know, adjust to what's available. 256 00:13:57,536 --> 00:14:00,356 And as you said, the medicines now that the patients are having 257 00:14:00,356 --> 00:14:02,196 at home are becoming more common. 258 00:14:02,396 --> 00:14:06,666 An intranasal Valium or intranasal diazepam is now much 259 00:14:06,666 --> 00:14:09,066 more of a common thing that's going home with these patients. 260 00:14:09,066 --> 00:14:13,296 So you can ask EMS in the field, Hey, do they have their intranasal Valium? 261 00:14:13,296 --> 00:14:14,046 Have they given it? 262 00:14:14,331 --> 00:14:14,661 Okay. 263 00:14:14,661 --> 00:14:17,361 Then if you want, you can give that if you don't have another option, if you 264 00:14:17,361 --> 00:14:18,861 don't have midazolam or something else. 265 00:14:19,041 --> 00:14:21,591 But really just figuring out quickly what your options are, and then 266 00:14:21,591 --> 00:14:24,681 making the best decision you can or helping your EMS crews make the 267 00:14:24,681 --> 00:14:25,941 best decision from what they have. 268 00:14:26,641 --> 00:14:26,821 Sam: Yeah. 269 00:14:27,571 --> 00:14:32,011 And then once that's been done, then you turn to your routine ABCs. 270 00:14:32,011 --> 00:14:36,271 So making sure their airway is controlled or patent, making sure they have 271 00:14:36,271 --> 00:14:39,931 adequate ventilation, especially if you've just given them a benzodiazepine. 272 00:14:39,931 --> 00:14:42,961 And whether or not that seizure has terminated, they're gonna need some 273 00:14:42,961 --> 00:14:47,861 supplemental oxygen and perhaps some bag valve mask assistance until 274 00:14:47,861 --> 00:14:50,981 you get to the hospital, especially if the benzos are causing a little 275 00:14:50,981 --> 00:14:52,331 bit of respiratory depression. 276 00:14:52,751 --> 00:14:53,561 Circulation. 277 00:14:53,561 --> 00:14:57,831 Certainly if they are getting hypotensive or having instability, then they need 278 00:14:57,831 --> 00:15:00,111 that IV access and the IV fluid boluses. 279 00:15:00,401 --> 00:15:03,261 And lastly glucose levels. 280 00:15:03,261 --> 00:15:07,131 So point of care glucose, gotta check that sugar to make sure, especially 281 00:15:07,131 --> 00:15:10,221 the younger they are, the more likely they are to be just hypoglycemic. 282 00:15:10,521 --> 00:15:15,196 And so that's an important piece that you need to add to your investigation 283 00:15:15,346 --> 00:15:17,236 when you're in the pre-hospital arena. 284 00:15:17,426 --> 00:15:19,946 And hopefully by then you are at the hospital. 285 00:15:19,946 --> 00:15:24,636 'cause these can be very anxiety provoking cases and getting to the 286 00:15:24,636 --> 00:15:26,676 nearest emergency department is important. 287 00:15:26,676 --> 00:15:30,366 You know, hopefully it's a peds emergency department, but if not, that's still okay. 288 00:15:30,576 --> 00:15:34,216 The ABCs and initial resuscitation should be the same regardless 289 00:15:34,216 --> 00:15:35,506 of wherever you land. 290 00:15:36,206 --> 00:15:39,566 Once you're in the emergency department, our initial evaluation 291 00:15:39,566 --> 00:15:42,416 begins and leads to our next question. 292 00:15:42,416 --> 00:15:46,406 What is the most important first step in the ED management of 293 00:15:46,406 --> 00:15:48,566 pediatric status epilepticus? 294 00:15:48,596 --> 00:15:49,046 Here we go. 295 00:15:49,106 --> 00:15:50,756 A, obtain a head, CT. 296 00:15:51,206 --> 00:15:54,026 B, secure airway breathing, and circulation. 297 00:15:54,386 --> 00:15:57,866 C. Start valproic acid or D order. 298 00:15:57,866 --> 00:15:58,616 An EEG 299 00:15:59,089 --> 00:16:02,149 T.R. Eckler: I would tell you that I think the answer to that question is A, 300 00:16:02,149 --> 00:16:08,659 B, C, and a second C. 'cause I liked how they added consciousness to their ABCs. 301 00:16:08,869 --> 00:16:13,789 'cause I do think sometimes a kid looks okay but is not actually conscious. 302 00:16:14,099 --> 00:16:16,259 Like, you could look at a kid quickly and be like, all right, they're 303 00:16:16,259 --> 00:16:17,819 not having status epilepticus. 304 00:16:17,819 --> 00:16:18,779 It's not convulsive. 305 00:16:18,959 --> 00:16:22,199 But if that kid's not there, they might be a non convulsive status. 306 00:16:22,229 --> 00:16:24,600 And I liked how they put that little nuance to it. 307 00:16:25,300 --> 00:16:25,690 Sam: Yeah. 308 00:16:25,960 --> 00:16:26,230 Yes. 309 00:16:26,230 --> 00:16:27,670 Well, first of all, you are correct. 310 00:16:27,670 --> 00:16:29,020 So it is the ABCs. 311 00:16:29,300 --> 00:16:33,660 And second, you know, I recall we talked about seizures when we talked about 312 00:16:33,660 --> 00:16:38,345 geriatric emergencies some time ago on a different podcast, and we talked 313 00:16:38,345 --> 00:16:41,975 about alterations in mental status in the geriatric population, maybe being 314 00:16:41,975 --> 00:16:43,775 something like non convulsive status. 315 00:16:43,775 --> 00:16:49,455 And so similarly in children, as you said, if they're not actively convulsing, 316 00:16:49,455 --> 00:16:52,695 but they haven't returned to their normal baseline, it's something you need 317 00:16:52,695 --> 00:16:56,115 to keep in mind in your differential and it can be very challenging to 318 00:16:56,115 --> 00:17:00,585 try and make that diagnosis and figure out, okay, what is it exactly 319 00:17:00,645 --> 00:17:02,925 that is now causing this alteration? 320 00:17:03,105 --> 00:17:06,015 Especially if they had a dose of benzodiazepines already. 321 00:17:06,715 --> 00:17:08,635 So it can certainly be a challenge. 322 00:17:08,855 --> 00:17:13,545 But yes, you are correct airway is a lways the first priority, especially if 323 00:17:13,545 --> 00:17:15,015 they've already had some benzodiazepine. 324 00:17:15,015 --> 00:17:17,925 So positioning suctioning, oxygen administration for the 325 00:17:17,925 --> 00:17:21,375 hypoxia because you're trying to reduce the neuronal injury. 326 00:17:21,735 --> 00:17:23,655 Second is making sure they're not apnic. 327 00:17:23,995 --> 00:17:28,165 Third is checking, breathing and circulation and hooking up the monitor. 328 00:17:28,165 --> 00:17:33,295 And if you have end tidal CO2, this is an ideal time to use it because not 329 00:17:33,295 --> 00:17:37,195 only are you interested in preventing hypoxia, but you also want to know if 330 00:17:37,195 --> 00:17:40,465 they've got hypoventilation and they need some assistance with ventilation. 