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Intensive Care 71

Administer high flow oxygen
Check blood glucose
Obtain intravenous (IV) access

IV Access?
Yes No

Lorazepam IV 0.1 mg/kg Diazepam PR 0.5 mg/kg
or or
Diazepam IV 0.2 mg/kg Midazolam buccal 0.2 mg/kg
Lorazepam IV 0.1 mg/kg Diazepam PR 0.5 mg/kg
or or
Diazepam IV 0.2 mg/kg Midazolam buccal 0.2 mg/kg

If no IV access establish
intraosseus (IO) access
Is patient on regular
phenytoin?

No Yes

Phenytoin IV 18 mg/kg Phenobarbitone IV 20 mg/kg
Paraldehyde PR 0.4 mg/kg—mix with Paraldehyde PR 0.4 mg/kg—mix with
equal amount olive oil (if not equal amount olive oil (if not
already given) already given)

Anaesthesia to stop seizures → Intubate and ventilate
Thiopentone IV 3–5 mg/kg and short-acting muscle relaxant

Consider:
• CT of head if signs of raised intracranial pressure or focal neurology
• Neurology and or neurosurgical opinion

Admit to paediatric intensive care unit (PICU)
Following consultation with intensivist/neurologist may require:
• Thiopentone infusion
• Midazolam infusion

Figure 12.1: Management of status epilepticus in a child.

(CT) of the head, may be required. The diagnosis of central nervous system mirrors the differential diagnosis of decreased level of consciousness,
(CNS) infection generally requires lumbar puncture to assess cell count, and establish oxygenation and circulation as detailed above. If
protein, and glucose content. appropriate, specific therapy should be instituted as soon as possible
Lumbar puncture should be performed in a controlled manner, provided (e.g., the treatment of hypoglycaemia with a dextrose infusion of 5–10
50
there are no contraindications, such as focal neurological signs, raised ml/kg of 10% dextrose solution). The treatment for a prolonged seizure
intracranial pressure (ICP), cardiovascular instability, coagulopathy, local or recurrent seizures is indicated in Figure 12.1. 55–57
skin infection over the proposed puncture site, suspected spinal cord mass Although the paediatric CNS may be relatively immature, children
or intracranial mass lesion, or spinal column deformities. do still have appropriate response to pain. It is therefore important to
remember that critically ill children who require invasive diagnostic or
therapeutic procedures, or intubation and mechanical ventilation, require
Always defer lumbar puncture in unstable patients, but never delay
antibiotic or antiviral treatment, if indicated. appropriate analgesia and sedation. In addition to the obvious benefits of
analgesia and sedation, there is evidence to support decreased morbidity
and mortality following cardiac surgery in infants treated with effective
analgesia. 58–60 In the intensive-care setting, opioids, such as morphine and
The use of hypotonic fluid is contraindicated when signs of raised fentanyl, are commonly used for analgesia, whereas sedation is commonly
intracranial pressure are evident. Hypotonic fluid should generally be avoided achieved with benzodiazepines, such as midazolam or diazepam.
in all children with acute neurological disease. This is due to the risk of sudden Infection
fluid shifts resulting from changes in plasma osmolality and the potential for Bacterial, viral, fungal, and protozoal infections are responsible for more
51
rapid increases in intracranial pressure. Not enough data exist to support than 60% of deaths worldwide. Acute respiratory infections are among the
routine fluid restriction. 52–53 In the setting of acute neurological deterioration leading cause of childhood mortality and account for almost two million
with signs of rising intracranial pressure and possible brain stem herniation, childhood deaths annually. Approximately 70% of these deaths occur in
the use of hypertonic saline or intravenous mannitol may be warranted. 54 Africa. The most important causes of death in the developing world con-
Seizures are a common feature of both primary and secondary CNS tinue to be malaria, pneumonia, malnutrition, and HIV-related illnesses. 61–63
abnormality. It is important to address the underlying cause, which