UpToDate
Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate®

儿童惊厥性癫痫持续状态的治疗

Author
Angus Wilfong, MD
Section Editor
Douglas R Nordli, Jr, MD
Deputy Editor
April F Eichler, MD, MPH

引言

癫痫持续状态(status epilepticus, SE)是一种常常会危及生命的严重急症，需要迅速干预。SE虽然定义有所不同，但通常是指癫痫单次持续发作超过30分钟或发作间期不能回复到基线临床状态的频繁临床癫痫发作，早期SE是指癫痫发作持续超过5分钟。在实践中，发现早期SE时就应该开始针对SE的治疗。 SE可以是急性病的一个并发症，其在12%的癫痫患儿身上表现为癫痫首次发作[1]。10%-20%的癫痫患儿至少会出现一次SE发作。

儿童SE的治疗总结在此。该疾病的定义、病理生理学、危险因素及结局将单独讨论。 (参见“儿童癫痫持续状态的临床特征和并发症”)

总则

了解患者既往对抗癫痫药(antiepileptic drug, AED)的反应和目前的用药情况可能对治疗方法有指导意义。在决定初始治疗时，需要考虑以下问题：

既往对药物的反应 — 儿童有既往SE史时，了解哪些抗癫痫药能有效抑制癫痫发作对治疗有所帮助。例如，如果既往苯妥英或磷苯妥英对患儿无效，则苯巴比妥或丙戊酸(valproic acid, VPA)等其他药物将会成为首选。

遗漏用药 — 如果患儿长期使用抗癫痫药，则需要确定是否最近遗漏用药或是否未用处方再次取药。入院时的抗癫痫药水平检测可能需数小时才能得出结果，因此可能需要在没有该数据的情况下作出初始治疗的决策。例如，如果丙戊酸可以有效控制患儿的癫痫发作，且已知患儿一次或多次遗漏用药，则应该考虑将静脉给予丙戊酸作为初始治疗，而非苯妥英。

                              

