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The Treatment of Convulsive Status Epilepticus in Children

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The Treatment of Convulsive Status Epilepticus in Children Arch Dis Child 2000;83:415–419 415 The treatment of convulsive status epilepticus in Arch Dis Child: first published as 10.1136/adc.83.5.415 on 1 November 2000. Downloaded from children The Status Epilepticus Working Party Abstract There is little agreement between hospital There is currently little agreement be- protocols when treating CSE in children.11 In a tween hospital protocols when treating recent study of published guidelines none used convulsive status epilepticus in children, the same three initial drugs in the same order.11 and a working party has been set up to Many hospitals use the Advanced Paediatric produce a national evidence based guide- Life Support (APLS) guidelines, although line for treating this condition. This four these are primarily practice based, rather than step guideline is presented in this paper. evidence based.12 A paper presented to the Its eVectiveness will be highlighted and its annual scientific meeting of the British Paedi- use audited in a number of centres. atric Neurology Association in Southampton in (Arch Dis Child 2000;83:415–419) 1997 highlighted these diVerences in treatment and proposed that a multidisciplinary working Keywords: convulsive status epilepticus; guideline; party be established to produce a national evi- working party dence based guideline for treating CSE. It has been shown that the provision of standardised Generalised convulsive (tonic-clonic) status guidelines or protocols, similar to treating car- diac arrest, improve the quality of emergency epilepticus (CSE) is currently defined as a gen- 13 eralised convulsion lasting 30 minutes or care and therefore outcome. The working longer, or repeated tonic-clonic convulsions party was represented by the specialties of pae- occurring over a 30 minute period without diatric neurology, paediatric A&E medicine, recovery of consciousness between each general paediatrics, and paediatric clinical convulsion.1–4 Most tonic-clonic convulsions pharmacology. stop spontaneously, often within five minutes, and usually before a child arrives in an accident 5 Method and discussion and emergency department. However, tonic- A comprehensive computer based literature clonic convulsions which persist beyond four search was performed using Cochrane group or five minutes may not stop spontaneously methods. Searches were limited to the English and can become prolonged, lasting 30 minutes language. All paediatric status epilepticus or longer, thereby meeting the definition for papers were then hand searched to ensure no convulsive status epilepticus. articles were overlooked. Over 1100 papers http://adc.bmj.com/ Convulsive status epilepticus (CSE) in were identified of which 371 included original childhood is a life threatening condition with 246 (non-review) data relevant to the guidelines. serious risk of neurological sequelae, and Over the course of 12 months the working constitutes a medical emergency. Although the party met to analyse the published evidence outcome from an episode of CSE is mainly from these papers. A consensus guideline was determined by its cause, the duration of CSE is consequently produced. It is important to also important. In addition, the longer the emphasise that only two paediatric randomised on September 25, 2021 by guest. Protected copyright. duration of the episode, the more diYcult it is 67 controlled trials were identified in the system- to terminate. Therefore for practical pur- atic review. Therefore the final guideline is poses, the approach to the child who presents based on both evidence (paediatric and where with a tonic-clonic convulsion lasting more appropriate, adult) and clinical experience. than five minutes should be the same as with The letters in brackets within the text refer to the child who is in “established” status—to the strength of recommendations (see Appen- stop the seizure and prevent the development dix). The working party also prospectively col- of status epilepticus. lected audit data on all children presenting Members of the Status with and requiring treatment for an acute Epilepticus Working Party R Appleton Background tonic-clonic convulsion over a 12 month period I Choonara There is no precise estimate of the incidence or in three large children’s accident and emer- T Martland frequency of CSE at any age. Data from epide- gency (A&E) departments. These departments B Phillips miological studies suggest that four to eight all had an identified protocol for the treatment R Scott children per 1000 may be expected to experi- of CSE, although minor variations existed W Whitehouse ence an episode of CSE before the age of 15 between the protocols. The results of this 12 8 Correspondence to: years, and in children with first seizures, 12% month prospective audit will be the subject of a Dr T Martland, Consultant present with CSE as their first unprovoked separate paper. Paediatric