331 00:17:40,765 --> 00:17:44,825 Bag valve mask ventilation is okay to use even briefly after 332 00:17:44,825 --> 00:17:46,715 administration of benzodiazepines. 333 00:17:46,865 --> 00:17:49,565 So they may need that for a few minutes until they start to 334 00:17:49,835 --> 00:17:51,965 adequately ventilate on their own. 335 00:17:52,195 --> 00:17:55,855 And then that'll start hopefully, your brain going down the pathway of, you 336 00:17:55,855 --> 00:17:59,485 know, at one point, do I need to decide about intubating this patient now? 337 00:17:59,605 --> 00:18:02,515 But if you're doing well with bag valve mask ventilation, that's okay. 338 00:18:02,515 --> 00:18:03,145 You got time. 339 00:18:03,495 --> 00:18:06,015 Establishing IV access or IO access. 340 00:18:06,015 --> 00:18:09,525 So if the pre-hospital personnel were unable to do so, then 341 00:18:09,565 --> 00:18:10,825 this is a good time to do it. 342 00:18:11,105 --> 00:18:12,935 And then gathering history, right? 343 00:18:12,935 --> 00:18:18,575 Talking to mom or dad about previous history, medication exposures, recent 344 00:18:18,575 --> 00:18:23,380 illnesses and if they're in the neonatal period or infant period, formula 345 00:18:23,380 --> 00:18:28,570 mixing is a big deal because you're trying to also exclude hypoglycemia and 346 00:18:28,600 --> 00:18:32,500 hyponatremia your differential diagnosis. 347 00:18:32,600 --> 00:18:33,830 And then lastly, trauma. 348 00:18:34,070 --> 00:18:35,630 Non-accidental trauma. 349 00:18:36,400 --> 00:18:40,150 I recall having a neonate come through the emergency department 350 00:18:40,150 --> 00:18:41,740 who had some abnormal movements. 351 00:18:41,740 --> 00:18:43,360 We weren't really sure if they were seizing. 352 00:18:43,890 --> 00:18:45,120 We gave some benzos. 353 00:18:45,180 --> 00:18:47,730 It didn't really change much, but it did cause respiratory depression. 354 00:18:47,730 --> 00:18:51,377 And at that point I was calling the ICU and we had gathered a 355 00:18:51,377 --> 00:18:54,377 bunch of labs and we weren't really sure if this was infectious. 356 00:18:54,377 --> 00:18:55,397 There was no fever. 357 00:18:55,457 --> 00:18:58,897 Ended up doing a lumbar puncture and as soon as I walked out of the room 358 00:18:59,027 --> 00:19:01,787 my ICU colleague was there and I said, gosh, you know, I'm really sorry. 359 00:19:01,787 --> 00:19:02,837 Like I got CSF. 360 00:19:02,897 --> 00:19:04,367 This was a really tiny neonate. 361 00:19:04,577 --> 00:19:08,627 I got CSF, but I think it was a traumatic tap because it was all just bloody. 362 00:19:09,017 --> 00:19:10,547 And he kinda looked at me and went, Hmm. 363 00:19:11,252 --> 00:19:12,782 Okay, well we're gonna send it anyway. 364 00:19:12,782 --> 00:19:14,582 And I said, oh yeah, we'll send it for fluid analysis. 365 00:19:14,582 --> 00:19:17,342 And we started the antibiotics and sure enough, the next day, now we'd already 366 00:19:17,342 --> 00:19:19,112 obtained a head CT, which was normal. 367 00:19:19,292 --> 00:19:22,712 And the next day the MRI showed, you know, bilateral subdural hemorrhages. 368 00:19:22,712 --> 00:19:25,772 And so it was not a traumatic lumbar puncture. 369 00:19:25,832 --> 00:19:29,522 It was trauma that was the cause of the blood in the CSF. 370 00:19:29,582 --> 00:19:32,512 And so, uh with a normal head CT 371 00:19:32,586 --> 00:19:33,726 T.R. Eckler: Oh, that's so. 372 00:19:33,872 --> 00:19:38,132 Sam: because there were like subacute, bilateral subdural hematomas. 373 00:19:38,832 --> 00:19:40,812 So trauma, trauma, trauma. 374 00:19:40,842 --> 00:19:43,392 Don't forget the non-accidental trauma in your differential. 375 00:19:44,112 --> 00:19:48,762 And then when we start, talking about initial management, so what are we 376 00:19:48,762 --> 00:19:50,732 gonna give first, first line therapy 377 00:19:50,732 --> 00:19:54,046 T.R. Eckler: Can I stop us for one second because I think this is a question I ask 378 00:19:54,046 --> 00:19:57,586 med students and residents all the time, and I thought they did a great job, is 379 00:19:57,706 --> 00:19:59,926 when do you intubate the seizure patient? 380 00:20:00,316 --> 00:20:03,410 Like what are your indications for rapid sequence intubation 381 00:20:03,410 --> 00:20:04,451 and mechanical ventilation. 382 00:20:04,451 --> 00:20:05,711 I like how they put that together. 383 00:20:05,711 --> 00:20:06,821 You gotta plan for both. 384 00:20:07,111 --> 00:20:08,771 It's inability to maintain their airway. 385 00:20:09,116 --> 00:20:12,416 Meaning they're not able to hold their airway open despite what 386 00:20:12,416 --> 00:20:13,466 other things you're gonna do. 387 00:20:13,826 --> 00:20:18,056 Hypoxemia, inadequate ventilation, apnea, and refractory status 388 00:20:18,056 --> 00:20:19,646 lasting longer than 30 minutes. 389 00:20:20,346 --> 00:20:23,166 So I think if you don't feel comfortable with any of those 390 00:20:23,166 --> 00:20:25,446 things, take that airway, it's time. 391 00:20:26,086 --> 00:20:30,166 I thought that was a nice line in the sand in a very gray world that we live in. 392 00:20:30,346 --> 00:20:34,606 I thought that was a nice, clear thing of you can feel comfortable if this 393 00:20:34,606 --> 00:20:37,396 is what you're looking at, then that's when you should take that airway. 394 00:20:38,096 --> 00:20:42,206 Sam: Yeah, they did actually mention under circulation as well that bradycardia can 395 00:20:42,206 --> 00:20:44,696 be the harbinger of impending badness. 396 00:20:44,776 --> 00:20:49,646 If it's not from hypoxia then it can be the potential clue that this person 397 00:20:49,646 --> 00:20:51,876 needs invasive ventilation as well. 398 00:20:51,966 --> 00:20:56,706 So lots of physical examination clues there, or if their seizure is persisting 399 00:20:56,896 --> 00:20:58,486 and you're not able to control it. 400 00:20:59,190 --> 00:21:02,620 Once we've passed through the ABCs the authors then had a little 401 00:21:02,980 --> 00:21:06,010 discussion here about diagnostic studies and what you should be 402 00:21:06,010 --> 00:21:07,300 ordering in the emergency department. 