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: 2017-07 . | This topic last updated: 2017-07-19.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
References
Top
  1. Shinnar S, Berg AT, Moshe SL, et al. The risk of seizure recurrence after a first unprovoked afebrile seizure in childhood: an extended follow-up. Pediatrics 1996; 98:216.
  2. Riviello JJ Jr, Ashwal S, Hirtz D, et al. Practice parameter: diagnostic assessment of the child with status epilepticus (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society. Neurology 2006; 67:1542.
  3. Maytal J, Novak G, Ascher C, Bienkowski R. Status epilepticus in children with epilepsy: the role of antiepileptic drug levels in prevention. Pediatrics 1996; 98:1119.
  4. Perucca E, Gram L, Avanzini G, Dulac O. Antiepileptic drugs as a cause of worsening seizures. Epilepsia 1998; 39:5.
  5. Tassinari CA, Dravet C, Roger J, et al. Tonic status epilepticus precipitated by intravenous benzodiazepine in five patients with Lennox-Gastaut syndrome. Epilepsia 1972; 13:421.
  6. Osorio I, Reed RC, Peltzer JN. Refractory idiopathic absence status epilepticus: A probable paradoxical effect of phenytoin and carbamazepine. Epilepsia 2000; 41:887.
  7. Smith PE, McBride A. Illicit drugs and seizures. Seizure 1999; 8:441.
  8. Fişgin T, Gürer Y, Senbil N, et al. Nasal midazolam effects on childhood acute seizures. J Child Neurol 2000; 15:833.
  9. Chin RF, Neville BG, Peckham C, et al. Treatment of community-onset, childhood convulsive status epilepticus: a prospective, population-based study. Lancet Neurol 2008; 7:696.
  10. Freeman JM. Status epilepticus: it's not what we've thought or taught. Pediatrics 1989; 83:444.
  11. Chin RF, Verhulst L, Neville BG, et al. Inappropriate emergency management of status epilepticus in children contributes to need for intensive care. J Neurol Neurosurg Psychiatry 2004; 75:1584.
  12. Johnson J, Wrenn K. Inappropriate fosphenytoin use in the ED. Am J Emerg Med 2001; 19:293.
  13. Singh BM, Strobos RJ. Epilepsia partialis continua associated with nonketotic hyperglycemia: clinical and biochemical profile of 21 patients. Ann Neurol 1980; 8:155.
  14. Placidi F, Floris R, Bozzao A, et al. Ketotic hyperglycemia and epilepsia partialis continua. Neurology 2001; 57:534.
  15. Hanhan UA, Fiallos MR, Orlowski JP. Status epilepticus. Pediatr Clin North Am 2001; 48:683.
  16. Tay SK, Hirsch LJ, Leary L, et al. Nonconvulsive status epilepticus in children: clinical and EEG characteristics. Epilepsia 2006; 47:1504.
  17. Jette N, Claassen J, Emerson RG, Hirsch LJ. Frequency and predictors of nonconvulsive seizures during continuous electroencephalographic monitoring in critically ill children. Arch Neurol 2006; 63:1750.
  18. Abend NS, Arndt DH, Carpenter JL, et al. Electrographic seizures in pediatric ICU patients: cohort study of risk factors and mortality. Neurology 2013; 81:383.
  19. Singh RK, Stephens S, Berl MM, et al. Prospective study of new-onset seizures presenting as status epilepticus in childhood. Neurology 2010; 74:636.
  20. Yoong M, Madari R, Martinos M, et al. The role of magnetic resonance imaging in the follow-up of children with convulsive status epilepticus. Dev Med Child Neurol 2012; 54:328.
  21. Appleton R, Choonara I, Martland T, et al. The treatment of convulsive status epilepticus in children. The Status Epilepticus Working Party, Members of the Status Epilepticus Working Party. Arch Dis Child 2000; 83:415.
  22. Brophy GM, Bell R, Claassen J, et al. Guidelines for the evaluation and management of status epilepticus. Neurocrit Care 2012; 17:3.
  23. Appleton R, Macleod S, Martland T. Drug management for acute tonic-clonic convulsions including convulsive status epilepticus in children. Cochrane Database Syst Rev 2008; :CD001905.
  24. Chamberlain JM, Okada P, Holsti M, et al. Lorazepam vs diazepam for pediatric status epilepticus: a randomized clinical trial. JAMA 2014; 311:1652.
  25. Appleton R, Sweeney A, Choonara I, et al. Lorazepam versus diazepam in the acute treatment of epileptic seizures and status epilepticus. Dev Med Child Neurol 1995; 37:682.
  26. Chiulli DA, Terndrup TE, Kanter RK. The influence of diazepam or lorazepam on the frequency of endotracheal intubation in childhood status epilepticus. J Emerg Med 1991; 9:13.
  27. Qureshi A, Wassmer E, Davies P, et al. Comparative audit of intravenous lorazepam and diazepam in the emergency treatment of convulsive status epilepticus in children. Seizure 2002; 11:141.
  28. Treiman DM, Meyers PD, Walton NY, et al. A comparison of four treatments for generalized convulsive status epilepticus. Veterans Affairs Status Epilepticus Cooperative Study Group. N Engl J Med 1998; 339:792.
  29. Leppik IE, Derivan AT, Homan RW, et al. Double-blind study of lorazepam and diazepam in status epilepticus. JAMA 1983; 249:1452.
  30. Alldredge BK, Gelb AM, Isaacs SM, et al. A comparison of lorazepam, diazepam, and placebo for the treatment of out-of-hospital status epilepticus. N Engl J Med 2001; 345:631.
  31. McDermott CA, Kowalczyk AL, Schnitzler ER, et al. Pharmacokinetics of lorazepam in critically ill neonates with seizures. J Pediatr 1992; 120:479.
  32. Greenblatt DJ, Shader RI, Franke K, et al. Pharmacokinetics and bioavailability of intravenous, intramuscular, and oral lorazepam in humans. J Pharm Sci 1979; 68:57.
  33. Relling MV, Mulhern RK, Dodge RK, et al. Lorazepam pharmacodynamics and pharmacokinetics in children. J Pediatr 1989; 114:641.
  34. Ahmad S, Ellis JC, Kamwendo H, Molyneux E. Efficacy and safety of intranasal lorazepam versus intramuscular paraldehyde for protracted convulsions in children: an open randomised trial. Lancet 2006; 367:1591.
  35. McIntyre J, Robertson S, Norris E, et al. Safety and efficacy of buccal midazolam versus rectal diazepam for emergency treatment of seizures in children: a randomised controlled trial. Lancet 2005; 366:205.
