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peds.status_epilepticus.v1

Pediatric status epilepticus

pediatricsacutepediatricneonatalacuteinpatient
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NEW pediatric dossier — no manifest / atoms / package on disk yet (manifest field intentionally empty). NEXT STEPS: (1) author manifest at prisma/seed/manifests/peds.status_epilepticus.v1.ts; (2) RxCUI validation for lorazepam, midazolam, diazepam, fosphenytoin, levetiracetam, valproate, pentobarbital, ketamine, pyridoxine, dextrose, magnesium sulfate; (3) calculator gaps — pediatric weight-based AED dose helper absent. Stage 1-3 algorithm explicit; weight-based dosing throughout; ESETT equivalence captured. Sibling differentiation from neuro.status-epilepticus.core.v1 covers 6 features. Deepened 2026-05-14 (shard-5-obped-id depth-pass-1): added co-located _briefs/peds.status_epilepticus.v1.depth.md (companion to existing 2026-04-27 brief) + _research-bundles/peds.status_epilepticus.v1.md. Added outpatient setting playbook (pediatric neurology follow-up within 1 wk; chronic AED titration — levetiracetam most common, valproate AVOID < 2 yr / mitochondrial / hepatic / pregnant adolescents, lamotrigine for focal + pregnancy-planning, ethosuximide for absence; breakthrough-seizure home rescue plan with age-appropriate benzo (IN midazolam, rectal diazepam, buccal midazolam); 1-page Seizure Action Plan; driving counseling for adolescents; medication-adherence counseling; pregnancy + contraception + folate 4 mg/d on teratogenic AEDs; school IEP/504 plan; psychosocial screen for child + family; ketogenic-diet evaluation if super-refractory history; SUDEP counseling per AAN 2017; epilepsy-surgery referral if drug-resistant). Added 7 severity triggers: refractory_se (life_threatening — AES/NCS 2016 anchor for anesthetic + intubation + cEEG bundle), super_refractory_se (life_threatening — ≥ 24 h on anesthetic + etiology pivot including FIRES/NORSE consideration), airway_compromise_during_se (life_threatening — intubate ASAP, do NOT delay for AED), persistent_ncse_on_eeg (severe — clinical cessation but cEEG shows ongoing electrographic SE), autoimmune_encephalitis_features_in_se (severe — Dalmau 2011 anti-NMDAR pattern + IVIG + steroids + plasma exchange + tumour search), pyridoxine_responsive_features (severe — neonate/infant refractory SE + EEG burst-suppression + B6 + folinic acid trial), fires_norse_pattern (life_threatening — Hirsch 2018 NORSE consensus + ketogenic + anakinra/tocilizumab). Appended 3 PMIDs: 31005385 (EcLiPSE Lancet 2019 — peds LEV non-inferior to phenytoin), 31005384 (ConSEPT Lancet 2019 — parallel peds confirmation), 21163445 (Dalmau Lancet Neurol 2011 — anti-NMDAR encephalitis 37% peds). Bumped evidence.last_reconciled to 2026-05-14. Phenotype matrix (age × etiology × phase × convulsive/non-convulsive) encoded indirectly via severity_triggers (refractory_se, super_refractory_se, airway_compromise_during_se, persistent_ncse_on_eeg, autoimmune_encephalitis_features_in_se, pyridoxine_responsive_features, fires_norse_pattern, hypoglycemia_at_presentation_se, febrile_se_with_altered_mental_status, infant_refractory_se, cardiac_compromise_on_fosphenytoin, rhabdo_after_prolonged_se) + per-setting playbook logic (ED triage, PICU anesthetic + cEEG, outpatient pediatric neurology). First-class TS field for phenotype matrix is schema-blocked. Bayesian linkage (pre-test mortality ~ 3-8% peds baseline, stratified ~ 10-20% refractory and ~ 30-40% super-refractory; LRs: Stage 1 benzo cessation ~ 70% within 5 min, Stage 2 second-line ~ 50% additive equivalence per ESETT/EcLiPSE/ConSEPT, cEEG-detected NCSE LR+ ~ 4-6, MRI focal abnormality LR+ ~ 3-4, anti-NMDAR CSF Ab LR+ ~ 20-40 for autoimmune encephalitis; T_treat anchored at ILAE 2015 t1 = 5 min benzo + 20 min second-line + 40 min anesthetic; cross-routing to id.bacterial-meningitis.peds.v1 (febrile + altered + CSF infectious), peds.dka.v1 (metabolic/glucose precipitant), id.sepsis.peds.v1 (shock features), peds.aki.v1 (rhabdo + AKI), and neuro.autoimmune.encephalitis sibling placeholder) documented in _research-bundles/peds.status_epilepticus.v1.md. ROS/DDx LR seed data audited by npm run audit:ros-ddx-coverage (cross-cutting; not touched by this shard). Prehospital recognition (EMS rescue benzo + airway) is currently encoded implicitly via transitions; a first-class 'prehospital' DossierSetting value is schema-blocked. Hirsch 2018 NORSE consensus + Raspall-Chaure 2007 peds SE outcome registry + Cervenka 2017 ketogenic diet for super-refractory SE PMID lookups deferred to next research:pubmed loop.