403 00:21:07,300 --> 00:21:09,120 And we you know, are pretty good about this. 404 00:21:09,120 --> 00:21:13,320 Really, most of these are protocoled or fit in line with the things 405 00:21:13,320 --> 00:21:15,570 that we're trying to eliminate from our differential diagnosis. 406 00:21:15,570 --> 00:21:19,420 So obviously we're going to get a point of care glucose if that wasn't already 407 00:21:19,420 --> 00:21:23,170 done by EMS, and then you're gonna get your comprehensive metabolic panels in 408 00:21:23,170 --> 00:21:28,895 order to exclude metabolic inborn errors, calcium, magnesium, and phosphorus. 409 00:21:28,895 --> 00:21:30,845 So your calcium may be part of your CMP. 410 00:21:30,845 --> 00:21:34,385 Your magnesium and phosphorus are usually not, so you gotta remember to order those. 411 00:21:34,565 --> 00:21:36,275 A lactic acid can be helpful. 412 00:21:36,275 --> 00:21:39,215 A serum pH, even if it's a venous pH, can be helpful. 413 00:21:39,815 --> 00:21:42,935 If they're already on seizure medications, you might be interested in getting levels 414 00:21:42,935 --> 00:21:44,495 for those to see if they're therapeutic. 415 00:21:44,805 --> 00:21:47,715 If you know that they've had a toxic ingestion, you may be able to send 416 00:21:47,715 --> 00:21:51,135 levels for those if that comes across in the history from the parent. 417 00:21:51,525 --> 00:21:54,345 If they're of age, you need a pregnancy test. 418 00:21:54,525 --> 00:21:58,095 Again, not to be the harbinger of terrible stories, but , I recall 419 00:21:58,095 --> 00:22:01,845 being in the emergency department and having a 15-year-old obese female 420 00:22:01,845 --> 00:22:04,135 come in with a seizure first time. 421 00:22:04,750 --> 00:22:05,920 No past medical history. 422 00:22:06,220 --> 00:22:10,720 EMS had given a dose of Lorazepam IV prior to arrival and the seizure 423 00:22:10,720 --> 00:22:16,340 stopped and she arrived appropriately postictal and sedated from the Lorazepam. 424 00:22:16,340 --> 00:22:19,250 And I was waiting for a parent to show up and a second seizure ensued. 425 00:22:19,310 --> 00:22:24,160 And so we gave another dose of Lorazepam and off went to CT because 426 00:22:24,180 --> 00:22:25,710 the rest of the vitals were normal. 427 00:22:25,890 --> 00:22:29,220 And while she was in CT, a parent showed up and confirmed, Hey, 428 00:22:29,220 --> 00:22:30,480 there's no history of this. 429 00:22:30,690 --> 00:22:35,220 And while she was in CT, she had a third seizure and got a third dose 430 00:22:35,220 --> 00:22:39,530 of Lorazepam, and then as soon as she came back from CT she gave birth. 431 00:22:40,184 --> 00:22:40,404 T.R. Eckler: Wow. 432 00:22:40,996 --> 00:22:44,266 Sam: no one knew that she was pregnant, she was obese. 433 00:22:44,366 --> 00:22:49,576 And unfortunately she gave birth to a fetal demise that was probably somewhere 434 00:22:49,576 --> 00:22:52,666 in the second trimester, so she hadn't even made it to the third trimester. 435 00:22:52,666 --> 00:22:56,750 And then now we were in the midst of trying to resuscitate what 436 00:22:56,750 --> 00:22:58,040 we thought were two patients. 437 00:22:58,230 --> 00:23:03,340 And so we've got the neonate born still, and then the 15-year-old who 438 00:23:03,580 --> 00:23:07,820 has received a bunch of Lorazepam who is now excessively sedated and 439 00:23:08,030 --> 00:23:12,145 still having seizures and now moving down a different differential and 440 00:23:12,145 --> 00:23:13,645 diagnosis and treatment modality. 441 00:23:13,645 --> 00:23:17,215 So don't forget to get the pregnancy test, and don't forget to consider 442 00:23:17,215 --> 00:23:19,855 that in anyone who is of the age 443 00:23:20,205 --> 00:23:22,385 T.R. Eckler: Also a patient like that is gonna be challenging 444 00:23:22,385 --> 00:23:23,497 To get a urine out of. 445 00:23:23,647 --> 00:23:27,097 But I like to remind people most of the rapid urine pregnancy 446 00:23:27,097 --> 00:23:31,087 cartridges that we use in the United States are dual certified for 447 00:23:31,177 --> 00:23:33,247 blood, like whole blood and urine. 448 00:23:33,427 --> 00:23:37,027 So you can drop whole blood onto those cartridges and then wait a few minutes. 449 00:23:37,027 --> 00:23:39,847 And just like a urine pregnancy test, it will show you if the 450 00:23:39,847 --> 00:23:40,872 patient is pregnant or not. 451 00:23:41,402 --> 00:23:42,512 Just from their whole blood. 452 00:23:42,572 --> 00:23:46,112 So if your lab tells you, oh, we can't run this, we have to run the quant, or 453 00:23:46,112 --> 00:23:49,472 it has to be a urine, you can basically just have them send you a cartridge and 454 00:23:49,472 --> 00:23:50,792 you can put blood on that cartridge. 455 00:23:50,792 --> 00:23:54,062 If the cartridge says it's okay, and you will know very, very quickly 456 00:23:54,152 --> 00:23:55,442 if your patient is pregnant or not. 457 00:23:55,532 --> 00:23:58,622 And you don't need to wait a couple hours for somebody to cath the patient for 458 00:23:58,622 --> 00:24:00,572 urine while they're altered and confused. 459 00:24:01,272 --> 00:24:01,542 Sam: Yeah. 460 00:24:01,962 --> 00:24:02,982 Yeah, great point. 461 00:24:02,982 --> 00:24:05,892 And sometimes, you know, it seems strange that we even have to say 462 00:24:05,892 --> 00:24:08,347 things like this, but sometimes it does take the physician to just say. 463 00:24:08,697 --> 00:24:12,657 Send me the cartridge, send me whatever it is that I have to put the drop on. 464 00:24:12,657 --> 00:24:16,047 I'll just do it myself because the lab technician is constrained by 465 00:24:16,047 --> 00:24:19,917 lab policies or rules or whatever it is from somebody who's nonclinical. 466 00:24:20,007 --> 00:24:22,347 Then you, you just have to say, okay, look, I'll do it and I'll 467 00:24:22,347 --> 00:24:25,107 take the heat for it, but I gotta save this person's life. 468 00:24:25,756 --> 00:24:26,671 T.R. Eckler: I gotta save this person. 469 00:24:26,671 --> 00:24:26,941 Yep. 470 00:24:27,127 --> 00:24:30,847 Sam: so diagnostic imaging, if you're suspecting some kind of intracranial 471 00:24:30,847 --> 00:24:33,817 lesion or they got a history of it, or if they come with a history of a 472 00:24:33,817 --> 00:24:38,387 VP shunt and you're worried about a VP shunt failure then yes, you have 473 00:24:38,387 --> 00:24:40,457 to obtain the CT imaging of the brain. 