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(e.g., pentobarbital 5 to 15 mg/kg load, then 1 mg/kg/hr starting dose),
benzodiazepines (e.g., continuous infusion midazolam 0.2 mg/kg load, then 0.05
to 0.2 mg/kg/hr), or continuous infusion propofol (3 to 5 mg/kg load, then 1 to 15
mg/kg/hr).
Patients requiring general anesthetics need to be intubated (if not already done)
and need continuous EEG monitoring. The level of anesthesia should be titrated
to maintain either a flat-line or burst-suppression pattern on the EEG. The
anesthesia can be then withdrawn slowly to see if any electrical seizure activity
persists.
It is important to note that prior CNS insult or seizure disorder accounts for a
high proportion of pediatric status epilepticus cases. Seizure management may be
very complex and may involve multiple AEDs; therefore, a seizure management
plan should be developed as rapidly as possible in consultation with a pediatric
neurologist, either preemptively or during an SE episode.

SPECIAL CONSIDERATIONS
Febrile Seizures
Febrile seizures are the most common convulsive disorder in young children,
occurring in 2% to 5% of the population. Most clinicians define a febrile seizure
as a seizure occurring between 6 months and 5 years of age that is associated with
a fever (temperature higher than 38°C [100.4°F]), but without the evidence of
intracranial infection or other defined cause or neurologic disease. Some
clinicians use 7 years as an upper age limit for febrile seizures, following the
International League Against Epilepsy (ILAE) from 1993 defining the age cutoff
of 1 month to 7 years.
Febrile seizures can be of any type, but most commonly, they are generalized
tonic-clonic seizures. They are usually self-limited and last for only a few
minutes. Febrile seizures are classified as simple when lasted less than 15
minutes, are generalized, and occur only once during a 24-hour period (two
seizures within a time period of <30 minutes will be considered a single episode).
In contrast, complex febrile seizures are prolonged, recur within 24 hours, or have

focal manifestations. Simple febrile seizures (85%) are much more common.
There is a family history of febrile seizures in an immediate family member in
25% to 40% of cases. Viral infections are frequently associated with febrile
seizures, and human herpesvirus is a commonly identified agent.
After the first febrile seizure, approximately 33% of patients will have at least
one recurrence and about 9% will have three or more episodes. The younger the


patient is at first presentation, the greater the likelihood of recurrence. In addition,
recurrences are more likely to recur in patients with lower temperatures on
presentation of their first seizure (lower than 40°C) and shorter duration of fever
before the seizure (less than 24 hours) and in patients with a family history of
febrile seizures. Most recurrences (75%) will happen within 1 year. The exact risk
of developing epilepsy after a febrile seizure is unknown, but most studies
indicate that it is less than 5%. Risk factors for developing epilepsy after a febrile
seizure include abnormal development before the episode, a family history of
afebrile seizures, and a complex first febrile seizure; without any of these risk
factors, the risk of developing epilepsy is approximately 1%, which is almost the
same risk as in the general population.
The treatment of a patient who presents with a febrile seizure is nearly identical
to that for other seizure types. The primary goal is the establishment of a clear
airway; secondary efforts are then directed at the termination of the seizure and
concurrent lowering of body temperature. However, because most febrile seizures
are brief in duration, the typical patient who presents for the evaluation of a
febrile seizure is no longer seizing upon arrival to the ED. In those instances, if
the history is consistent with a simple febrile seizure, the patient has no stigmata
of a CNS infection, and the patient’s neurologic examination is completely
normal (other than the patient may be postictal or slightly hyperreflexive), further
evaluation for the cause of the seizure is unnecessary. As such, routine laboratory
studies are not recommended for the patient with a simple febrile seizure. While

seizure may be the first manifestation of meningitis, LP is only indicated for
children in whom meningitis is clinically suspected and it is no longer
recommended routinely. Similarly, routine neuroimaging or EEG screening is not
recommended for the patient with a first-time simple febrile seizure. However,
the evaluation should focus on the possible cause of the fever. Outpatient EEG is
performed in some institutions for patients with complex febrile seizure. While
complex febrile seizures are associated with a slightly higher risk of subsequent
epilepsy, the predictive value of these EEG studies and their yield on
management changes remains controversial.
A patient who has had a febrile seizure and is well appearing and back to
baseline may be safely discharged to home. Parents should be reassured that
febrile seizures are common and that most patients have no further episodes.
They need to be cautioned that a recurrence may happen and should be given
simple instructions on what to do should another seizure occur and indications for
returning for evaluation. They can also be instructed on the proper use of
antipyretics, even though studies have failed to demonstrate that this is effective


in reducing the recurrence rate. Finally, any identified source of the fever should
be properly treated.
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an open-label, multicentre, randomised controlled trial. Lancet
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