Hubert P, Parain D, Vallée L
Unité de réanimation pédiatrique polyvalente, hôpital Necker-Enfants-Malades, AP-HP, 149, rue de Sèvres, 75743 Paris cedex 15, France.
Rev Neurol (Paris). 2009 Apr;165(4):390-7. doi: 10.1016/j.neurol.2008.11.009. Epub 2009 Mar 4.
Convulsive status epilepticus in childhood is a life threatening condition with serious risk of neurological sequelae which constitutes a medical emergency. Clinical and experimental data suggest that prolonged seizures can have immediate and long-term adverse consequences on the immature and developing brain. So the child who presents with a continuous generalized convulsive seizure lasting greater than five minutes should be promptly treated. The outcome is mainly determined by the underlying etiology, age and duration of status epilepticus. In children the mortality from status epilepticus ranges from 3 to 5% and the morbidity is two-fold higher. Mortality and morbidity are highest with status epilepticus associated with central nervous system infections, which is the most important cause of status epilepticus. There are few evidence-based data to guide management decisions for the child with status epilepticus. Immediate goals are stabilization of airways, breathing and circulation and termination of seizures. Benzodiazepines remain the first-line drugs recommended for prompt termination of seizures. As intravenous lorazepam is not available in France, we suggest clonazepam as the best choice for initial therapy. Rectal diazepam or buccal midazolam remain important options. Intravenous phenytoin/fosphenytoin and phenobarbital are the second-line drugs. Phenytoin is being increasingly substituted by fosphenytoin, but pediatric data are scarce and fosphenytoin is not authorized for use in France below five years old. In children, phenytoin is often preferred to phenobarbital, even though no comparative studies have demonstrated a better efficacy. To manage status epilepticus refractory to a benzodiazepine and administration of phenytoin and/or phenobarbital, many pediatricians today prefer high-dose midazolam infusion rather than thiopental to minimize serious side effects from barbiturate anesthesia. There is no benefit/risk ratio to support the use of propofol for children with refractory status epilepticus.
儿童惊厥性癫痫持续状态是一种危及生命的疾病，具有严重的神经后遗症风险，属于医疗急症。临床和实验数据表明，长时间发作会对未成熟和发育中的大脑产生即时和长期的不良后果。因此，出现持续全身性惊厥发作超过五分钟的儿童应立即接受治疗。预后主要取决于潜在病因、癫痫持续状态的年龄和持续时间。儿童癫痫持续状态的死亡率为3%至5%，发病率则高出两倍。与中枢神经系统感染相关的癫痫持续状态死亡率和发病率最高，这是癫痫持续状态最重要的原因。几乎没有循证数据可指导癫痫持续状态患儿的管理决策。 immediate goals are stabilization of airways, breathing and circulation and termination of seizures. Benzodiazepines remain the first-line drugs recommended for prompt termination of seizures. As intravenous lorazepam is not available in France, we suggest clonazepam as the best choice for initial therapy. Rectal diazepam or buccal midazolam remain important options. Intravenous phenytoin/fosphenytoin and phenobarbital are the second-line drugs. Phenytoin is being increasingly substituted by fosphenytoin, but pediatric data are scarce and fosphenytoin is not authorized for use in France below five years old. In children, phenytoin is often preferred to phenobarbital, even though no comparative studies have demonstrated a better efficacy. To manage status epilepticus refractory to a benzodiazepine and administration of phenytoin and/or phenobarbital, many pediatricians today prefer high-dose midazolam infusion rather than thiopental to minimize serious side effects from barbiturate anesthesia. There is no benefit/risk ratio to support the use of propofol for children with refractory status epilepticus.
直接目标是稳定气道、呼吸和循环并终止发作。苯二氮䓬类药物仍然是推荐用于迅速终止发作的一线药物。由于法国没有静脉注射用劳拉西泮，我们建议氯硝西泮作为初始治疗的最佳选择。直肠用安定或口腔用咪达唑仑仍然是重要的选择。静脉注射苯妥英/磷苯妥英和苯巴比妥是二线药物。苯妥英正越来越多地被磷苯妥英取代，但儿科数据稀缺，且磷苯妥英在法国未获批准用于5岁以下儿童。在儿童中，苯妥英通常比苯巴比妥更受青睐，尽管没有比较研究表明其疗效更好。对于对苯二氮䓬类药物以及苯妥英和/或苯巴比妥治疗无效的癫痫持续状态，如今许多儿科医生更倾向于使用高剂量咪达唑仑输注而非硫喷妥钠，以尽量减少巴比妥类麻醉的严重副作用。没有支持将丙泊酚用于难治性癫痫持续状态患儿的效益/风险比。