474 00:24:40,817 --> 00:24:46,127 And then there's other ancillary testing, ECG EEG, et cetera, that comes later 475 00:24:46,127 --> 00:24:47,687 down the line if you have the time. 476 00:24:48,127 --> 00:24:54,107 If they have a history of VP shunt or if they have a focal seizure or 477 00:24:54,107 --> 00:24:57,377 if you're worried about head trauma, you need to order the head CT. 478 00:24:57,377 --> 00:25:00,857 Now we are usually radiation sparing, especially in our 479 00:25:00,857 --> 00:25:03,087 children and pediatric populations. 480 00:25:03,117 --> 00:25:07,922 But in this scenario, this is not the time to be radiation sparing. 481 00:25:07,977 --> 00:25:12,967 If they have a history of anything intracranial or if you're suspecting 482 00:25:13,162 --> 00:25:17,422 even mildly suspecting something traumatic, you need to get that head CT. 483 00:25:17,652 --> 00:25:21,612 You know, reducing radiation exposure is not the appropriate step in this scenario. 484 00:25:22,275 --> 00:25:25,275 T.R. Eckler: I think the key to that is we're not talking about all seizure 485 00:25:25,275 --> 00:25:26,715 patients that come into the ER. 486 00:25:26,925 --> 00:25:28,815 We're not talking about your febrile seizure children. 487 00:25:28,935 --> 00:25:31,815 We're talking about patients in status that are not returning to 488 00:25:31,815 --> 00:25:35,025 their baseline, that you're having trouble controlling their seizures. 489 00:25:35,235 --> 00:25:37,725 You want to get the CT in that patient because it's 490 00:25:37,725 --> 00:25:39,135 often gonna change management. 491 00:25:39,225 --> 00:25:41,745 I remember I had a well-known seizure patient that came in 492 00:25:41,745 --> 00:25:44,745 in rural Colorado, and I just couldn't get his seizures to stop. 493 00:25:45,015 --> 00:25:48,795 And I finally, after like three different medications, got his seizures under 494 00:25:48,795 --> 00:25:52,575 control and got him intubated and got him to CT and he had a huge brain bleed. 495 00:25:53,225 --> 00:25:54,905 and that was just something that stuck with me. 496 00:25:54,905 --> 00:25:59,030 That if you can't control the seizures, take pictures, do more things because 497 00:25:59,030 --> 00:26:01,955 there's something there that, that you just need to get there and you'll find it. 498 00:26:02,655 --> 00:26:02,865 Sam: Yeah. 499 00:26:03,565 --> 00:26:06,265 And really that brings us to first line treatment. 500 00:26:06,325 --> 00:26:08,485 So again, we're in the emergency department. 501 00:26:08,705 --> 00:26:12,245 We're going to give something regardless of what EMS has given so far. 502 00:26:12,465 --> 00:26:13,545 Which leads me to the next question. 503 00:26:14,135 --> 00:26:15,715 Which benzodiazepine is preferred? 504 00:26:15,735 --> 00:26:22,825 If IV access is available, is it diazepam, midazolam, or clonazepam? 505 00:26:23,525 --> 00:26:26,470 T.R. Eckler: So I will tell you that I know the right answer 506 00:26:26,470 --> 00:26:28,120 to this question is Lorazepam. 507 00:26:28,795 --> 00:26:32,665 And I will tell you that I firmly disagree with the authors and I would like someone 508 00:26:32,665 --> 00:26:37,465 to check my record because I have a long track record of being appreciative 509 00:26:37,465 --> 00:26:38,515 and supportive of the authors. 510 00:26:38,755 --> 00:26:43,705 But I find in clinical practice it is so much easier to dose stack Lorazepam 511 00:26:43,945 --> 00:26:47,005 where you give some, nothing happens, and then you give more and then they get 512 00:26:47,005 --> 00:26:48,235 respiratory depression and get intubated. 513 00:26:48,685 --> 00:26:52,945 I think that in my practice I have seen better results from Diazepam, 514 00:26:53,275 --> 00:26:57,790 but I do like how they focused clearly on a weight-based dosing where 515 00:26:57,790 --> 00:26:59,950 Lorazepam should be 0.1 mg per kilos. 516 00:27:00,535 --> 00:27:05,425 But then diazepam can be 0.1 to 0.3, and I think that Lorazepam is 517 00:27:05,425 --> 00:27:07,375 a significantly stronger medication. 518 00:27:07,555 --> 00:27:13,135 So I would be more inclined to go 0.1 of Lorazepam, 0.2 of Midazolam, or 0.3 519 00:27:13,135 --> 00:27:15,505 of Diazepam if I was treating patients. 520 00:27:15,685 --> 00:27:19,070 And I think that as we talked about earlier, you need to be ready to use 521 00:27:19,070 --> 00:27:22,130 any of these medications because your favorites aren't always gonna be there. 522 00:27:22,370 --> 00:27:26,600 So I think you need to have a sense of that dosing, or you need to have a sense 523 00:27:26,600 --> 00:27:29,750 that I know the medicines I need, but I can't keep these doses in my head. 524 00:27:29,900 --> 00:27:33,110 So you need to either have support from an ER pharmacist to help you dose, or 525 00:27:33,110 --> 00:27:36,500 you need to be your own ER pharmacist and have an application like PD stat. 526 00:27:36,710 --> 00:27:40,465 I love PD stat for basically making sure when I'm running a complex 527 00:27:40,465 --> 00:27:43,765 pediatric resuscitation that I know exactly the doses I'm giving. 528 00:27:43,975 --> 00:27:46,795 'cause I put in the child's Braslow or their weight, and then 529 00:27:46,795 --> 00:27:50,125 I hand the phone to the nurses and say, I'm gonna give you drugs. 530 00:27:50,245 --> 00:27:52,435 You just look down and tell me what the doses are from that 531 00:27:52,835 --> 00:27:52,985 . Sam: Yeah. 532 00:27:53,345 --> 00:27:53,765 Perfect. 533 00:27:54,142 --> 00:27:57,602 and I will say, page seven of the article table four medications 534 00:27:57,602 --> 00:28:00,962 for status epilepticus first line anti-seizure medications lists all 535 00:28:00,962 --> 00:28:02,462 three of those as an option, right? 536 00:28:02,462 --> 00:28:04,262 Lorazepam midazolam and diazepam. 537 00:28:04,262 --> 00:28:07,862 Now, they do have a preference for Lorazepam, but it's not to 538 00:28:07,862 --> 00:28:09,422 the exclusion of the other two. 539 00:28:09,422 --> 00:28:14,077 So whatever of the three that you have they do recommend Lorazepam because of 540 00:28:14,122 --> 00:28:16,162 its reliable onset and its duration. 541 00:28:16,422 --> 00:28:19,517 But if you don't have, or if you have a preference, it's okay. 542 00:28:19,647 --> 00:28:20,937 , You've got some flexibility there. 543 00:28:21,237 --> 00:28:26,907 Midazolam does come with the other delivery options too, so IO, 544 00:28:26,907 --> 00:28:31,237 intranasal, intramuscular and has had efficacy in all of those areas. 