Neurologist, seizure.9 CSE in children has a mortality of Figure 1 shows the consensus guideline Department of Neurology, 10 Booth Hall Children’s approximately 4%. Neurological sequelae of drawn up by the working party. There are many Hospital, Blackley, CSE (epilepsy, motor deficits, learning diYcul- diVerent clinical situations in which CSE can Manchester M9 7AA, UK ties, and behaviour problems) are age depend- occur. It was felt that a guideline that would [email protected] ent, occurring in 6% of those over 3 years but cover all possible circumstances and clinical Accepted 17 May 2000 in 29% of those under 1 year.10 situations would be impractical and lead to www.archdischild.com 416 Status Epilepticus Working Party Arch Dis Child: first published as 10.1136/adc.83.5.415 on 1 November 2000. Downloaded from Airway Breathing Circulation be given and the blood glucose measured by stick testing. It is important to emphasise that Give high flow oxygen not all episodes that appear to be seizures are Measure blood glucose epileptic. A brief history and clinical examina- Confirm epileptic seizure tion should therefore be undertaken to confirm genuine seizure activity and not, for example, a IMMEDIATE IV ACCESS NO IV ACCESS movement disorder (for example, drug induced 1. LORAZEPAM 0.1 MG/KG IV1. DIAZEPAM 0.5 MG/KG PR dystonic reaction or a tonic spasm caused by (give over 30–60 seconds) raised intracranial pressure) or psychogenic (pseudoepileptic) attack. seizure continuing at IV ACCESS seizure continuing at Most seizures stop within five minutes of 10 minutes 10 minutes onset. Although the definition of CSE implies that the seizure should last 30 minutes, in 2. LORAZEPAM 0.1 MG/KG IV2. PARALDEHYDE 0.4 ML/KG PR practice treatment should start within, and (give over 30–60 seconds) (give with the same volume of olive oil) certainly no more than 10 minutes of continu- ous generalised tonic-clonic (GTC) seizure seizure continuing at 10 minutes seizure continuing at 10 minutes activity. The times of drug administration on the guideline are from the time of arrival in A&E. It must be assumed that the convulsion CALL FOR SENIOR HELP will have been continuing for at least five min- 3. PHENYTOIN 18 MG/KG IV OVER 20 MINUTES utes prior to arrival. Those treating the child or should be aware of the signs of physiological IF ALREADY ON PHENYTOIN GIVE PHENOBARBITONE 20 MG/KG IV OVER 10 decompensation that occur in prolonged sei- MINUTES zures and should consider moving directly to step 4 if systemic compromise is severe with (use intraosseous route if still no IV access) hypotension and metabolic acidosis. AND Many children arrive at hospital having received rectal diazepam, or rarely, rectal PARALDEHYDE 0.4 ML/KG PR + SAME VOLUME OF OLIVE OIL IF NOT paraldehyde, from parents or paramedics. It ALREADY GIVEN was agreed not to take such treatment into account in drawing up the guidelines as both AND the drug used and dose given will vary. CALL ON-CALL ANAESTHETIST OR INTENSIVE CARE MEDIC For those children in whom intravenous access is immediately established, lorazepam Seizure continues 20 minutes after commencing step 3 0.1 mg/kg should be given intravenously. Lorazepam is equally or more eVective than 4. RAPID SEQUENCE INDUCTION OF ANAESTHESIA USING THIOPENTONE 4 MG/KG IV diazepam but possibly with less respiratory depression14–17 (A). Pharmacokinetic data also TRANSFER TO INTENSIVE CARE UNIT suggest a far longer duration of action for http://adc.bmj.com/ lorazepam (12–24 hours) than diazepam (<1 Figure 1 Treatment guideline for an acute tonic-clonic convulsion including established 15 18 convulsive status epilepticus. hour). In those children in whom attempts at immediate intravenous cannulation have confusion. Specifically, many patients with failed, rectal diazepam 0.5 mg/kg should be chronic epilepsy who have had repeated given6719 (B). Although lorazepam has been episodes of CSE may be recognised by their administered rectally using the intravenous usual medical team to respond (or not preparation,14 15 there are doubts about its respond) to certain drugs and in this situation absorption. Midazolam, administered by either on September 25, 2021 by guest. Protected copyright. an individual protocol would obviously be the buccal or nasal route, has been shown to be more appropriate. Seizures in neonates (less eVective and “safe” in a small number of than 28 days old) are usually symptomatic and selected patients.20–22 Its role in the accident frequently have a diVerent semiology com- and emergency department and the eVective pared to seizures in older children. This guide- dose has not yet been completely evaluated, line does not therefore address the treatment of although a multicentre randomised controlled seizures in neonates, although many of the trial (RCT) is currently being designed. principles may still be relevant. This consensus guideline is primarily designed for the A&E STEP 2 department or the ward when a child is first If after 10 minutes the initial convulsion has seen for an acute tonic-clonic convulsion.
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