Paediatric Status Epilepticus

I: You are the ICU registrar. The ED registrar bleeps you with a referral

S: There is a child in resus who has been admitted with tonic-clonic seizures

B: 6M with known epilepsy admitted following a tonic-clonic seizure at home (20 min ago). Further tonic-clonic seizure observed in resus by the registrar. He received diazepam with LAS and 1 dose IV lorazepam in ED

A: Drowsy, maintaining own airway but concerns given multiple seizures

R: 2 doses of benzodiazepine given so need additional support

• Initially A own, B SpO₂ 100% on 15L O2, chest clear, C HR102 bpm, BP 98/54, D E1V2M5
• Shortly after arrival patient has further seizure (3^rd since admission)- appropriately starts phenytoin infusion/considers Keppra/status algorithm

• Opens/supports airway/suctions
• Gas provided when asked for:

pH 7.30, pO2 35.3, pCO2 4.5, Na 143, K 4.5, Lac 9, BE – 7.1

• Asks for glucose (5.7)
• Asks for temperature (37.9)
• Gives fluid bolus +/- asks for antibiotics
• Patient remains drowsy throughout scenario with no improvement in GCS. If prolonged deliberation can have further seizures

DECISION TO INTUBATE

• Calculates WETFLAG for patient
  • (Estimated weight should be 20kg) – if using age +4 x2
  • (Accept weight 25kg) – if using (age x3) +7
• Calculates appropriate ETT size and distance, appropriate MAC blade
• Calculates appropriate drug doses & plan for intubation
• Ensures appropriate equipment available (ventilator, pumps, infusions)
• Liaises with paediatric team/CATS & contacts ODP
• Explains what is about to happen to family and informs senior
• Considers organising septic screen/CXR/CT head
• CATS call at the end of scenario asking for an update: please hand over

End of scenario (Scenario can also be terminated after calculations and explanations prior to proceeding to drug assisted intubation)

• Initial settings:            SpO₂ 100% on 15L O2

                                         RR 24/min

                                         Bilateral breath sounds, no added sounds

                                         HR 110

                                         BP 92/54

                                         Groans when stimulated. Eyes closed, M5

• Progress to:                Seizure activity 

                                         Dilated pupils

                                         Movement artefact on spO2 / HR                           

• On seizure termination:  SpO₂ 100% pn 15L 02

                                              RR 20/min

                                              HR 98

                                              BP 89/49

                                              No verbal response, eyes closed, M4

Further observations depend upon actions.

ED nurse:

• You are a senior ED nurse
• The ED reg is busy with other patients and asked you to stay with this patient
• This is a 6M with tonic clonic seizures (he has had 1 at home and 1 in resus) and has been given 2 doses of benzodiazepines (1 with LAS).
• You are worried that this patient has continued to seize despite treatment
• You sent initial blood tests to the lab when you cannulated (FBC, U&Es and CRP)
• His parent is incredibly anxious, and you want the ICU doctor to reassure them
• You take direction well, and can perform tasks asked if you in a timely fashion, you just lack impetus
• If the candidate asks for the on-call ODP say that you’ve called, and they are on the way but that you can help them get any equipment needed

Parent:

• You are worried about your son, his epilepsy is usually very well-controlled.

• You want to know what is going on and when he can go home.
• You are worried this is your fault because he’s not been himself these last few days and you just thought he had a cold.
• You are not disruptive but refuse to leave your sons bedside and hold his hand throughout. When he has a seizure, you get very upset and distressed.
• If you hear the doctor discussing intubation you get very worried. He has never been intubated/been to ICU before, and you don’t know what this means. You just want an explanation and if you get one you are amenable.