545 00:28:31,237 --> 00:28:34,597 So if you don't have an IV in place, that's probably the better choice. 546 00:28:35,101 --> 00:28:38,366 T.R. Eckler: To clarify, you can use any of those through an IV 547 00:28:38,546 --> 00:28:43,916 or an IO, but if you need to give them IN like nasally or muscularly, 548 00:28:44,186 --> 00:28:45,896 then you have to use Midazolam. 549 00:28:46,166 --> 00:28:50,721 But I think that to be clear, midazolam is a significantly shorter acting drug. 550 00:28:50,931 --> 00:28:53,691 So you need to know if you're giving Midazolam that you need to be ready 551 00:28:53,691 --> 00:28:57,111 to catch that patient an hour or two, either by starting them on infusion or 552 00:28:57,111 --> 00:29:00,351 giving them other medications that are gonna gain control of that seizure. 553 00:29:00,561 --> 00:29:03,591 'cause the, solution you've provided is a shorter term one 554 00:29:03,771 --> 00:29:07,101 than the four to six hours you'll get out of Diazepam or Lorazepam. 555 00:29:07,801 --> 00:29:07,981 Sam: Yeah. 556 00:29:08,521 --> 00:29:11,521 Which brings us to second and third line medications. 557 00:29:11,571 --> 00:29:16,561 The authors cited the ECET study, which is efficacy of levetiracetam, fosphenytoin, 558 00:29:16,581 --> 00:29:19,701 and valproate for established status epilepticus by age group. 559 00:29:19,891 --> 00:29:25,621 And that study looked at which of these agents has the best efficacy as a second 560 00:29:25,621 --> 00:29:28,181 and third line anti-seizure medication. 561 00:29:28,411 --> 00:29:33,464 The point being that  levetiracetam, fosphenytoin, and valproate were 562 00:29:33,464 --> 00:29:35,414 all shown to have similar efficacy. 563 00:29:35,674 --> 00:29:38,794 But there are some specific scenarios where you might wanna 564 00:29:38,794 --> 00:29:40,264 give one instead of the other. 565 00:29:40,691 --> 00:29:43,811 T.R. Eckler: my takeaway from this was just that, you know, if you're 566 00:29:43,811 --> 00:29:48,101 worried about trauma, if you're worried about ingestion, there's a 567 00:29:48,131 --> 00:29:51,821 case to be made for  levetiracetam being the best first choice. 568 00:29:51,941 --> 00:29:56,021 And I also think that it has such a high threshold for how high you can 569 00:29:56,021 --> 00:30:00,071 dose it in status, that even if they're on Keppra, you can give them another 570 00:30:00,071 --> 00:30:03,791 dose safely 'cause it's gonna take a lot to get them to 60 mgs per kilo. 571 00:30:04,031 --> 00:30:07,781 And I think that that's the reason you're seeing so much of it given in 572 00:30:07,781 --> 00:30:11,511 clinical practices that there's such a better safety profile and such an 573 00:30:11,511 --> 00:30:15,431 ease of administration that's there as opposed to some of the other medicines in 574 00:30:15,431 --> 00:30:18,821 terms of like needing the pharmacy to be involved to get those other medications. 575 00:30:18,821 --> 00:30:24,101 So I think that, that was my takeaway was just Keppra if I can get it and if I think 576 00:30:24,101 --> 00:30:25,691 it's safe to give another dose, great. 577 00:30:25,841 --> 00:30:29,201 If not, if I need to use the other medicines, then I go to those because 578 00:30:29,201 --> 00:30:31,571 that's what I have available to me and that's where I'm at at the moment. 579 00:30:32,348 --> 00:30:34,833 Sam: And, and honestly, I, I like Levetiracetam. 580 00:30:34,883 --> 00:30:38,333 It is definitely my preferred agent, and I think the, our, really, our 581 00:30:38,333 --> 00:30:39,773 neurologists feel the same way. 582 00:30:40,023 --> 00:30:43,859 You can give  fosphenytoin, even in the setting of trauma. 583 00:30:44,079 --> 00:30:46,899 But you know, sometimes in the settings of drug or toxic 584 00:30:46,899 --> 00:30:48,399 ingestions, it's less effective. 585 00:30:48,619 --> 00:30:52,519 And it has the potential for arrhythmia and hypotension, especially if 586 00:30:52,519 --> 00:30:53,989 you're exceeding certain doses. 587 00:30:54,349 --> 00:30:56,339 Valproate is an option. 588 00:30:56,339 --> 00:30:59,999 You do have to avoid it if there's any kind of history of mitochondrial disease. 589 00:31:00,219 --> 00:31:03,189 And there used to be a stipulation that you couldn't give it to children 590 00:31:03,189 --> 00:31:06,219 under two years old, but recent studies have actually said that 591 00:31:06,219 --> 00:31:09,839 that's not true and that the side effects are similar to older children. 592 00:31:10,059 --> 00:31:11,829 And so that is an option as well. 593 00:31:12,028 --> 00:31:15,418 This might come up in a conversation with your peds neurologist, which hopefully 594 00:31:15,418 --> 00:31:16,828 you've already contacted at this point. 595 00:31:17,128 --> 00:31:21,268 Phenobarbital is recommended by the American Epilepsy Society 596 00:31:21,268 --> 00:31:24,868 only if your usual first or second line medications are unavailable. 597 00:31:24,988 --> 00:31:27,118 So just know that it's another option. 598 00:31:27,308 --> 00:31:30,418 It's probably not the ideal second or third line option, but, if it's 599 00:31:30,418 --> 00:31:31,468 all you got, it's all you got. 600 00:31:31,528 --> 00:31:34,018 And if you've tried others and they've failed, something to consider. 601 00:31:34,718 --> 00:31:37,178 T.R. Eckler: They listed under second, but they really want you to 602 00:31:37,178 --> 00:31:38,378 think about it in the third line. 603 00:31:39,004 --> 00:31:40,204 Sam: Yeah, maybe even fourth. 604 00:31:40,808 --> 00:31:41,198 T.R. Eckler: Yeah. 605 00:31:41,423 --> 00:31:43,118 Or, or refractory only. 606 00:31:43,123 --> 00:31:44,618 Super, super refractory. 607 00:31:44,618 --> 00:31:45,938 You're allowed to start at that point. 608 00:31:46,638 --> 00:31:47,568 Sam: That's right, that's right. 609 00:31:47,968 --> 00:31:51,928 And then when we're talking about the refractory category, so this is someone 610 00:31:51,928 --> 00:31:55,888 who's had two doses of benzodiazepines, has had a second and maybe third 611 00:31:55,888 --> 00:31:57,838 line agent, and is still seizing. 612 00:31:57,838 --> 00:32:03,833 Now we're looking at infusions and at this point it is very likely that you've 613 00:32:03,833 --> 00:32:07,613 already controlled the airway or you're going to control the airway before 614 00:32:07,613 --> 00:32:11,663 you move on to one of these infusions, because these things are heavily sedating. 