Entry points (3)

  • symptom
    Ongoing seizure ≥5 min in a child (ILAE 2015 SE definition; NCS/AES 2016 Glauser)
    ongoing_seizure_ge_5_min_child
  • symptom
    ≥2 seizures without recovery to baseline in a child (ILAE 2015 SE definition)
    multiple_seizures_no_recovery_child
  • symptom
    Post-ictal child not returning to baseline — concern for non-convulsive SE (NCS/AES 2016 Glauser)
    post_ictal_not_waking_child

Required inputs (18)

  • agerequired
    demographic • used at CONTEXT
    <2 yr — pyridoxine trial, ammonia for IEM; valproate hepatotoxicity if <2 (NCS/AES 2016 Glauser)
  • weightrequired
    demographic • used at CONTEXT
    All AED dosing weight-based (NCS/AES 2016 Glauser; ESETT Kapur NEJM 2019)
  • spo2required
    vital • used at RED_FLAGS
    Hypoxia is a treatable contributor (NCS/AES 2016 Glauser)
  • sbprequired
    vital • used at TREATMENT
    Avoid AED-induced hypotension (NCS/AES 2016 Glauser)
  • hrrequired
    vital • used at TREATMENT
    Bradycardia from fosphenytoin (NCS/AES 2016 Glauser)
  • temperaturerequired
    vital • used at CONTEXT
    Febrile precipitant; encephalitis (NCS/AES 2016 Glauser)
  • glucose_fingerstickrequired
    lab • used at INITIAL_WORKUP
    Hypoglycemia is a reversible cause (NCS/AES 2016 Glauser)
  • sodiumrequired
    lab • used at INITIAL_WORKUP
    Hyponatremia precipitant (NCS/AES 2016 Glauser)
  • calcium_magnesiumrequired
    lab • used at INITIAL_WORKUP
    Reversible electrolyte cause (NCS/AES 2016 Glauser)
  • ammonia
    lab • used at BRANCHING_WORKUP
    IEM screening in young infant + persistent SE (NCS/AES 2016 Glauser)
  • aed_levels
    lab • used at CONTEXT
    Adherence assessment in known epilepsy (NCS/AES 2016 Glauser)
  • toxicology_screen
    lab • used at BRANCHING_WORKUP
    Intoxication / accidental ingestion (NCS/AES 2016 Glauser)
  • lactate_ck
    lab • used at INITIAL_WORKUP
    Prolonged seizure → rhabdo + lactic acidosis (NCS/AES 2016 Glauser)
  • epilepsy_history_aed_adherencerequired
    history • used at CONTEXT
    Breakthrough vs new (NCS/AES 2016 Glauser)
  • fever_or_recent_illnessrequired
    history • used at CONTEXT
    Febrile SE / encephalitis (NCS/AES 2016 Glauser)
  • traumarequired
    history • used at CONTEXT
    Structural cause (NCS/AES 2016 Glauser)
  • head_ct_if_focal_or_trauma
    imaging • used at BRANCHING_WORKUP
    Structural lesion (NCS/AES 2016 Glauser)
  • eeg_continuous
    imaging • used at BRANCHING_WORKUP
    NCSE detection; titration of stage 3 (NCS/AES 2016 Glauser)