  36. Wills B, Erickson T. Chemically induced seizures. Clin Lab Med 2006; 26:185.
  37. Paloucek FP, Rodvold KA. Evaluation of theophylline overdoses and toxicities. Ann Emerg Med 1988; 17:135.
  38. Blake KV, Massey KL, Hendeles L, et al. Relative efficacy of phenytoin and phenobarbital for the prevention of theophylline-induced seizures in mice. Ann Emerg Med 1988; 17:1024.
  39. Koul R, Deleu D. Subtherapeutic free phenytoin levels following fosphenytoin therapy in status epilepticus. Neurology 2002; 58:147.
  40. Donn SM, Grasela TH, Goldstein GW. Safety of a higher loading dose of phenobarbital in the term newborn. Pediatrics 1985; 75:1061.
  41. Uberall MA, Trollmann R, Wunsiedler U, Wenzel D. Intravenous valproate in pediatric epilepsy patients with refractory status epilepticus. Neurology 2000; 54:2188.
  42. Sofou K, Kristjánsdóttir R, Papachatzakis NE, et al. Management of prolonged seizures and status epilepticus in childhood: a systematic review. J Child Neurol 2009; 24:918.
  43. Yu KT, Mills S, Thompson N, Cunanan C. Safety and efficacy of intravenous valproate in pediatric status epilepticus and acute repetitive seizures. Epilepsia 2003; 44:724.
  44. Mehta V, Singhi P, Singhi S. Intravenous sodium valproate versus diazepam infusion for the control of refractory status epilepticus in children: a randomized controlled trial. J Child Neurol 2007; 22:1191.
  45. Rai A, Aggarwal A, Mittal H, Sharma S. Comparative efficacy and safety of intravenous valproate and phenytoin in children. Pediatr Neurol 2011; 45:300.
  46. White JR, Santos CS. Intravenous valproate associated with significant hypotension in the treatment of status epilepticus. J Child Neurol 1999; 14:822.
  47. Silbergleit R, Durkalski V, Lowenstein D, et al. Intramuscular versus intravenous therapy for prehospital status epilepticus. N Engl J Med 2012; 366:591.
  48. Barberio M, Reiter PD, Kaufman J, et al. Continuous infusion pentobarbital for refractory status epilepticus in children. J Child Neurol 2012; 27:721.
  49. Rivera R, Segnini M, Baltodano A, Pérez V. Midazolam in the treatment of status epilepticus in children. Crit Care Med 1993; 21:991.
  50. Igartua J, Silver P, Maytal J, Sagy M. Midazolam coma for refractory status epilepticus in children. Crit Care Med 1999; 27:1982.
  51. Hanley DF, Kross JF. Use of midazolam in the treatment of refractory status epilepticus. Clin Ther 1998; 20:1093.
  52. Yoshikawa H, Yamazaki S, Abe T, Oda Y. Midazolam as a first-line agent for status epilepticus in children. Brain Dev 2000; 22:239.
  53. Papavasiliou AS, Kotsalis C, Paraskevoulakos E, et al. Intravenous midazolam in convulsive status epilepticus in children with pharmacoresistant epilepsy. Epilepsy Behav 2009; 14:661.
  54. Hertzog JH, Dalton HJ, Anderson BD, et al. Prospective evaluation of propofol anesthesia in the pediatric intensive care unit for elective oncology procedures in ambulatory and hospitalized children. Pediatrics 2000; 106:742.
  55. Prasad A, Worrall BB, Bertram EH, Bleck TP. Propofol and midazolam in the treatment of refractory status epilepticus. Epilepsia 2001; 42:380.
  56. Harrison AM, Lugo RA, Schunk JE. Treatment of convulsive status epilepticus with propofol: case report. Pediatr Emerg Care 1997; 13:420.
  57. Tobias JD. The use of propofol to treat status epilepticus in a nine-month-old female patient. Pediatr Emerg Care 1998; 14:248.
  58. Hanna JP, Ramundo ML. Rhabdomyolysis and hypoxia associated with prolonged propofol infusion in children. Neurology 1998; 50:301.
  59. Stelow EB, Johari VP, Smith SA, et al. Propofol-associated rhabdomyolysis with cardiac involvement in adults: chemical and anatomic findings. Clin Chem 2000; 46:577.
  60. van Gestel JP, Blussé van Oud-Alblas HJ, Malingré M, et al. Propofol and thiopental for refractory status epilepticus in children. Neurology 2005; 65:591.
  61. Baumeister FA, Oberhoffer R, Liebhaber GM, et al. Fatal propofol infusion syndrome in association with ketogenic diet. Neuropediatrics 2004; 35:250.
  62. Gaspard N, Foreman B, Judd LM, et al. Intravenous ketamine for the treatment of refractory status epilepticus: a retrospective multicenter study. Epilepsia 2013; 54:1498.
  63. Abend NS, Dlugos DJ. Treatment of refractory status epilepticus: literature review and a proposed protocol. Pediatr Neurol 2008; 38:377.
  64. Reiter PD, Huff AD, Knupp KG, Valuck RJ. Intravenous levetiracetam in the management of acute seizures in children. Pediatr Neurol 2010; 43:117.
  65. Gallentine WB, Hunnicutt AS, Husain AM. Levetiracetam in children with refractory status epilepticus. Epilepsy Behav 2009; 14:215.
  66. Höfler J, Trinka E. Lacosamide as a new treatment option in status epilepticus. Epilepsia 2013; 54:393.
  67. Miró J, Toledo M, Santamarina E, et al. Efficacy of intravenous lacosamide as an add-on treatment in refractory status epilepticus: a multicentric prospective study. Seizure 2013; 22:77.
  68. Sutter R, Marsch S, Rüegg S. Safety and efficacy of intravenous lacosamide for adjunctive treatment of refractory status epilepticus: a comparative cohort study. CNS Drugs 2013; 27:321.
  69. Shiloh-Malawsky Y, Fan Z, Greenwood R, Tennison M. Successful treatment of childhood prolonged refractory status epilepticus with lacosamide. Seizure 2011; 20:586.
  70. Jain V, Harvey AS. Treatment of refractory tonic status epilepticus with intravenous lacosamide. Epilepsia 2012; 53:761.
  71. Kahriman M, Minecan D, Kutluay E, et al. Efficacy of topiramate in children with refractory status epilepticus. Epilepsia 2003; 44:1353.
  72. Blumkin L, Lerman-Sagie T, Houri T, et al. Pediatric refractory partial status epilepticus responsive to topiramate. J Child Neurol 2005; 20:239.
  73. Perry MS, Holt PJ, Sladky JT. Topiramate loading for refractory status epilepticus in children. Epilepsia 2006; 47:1070.