615 00:32:11,793 --> 00:32:16,353 You're in the induction of coma kind of portion of the treatment protocol, 616 00:32:16,563 --> 00:32:20,493 and we're talking about things like Midazolam continuous infusion, 617 00:32:20,793 --> 00:32:25,253 pentobarbital continuous infusion, or Propofol continuous infusion. 618 00:32:25,313 --> 00:32:28,113 And again, another clinical case. 619 00:32:28,113 --> 00:32:32,733 I recall actually being in a brand new freestanding emergency 620 00:32:32,733 --> 00:32:36,973 department which unfortunately meant we were separate from the main 621 00:32:36,973 --> 00:32:39,673 hospital and had a limited pharmacy. 622 00:32:39,673 --> 00:32:45,923 And in came a child in status, first line benzos by EMS unsuccessful. 623 00:32:46,143 --> 00:32:50,103 Second dose of benzo given in the emergency department and seizure stopped 624 00:32:50,523 --> 00:32:53,013 and then came the clinical examination. 625 00:32:53,253 --> 00:32:56,913 And the nurse and I are undressing the child and she's looking at the skin 626 00:32:56,913 --> 00:33:01,203 and then looks up at me with these big, glaring eyes as we're looking at bruises. 627 00:33:01,203 --> 00:33:03,918 And she's thinking is this child getting beaten? 628 00:33:03,918 --> 00:33:05,628 Is there some non-accidental trauma? 629 00:33:05,868 --> 00:33:09,378 Mom is there and I'm looking at the child and thinking something 630 00:33:09,378 --> 00:33:13,008 completely different because the bruises have no pattern whatsoever. 631 00:33:13,248 --> 00:33:17,448 There's small little petechial hemorrhages all over this patient's body. 632 00:33:17,758 --> 00:33:22,198 There's some larger confluent ecchymosis, but mostly on the back and the buttocks. 633 00:33:22,478 --> 00:33:25,058 And I'm thinking, yes, this is definitely a problem. 634 00:33:25,253 --> 00:33:27,593 But this doesn't look like non-accidental trauma. 635 00:33:27,803 --> 00:33:29,693 And then the third seizure ensued. 636 00:33:29,943 --> 00:33:31,863 And in that case, we were pretty limited. 637 00:33:31,863 --> 00:33:35,913 We did not have levetiracetam or fosphenytoin at the time was a brand 638 00:33:35,913 --> 00:33:37,263 new freestanding emergency department. 639 00:33:37,263 --> 00:33:41,553 It was benzos or propofol, and I think we had one vial of propofol. 640 00:33:41,603 --> 00:33:44,833 So it was okay get the propofol. 641 00:33:44,953 --> 00:33:45,703 Here we go. 642 00:33:45,803 --> 00:33:47,753 So we gave the third dose of benzodiazepine. 643 00:33:47,753 --> 00:33:48,293 It didn't work. 644 00:33:48,293 --> 00:33:50,333 And I ended up having to intubate this child. 645 00:33:50,363 --> 00:33:54,733 And unfortunately the child did have what looked like new onset leukemia, 646 00:33:54,733 --> 00:33:58,943 had severe thrombocytopenia, CT scan of the head showed petechial hemorrhages. 647 00:33:59,283 --> 00:34:01,923 And so there we were trying to stabilize this patient and send them 648 00:34:01,923 --> 00:34:06,153 out somewhere where they could take care of them to a pediatric tertiary center. 649 00:34:06,543 --> 00:34:11,793 But the point being that sometimes you have to go to this third infusion 650 00:34:11,793 --> 00:34:14,763 state, and when you do, you really need to control the airway at this 651 00:34:14,763 --> 00:34:16,663 point because you're inducing a coma. 652 00:34:17,083 --> 00:34:20,893 And again, I thought the authors did a good job of reminding us that at 653 00:34:20,893 --> 00:34:26,293 some point, an EEG needs to enter this pathway because even after you induce 654 00:34:26,293 --> 00:34:30,973 a coma or intubate this person and sedate them with a continuous infusion, 655 00:34:30,973 --> 00:34:32,713 now they're just no longer moving. 656 00:34:33,073 --> 00:34:35,893 But you don't know if they're no longer seizing, and that's 657 00:34:35,893 --> 00:34:37,148 really where you need the EEG. 658 00:34:37,538 --> 00:34:39,038 T.R. Eckler: I think excellent. 659 00:34:39,128 --> 00:34:40,088 Super well said. 660 00:34:40,208 --> 00:34:43,538 I don't think I realized how much of a black cloud you were, but now the more you 661 00:34:43,538 --> 00:34:49,088 tell stories, the more I'm like, man, you have really had quite a black cloud run. 662 00:34:49,758 --> 00:34:52,898 I think that when you're dealing with such a challenging patient like this, 663 00:34:53,048 --> 00:34:56,468 I like that midazolam infusion because of its short acting nature that, you 664 00:34:56,468 --> 00:34:59,708 know, you can back out of it if you need to, but I just think that that's 665 00:34:59,708 --> 00:35:03,548 a nice thing to gain short term control as you're figuring out what's going on. 666 00:35:03,668 --> 00:35:06,968 And I think if you only have propofol, that's okay short term, but you need 667 00:35:06,968 --> 00:35:10,328 to be aware that that can't continue long term because of the potential 668 00:35:10,448 --> 00:35:12,098 for  propofol infusion syndrome. 669 00:35:12,248 --> 00:35:15,218 So I think that's something where you need to quickly have a plan for how am 670 00:35:15,218 --> 00:35:16,838 I gonna get this kid somewhere else? 671 00:35:17,083 --> 00:35:20,413 Or to someone else that has other kinds of medications they can try. 672 00:35:21,113 --> 00:35:26,453 Sam: Yes, and that propofol infusion syndrome specifically is characterized 673 00:35:26,468 --> 00:35:31,858 by rhabdomyolysis, ECG changes, severe metabolic acidosis, renal 674 00:35:31,858 --> 00:35:36,418 failure, transaminitis, and sometimes cardiovascular decompensation. 675 00:35:36,418 --> 00:35:38,548 So it's a big deal. 676 00:35:38,708 --> 00:35:42,488 And the primary risk factor there being a history of a ketogenic diet or 677 00:35:42,518 --> 00:35:44,448 high infusion rates of your propofol. 678 00:35:44,448 --> 00:35:48,528 So if they have epilepsy and they're on a special diet, or if you're having to crank 679 00:35:48,528 --> 00:35:53,178 up the propofol to stop the seizures, both of those are reasons to keep that infusion 680 00:35:53,178 --> 00:35:57,018 syndrome in your mind and maybe get them off the propofol as soon as possible 681 00:35:57,018 --> 00:35:59,418 after they reach, for example, the PICU. 682 00:35:59,758 --> 00:36:03,958 And another thing to keep in mind is that about 14 to 20% of these 683 00:36:03,958 --> 00:36:08,308 patients will continue to seize after being placed on this infusion 684 00:36:08,308 --> 00:36:10,853 for persistent status epilepticus. 