12-phase flow (12)

  1. 1FRAME
    Confirm seizure (vs syncope, rigors, PNES); convulsive vs non-convulsive; SE definition met (ILAE 2015; NCS/AES 2016 Glauser)
    inputs: weight, age
    advance: SE confirmed
  2. 2ENTRY
    Ongoing seizure ≥5 min, ≥2 without recovery, post-ictal not waking (ILAE 2015 SE definition)
    inputs: age
    advance: Entry trigger captured
  3. 3CONTEXT
    Known epilepsy + adherence, fever, trauma, intoxication, hypoglycemia, electrolyte, sodium, recent illness (NCS/AES 2016 Glauser)
    inputs: epilepsy_history_aed_adherence, fever_or_recent_illness, trauma
    advance: Context complete
  4. 4RED_FLAGS
    Refractory >30 min, hypoxia, hypoglycemia, hypotension, rhabdo, encephalitis features, anti-NMDAR features (NCS/AES 2016 Glauser)
    inputs: spo2, glucose_fingerstick
    actions: workup.anti_nmdar_encephalitis
    advance: Reversible causes identified
  5. 5INITIAL_WORKUP
    ABC, fingerstick glucose, IV/IO access, basic labs (BMP, Mg, Ca, Phos, ammonia in young), ABG/VBG, AED levels if known epileptic (NCS/AES 2016 Glauser)
    inputs: weight, glucose_fingerstick, sodium, calcium_magnesium
    actions: panel.glucose_a1c, panel.renal, panel.abg, workup.first_seizure, workup.status_epilepticus
    advance: Bedside reversibles addressed
  6. 6BRANCHING_WORKUP
    LP if febrile + altered (after CT), MRI brain, cEEG, toxicology, ammonia, pyridoxine trial in infants, autoimmune encephalitis panel (NCS/AES 2016 Glauser)
    inputs: head_ct_if_focal_or_trauma, eeg_continuous
    actions: workup.bacterial_meningitis, workup.encephalopathy
    advance: Etiology workup ongoing
  7. 7DIFFERENTIAL
    Febrile SE / breakthrough epilepsy / structural / metabolic / encephalitis / intox / anti-NMDAR / mitochondrial / pyridoxine-dependent (infant) (NCS/AES 2016 Glauser)
    advance: Differential narrowed
  8. 8RISK_STRATIFICATION
    Refractory tier, etiology severity, EEG burden (NCS/AES 2016 Glauser)
    advance: Tier documented
  9. 9TREATMENT
    Stage 1 (5-20 min) lorazepam IV repeat once OR midazolam IM/IN/buccal (RAMPART Silbergleit NEJM 2012); Stage 2 (20-40 min) fosphenytoin 20 PE/kg OR levetiracetam 60 mg/kg OR valproate 40 mg/kg (ESETT Kapur NEJM 2019 — no winner); Stage 3 (>40 min) midazolam infusion / pentobarbital / ketamine (NCS/AES 2016 Glauser); etiology-directed (pyridoxine, glucose, Mg, abx)
    inputs: weight
    advance: Stage 1-3 plan documented
  10. 10DISPOSITION
    PICU (intubated for stage 3); ward post-stabilization with cEEG continuation as needed (NCS/AES 2016 Glauser)
    advance: Disposition + level of care set
  11. 11MONITORING
    cEEG, neurochecks, vitals, ammonia, lactate, CK, AED levels (NCS/AES 2016 Glauser)
    advance: Monitoring orders documented
  12. 12FOLLOWUP
    Pediatric neurology, AED titration, family training (rescue benzo at home — diazepam rectal, midazolam buccal/IN) (NCS/AES 2016 Glauser; RAMPART Silbergleit NEJM 2012); MRI as needed
    advance: Follow-up + family education arranged