685 00:36:10,948 --> 00:36:13,918 So even though you can't see it, this is just driving home that point. 686 00:36:13,918 --> 00:36:15,328 Again, they need that EEG. 687 00:36:16,028 --> 00:36:18,788 And then just to touch on some special scenarios. 688 00:36:18,788 --> 00:36:22,478 So if you happen to do a point of care glucose, especially in the neonate, 689 00:36:22,508 --> 00:36:26,048 and they're hypoglycemic, you treat that to stop the seizure, right? 690 00:36:26,048 --> 00:36:29,778 Benzos are not the ideal choice in this scenario. 691 00:36:29,873 --> 00:36:33,723 You're gonna be giving them the D 10 or if they're a young child, the D 25. 692 00:36:34,173 --> 00:36:38,353 And if they are in the neonatal period and they're on the formula and 693 00:36:38,353 --> 00:36:41,683 it's being inappropriately mixed and they're hyponatremic and their sodium 694 00:36:41,683 --> 00:36:46,453 is less than 120, then you're gonna treat the hyponatremia with 3% saline. 695 00:36:46,673 --> 00:36:51,713 Give them that three to five milliliter per kilogram dose over 20 minutes to try 696 00:36:51,713 --> 00:36:55,203 and stop the seizures, and then you stop that infusion as soon as the seizures end. 697 00:36:55,823 --> 00:36:57,983 And then the rest is slowly treated over time. 698 00:36:58,413 --> 00:36:59,883 And the same with hypocalcemia. 699 00:37:00,033 --> 00:37:04,633 So if they're hypocalcemic and you're gonna treat that, then calcium gluconate, 700 00:37:04,693 --> 00:37:07,603 or if they have a central line, the calcium chloride and all of those 701 00:37:07,603 --> 00:37:10,243 doses are there for you in the issue. 702 00:37:10,643 --> 00:37:13,433 Neonatal seizures was another one of those special populations 703 00:37:13,433 --> 00:37:14,393 that the authors brought up. 704 00:37:14,453 --> 00:37:20,373 And just as a reminder, some of the things you may see on clinical exam include 705 00:37:20,703 --> 00:37:26,983 the automatisms like blinking, chewing, lip smacking, tongue thrusting, or the 706 00:37:26,983 --> 00:37:28,723 bicycling of the lower extremities. 707 00:37:28,973 --> 00:37:33,113 Those are the kinds of symptoms that you might pick up on physical exam for 708 00:37:33,163 --> 00:37:36,773 a child that's persistently seizing in this neonatal period and that they 709 00:37:36,773 --> 00:37:40,843 might have jitteriness and kind of an exaggerated Moro reflex that sometimes 710 00:37:40,843 --> 00:37:42,933 can be misconstrued as seizing. 711 00:37:42,933 --> 00:37:44,383 So you just gotta be careful. 712 00:37:44,383 --> 00:37:45,913 Do your own exam, be thorough. 713 00:37:46,253 --> 00:37:48,053 And then the etiology there is very broad. 714 00:37:48,053 --> 00:37:51,353 It does include trauma, but includes things like asphyxia, maternal 715 00:37:51,353 --> 00:37:54,533 medication use, especially if they're breastfeeding, maternal substance 716 00:37:54,533 --> 00:37:58,523 abuse, maternal infections, the neonatal infections, the inborn errors. 717 00:37:58,793 --> 00:38:01,463 And this is where, you know, if they were born at your hospital, you might be able 718 00:38:01,463 --> 00:38:04,973 to look up their birth history and see if they had a genetic screening at birth. 719 00:38:05,323 --> 00:38:08,263 And if not, then, you know, maybe ask Mom about those kinds of things. 720 00:38:08,573 --> 00:38:13,793 And then keep in mind that CNS infections, especially with herpes simplex virus, can 721 00:38:13,823 --> 00:38:16,313 also cause seizures in this population. 722 00:38:16,643 --> 00:38:21,123 So lots of special considerations for the neonatal seizures. 723 00:38:21,523 --> 00:38:25,063 T.R. Eckler: I think febrile status epilepticus is something you need 724 00:38:25,063 --> 00:38:28,933 to be a little more cautious about just because those kids that are not 725 00:38:28,933 --> 00:38:32,563 your common febrile seizures, that like they have one and they stop. 726 00:38:32,563 --> 00:38:35,323 Or even if they're, you know, like the complex ones where they have 727 00:38:35,323 --> 00:38:36,613 one or two and then they stop. 728 00:38:36,628 --> 00:38:41,068 The ones that are really truly febrile and in status, you need to be more 729 00:38:41,068 --> 00:38:45,208 cautious and especially ask about vaccine status because you need to be 730 00:38:45,208 --> 00:38:49,828 more aggressive about considering an LP in these kids and basically making 731 00:38:49,828 --> 00:38:53,758 sure that you talk to the parents about your recommendation to do that LP. 732 00:38:53,968 --> 00:38:58,048 'cause I don't think I would want in practice to admit a child with febrile 733 00:38:58,048 --> 00:39:01,948 status and not have recommended in my chart that I wanted to get an LP and 734 00:39:01,948 --> 00:39:02,953 let the parents make that decision. 735 00:39:03,653 --> 00:39:04,583 Sam: I think that's well said. 736 00:39:04,583 --> 00:39:08,033 So febrile status epilepticus is very different than just 737 00:39:08,033 --> 00:39:09,503 a simple febrile seizure. 738 00:39:09,603 --> 00:39:13,293 Those two entities do have the word febrile in them, but otherwise there's 739 00:39:13,343 --> 00:39:14,993 really very little overlap there. 740 00:39:15,243 --> 00:39:18,653 So just be sure that you're making that distinction and understanding 741 00:39:18,653 --> 00:39:22,443 that you really need to rule out the infectious causes there for sure. 742 00:39:22,693 --> 00:39:26,413 And that your first line treatment in those is going to include 743 00:39:26,413 --> 00:39:30,403 benzodiazepines, but also can include things to treat fever. 744 00:39:30,613 --> 00:39:33,303 You know, the fever does lower seizure threshold and you 745 00:39:33,303 --> 00:39:34,833 want to address that as well. 746 00:39:35,503 --> 00:39:38,473 T.R. Eckler: to clarify my point, the authors said basically that if 747 00:39:38,473 --> 00:39:41,983 there's signs of meningitis, you need to consider a lumbar puncture. 748 00:39:41,983 --> 00:39:46,644 But I think in the unvaccinated child, making sure that you were clear, that you 749 00:39:46,644 --> 00:39:49,674 were really concerned and really wanted to make sure you worked them up thoroughly. 750 00:39:49,884 --> 00:39:53,214 I think you wanna be really cautious about making sure that you think 751 00:39:53,244 --> 00:39:55,944 carefully about, does this child need an LP If they're in febrile status. 752 00:39:57,088 --> 00:40:01,028 Sam: Yeah, I mean, honestly again, it is just a reflection of my age. 753 00:40:01,028 --> 00:40:03,308 I tend to be pretty aggressive with lumbar punctures. 754 00:40:03,308 --> 00:40:07,238 You know, having treated patients at the very cusp or the beginning 755 00:40:07,238 --> 00:40:09,818 of the, super effective vaccine era. 756 00:40:10,028 --> 00:40:14,128 We were lumbar puncturing all of these infants and, honestly, it's 757 00:40:14,128 --> 00:40:15,778 a relatively benign procedure. 758 00:40:15,778 --> 00:40:19,928 Now, it may be difficult for you to get CSF out of a neonate, but still 759 00:40:19,988 --> 00:40:22,748 I have a very low threshold for just saying, yeah, we're gonna do the lumbar 760 00:40:22,748 --> 00:40:25,988 puncture, and this is why and there's no other way to really make this diagnosis 761 00:40:26,048 --> 00:40:29,948 if they have something infectious, especially if they're at risk for HSV. 762 00:40:30,198 --> 00:40:32,208 It's something you don't wanna miss and can certainly be 763 00:40:32,208 --> 00:40:33,468 catastrophic for the patient. 764 00:40:34,168 --> 00:40:37,918 The authors did do a good job of talking about some of the other newer medications, 765 00:40:37,918 --> 00:40:39,178 and we won't get into those today. 766 00:40:39,178 --> 00:40:40,948 But I do wanna just touch on ketamine. 767 00:40:41,128 --> 00:40:44,788 We have used ketamine significantly in the adult population for treatment 768 00:40:44,788 --> 00:40:48,958 of seizures, and there are case reports in the pediatric literature 769 00:40:49,178 --> 00:40:53,308 but still limited case reports so wasn't a strong recommendation for 770 00:40:53,308 --> 00:40:55,138 ketamine in status epilepticus. 771 00:40:55,448 --> 00:40:58,453 It doesn't mean your pediatric neurologist might not recommend it. 772 00:40:58,703 --> 00:40:59,903 But there are some others. 773 00:41:00,063 --> 00:41:06,063 things like lacosamide and brivaracetam uh, like a longer more potent acting 774 00:41:06,063 --> 00:41:10,913 version of levetiracetam that binds to the same receptor but has a higher affinity. 775 00:41:11,093 --> 00:41:14,003 So lots of other things that your pediatric neurologist might 776 00:41:14,003 --> 00:41:17,183 recommend if you get to the point where you've thrown everything in 777 00:41:17,183 --> 00:41:18,473 the kitchen sink at the patient. 778 00:41:18,693 --> 00:41:21,123 But hopefully by then they're in the pediatric ICU. 779 00:41:21,823 --> 00:41:24,403 T.R. Eckler: I think the last thing I would wanna say is I really like their 780 00:41:24,403 --> 00:41:28,423 note about disposition, and I think some of these patients are gonna come in with 781 00:41:28,423 --> 00:41:32,503 seizures that are, you know, epilepsy patients that are on their medications. 782 00:41:32,683 --> 00:41:35,473 You give them medications, things calm down, they go back to the baseline. 783 00:41:35,533 --> 00:41:39,013 And if you talk to their neurologist, a lot of times these kids can go home. 784 00:41:39,283 --> 00:41:42,443 But I think especially if they have a concern that they've 785 00:41:42,443 --> 00:41:44,123 outgrown their seizure coverage. 786 00:41:44,213 --> 00:41:46,763 You wanna ask their neurologist if you want to adjust their medications. 787 00:41:47,243 --> 00:41:51,443 Or if they need refills of their rectal diazepam, their intranasal midazolam, 788 00:41:51,443 --> 00:41:55,373 or diazepam, or even what's called a klonopin bridge or clonazepam bridge, 789 00:41:55,613 --> 00:41:58,343 to get them through a period of time, let's say if they have an infection, 790 00:41:58,583 --> 00:42:01,613 that they're gonna be more prone to seizures and you can give them an 791 00:42:01,613 --> 00:42:03,323 additional layer of seizure coverage. 792 00:42:03,533 --> 00:42:06,803 I've seen a few neurologists do this where the patient goes home with a short 793 00:42:06,803 --> 00:42:10,943 course of Clonazepam, and I think it works really great for helping educated 794 00:42:10,943 --> 00:42:14,573 parents that do a great job of managing their kids have the tools to keep them 795 00:42:14,573 --> 00:42:15,893 outta the emergency department again. 796 00:42:16,563 --> 00:42:17,063 Sam: Fantastic. 797 00:42:17,563 --> 00:42:18,093 Well said. 798 00:42:18,093 --> 00:42:20,253 And that brings us to the end of the episode. 799 00:42:20,253 --> 00:42:24,273 Thanks again to Dr. Bowen and Dr. Bolton, our two authors for this 800 00:42:24,273 --> 00:42:27,373 July 2025 pediatric emergency medicine practice article on the 801 00:42:27,373 --> 00:42:32,798 treatment of peds status epilepticus in the ED and keep this in mind. 802 00:42:32,798 --> 00:42:34,268 Keep those tables in your pocket. 803 00:42:34,268 --> 00:42:37,928 It's a great reference, especially when you're standing there at the 804 00:42:37,928 --> 00:42:40,058 bedside treating this critical patient. 805 00:42:40,338 --> 00:42:42,558 And until next time, everyone, be safe. 806 00:42:42,588 --> 00:42:44,747 I am one of your hosts , Sam Ashoo. 807 00:42:45,217 --> 00:42:47,557 T.R. Eckler: Dr. TR Eckler, stay safe out there. 808 00:42:47,557 --> 00:42:48,307 Good luck. 809 00:42:48,727 --> 00:42:50,887 Try to deal with your newfound celebrity from the pit. 810 00:42:51,237 --> 00:42:52,017 Sam: and that's a wrap. 811 00:42:52,057 --> 00:42:54,677 Thanks for joining us for this episode of EMPlify. 812 00:42:54,697 --> 00:42:59,323 I hope you found it informative, and I want to remind you that ebmedicine.net 813 00:42:59,573 --> 00:43:04,433 is your one stop shop for all of your CME needs, whether that be for emergency 814 00:43:04,433 --> 00:43:06,253 medicine or urgent care medicine. 815 00:43:06,533 --> 00:43:10,063 There are three journals, there's tons of CME, there's lots of 816 00:43:10,093 --> 00:43:13,853 courses, there's so many clinical pathways, all this information at 817 00:43:13,853 --> 00:43:16,693 your fingertips at ebmedicine.net. 818 00:43:17,093 --> 00:43:19,533 Until next time, everyone, I'm your host, Sam Ashoo. 819 00:43:19,873 --> 00:43:20,433 Be safe.