Inappropriate emergency management of status epilepticus in children contributes to need for intensive care

A retrospective observational study of current treatment for generalized convulsive status epilepticus

OBJECTIVES

This study aimed at determining the current state of practice of treatment for acute generalized convulsive status epilepticus (GCSE) and responsiveness to therapy.

METHODS

This observational study was performed by retrospectively identifying patients with GCSE presenting to an emergency room setting. The primary outcome was seizure cessation following medication administration. Secondary outcomes were rates of intubation and mortality.

RESULTS

One hundred seventy-seven episodes of GCSE were identified. All patients, except 1, received a benzodiazepine for first-line treatment. Only 11% of these patients, all children, were treated with at least 0.1mg/kg of lorazepam or an equivalent dose of an alternative benzodiazepine. A first-line treatment was effective in 56% of the patients, a second-line treatment in an additional 28%, and a third-line treatment in 12%. Phenytoin was the most prescribed second-line treatment (41%) but statistically significantly least effective (22% versus 86% seizure cessation, p<0.0001) compared with all other second-line agents together. Propofol was the most prescribed third-line treatment.

CONCLUSIONS

Results emphasize that, in clinical practice, approximately half of GCSE patients respond to first-line therapy and, among nonresponders, approximately two-thirds respond to second-line and approximately three-quarters respond to third-line therapies. The variations in treatment selection reflect that there are no randomized controlled trials to guide treatment beyond use of benzodiazepines for first-line treatment. The observation that phenytoin is statistically substantially worse than other second-line treatments raises the possibility that the most commonly selected second-line treatment is the least effective and provides equipoise for a large randomized controlled trial of second-line therapies.

Management of pediatric status epilepticus

OPINION STATEMENT

Status epilepticus (SE) is a medical emergency consisting of persistent or recurring seizures without a return to baseline mental status. SE can be divided into subtypes based on seizure types and underlying etiologies. Management should be implemented rapidly and based on pre-determined care pathways. The aim is to terminate seizures while simultaneously identifying and managing precipitant conditions. Seizure management involves "emergent" treatment with benzodiazepines (lorazepam intravenously, midazolam intramuscularly, or diazepam rectally) followed by "urgent" therapy (phenytoin/fosphenytoin, phenobarbital, levetiracetam or valproate sodium). If seizures persist, "refractory" treatments include infusions of midazolam or pentobarbital. Prognosis is dependent on the underlying etiology and seizure persistence. This article reviews the current management strategies for pediatric convulsive SE.

Doing challenging research studies in a patient-centred way: a qualitative study to inform a randomised controlled trial in the paediatric emergency care setting

OBJECTIVE

To inform the design of a randomised controlled trial (called EcLiPSE) to improve the treatment of children with convulsive status epilepticus (CSE). EcLiPSE requires the use of a controversial deferred consent process.

DESIGN

Qualitative interview and focus group study.

SETTING

8 UK support groups for parents of children who have chronic or acute health conditions and experience of paediatric emergency care.

PARTICIPANTS

17 parents, of whom 11 participated in telephone interviews (10 mothers, 1 father) and 6 in a focus group (5 mothers, 1 father). 6 parents (35%) were bereaved and 7 (41%) had children who had experienced seizures, including CSE.

RESULTS

Most parents had not heard of deferred consent, yet they supported its use to enable the progress of emergency care research providing a child's safety was not compromised by the research. Parents were reassured by tailored explanation, which focused their attention on aspects of EcLiPSE that addressed their priorities and concerns. These aspects included the safety of the interventions under investigation and how both EcLiPSE interventions are used in routine clinical practice. Parents made recommendations about the appropriate timing of a recruitment discussion, the need to individualise approaches to recruiting bereaved parents and the use of clear written information.

CONCLUSIONS

Our study provided information to help ensure that a challenging trial was patient centred in its design. We will use our findings to help EcLiPSE practitioners to: discuss potentially threatening trial safety information with parents, use open-ended questions and prompts to identify their priorities and concerns and clarify related aspects of written trial information to assist understanding and decision-making.

Emergency management of febrile status epilepticus: results of the FEBSTAT study

OBJECTIVE

Treatment of seizures varies by region, with no standard emergency treatment protocol. Febrile status epilepticus (FSE) is often a child's first seizure; therefore, families are rarely educated about emergency treatment.

METHODS

From 2002 to 2010, 199 subjects, age 1 month to 6 years, were recruited as part of a prospective, multicenter study of consequences of FSE, which was defined as a febrile seizure or series of seizures lasting >30 min. The patients' charts were reviewed. No standardized treatment protocol was implemented for this observational study.

RESULTS

One hundred seventy-nine children received at least one antiepileptic drug (AED) to terminate FSE, and more than one AED was required in 140 patients (70%). Median time from the seizure onset to first AED by emergency medical services (EMS) or emergency department (ED) was 30 min. Mean seizure duration was 81 min for subjects given medication prior to ED and 95 min for those who did not (p = 0.1). Median time from the first dose of AED to end of seizure was 38 min. Initial dose of lorazepam or diazepam was suboptimal in 32 (19%) of 166 patients. Ninety-five subjects (48%) received respiratory support by EMS or ED. Median seizure duration for the respiratory support group was 83 min; for the nonrespiratory support group the duration was 58 min (p-value < 0.001). Reducing the time from seizure onset to AED initiation was significantly related to shorter seizure duration.

SIGNIFICANCE

FSE rarely stops spontaneously, is fairly resistant to medications, and even with treatment persists for a significant period of time. The total seizure duration is composed of two separate factors, the time from seizure onset to AED initiation and the time from first AED to seizure termination. Earlier onset of treatment results in shorter total seizure duration. A standard prehospital treatment protocol should be used nationwide and education of EMS responders is necessary.

An educational campaign toward epilepsy among Italian primary school teachers: 1. Survey on knowledge and attitudes

A questionnaire survey was undertaken to assess the impact of a nationwide educational campaign about epilepsy on the knowledge and attitudes toward the disease among Italian primary school teachers. Five hundred and eighty-two teachers participated. All interviewees were aware of the existence of epilepsy, and most of them had direct experience with the disease. Answers about frequency, causes, outcome, and response to treatments were variable and not correlated with age, residency, and years of experience. Teachers had positive attitudes toward epilepsy, except for the idea that driving and sports can be safe for people with epilepsy. Epilepsy and its treatment were considered a source of learning disability and social disadvantages. Several teachers declared themselves being unable to help a child having seizures. Calling an ambulance was a frequent action. Knowledge and attitudes toward epilepsy are improved compared with those reported in our previous studies. Although this may be a positive reflection of the increasing knowledge and the greater availability of information on epilepsy, there are still areas of uncertainty and incorrect behaviors.

Pharmacologic management of convulsive status epilepticus in childhood

The incidence of convulsive status epilepticus in children is approximately 20-50/100,000/year, and is an emergency requiring prompt medical intervention. Prolonged seizures lasting over 5 min are unlikely to stop spontaneously, and time-to-treatment influences treatment response. Prolonged seizures should thus be treated as early status epilepticus. Mortality and morbidity increase significantly with the length of ongoing seizure activity, especially after 60 min. Benzodiazepines remain the first-line drug therapy due to their rapid onset of action. Recent studies imply that buccal midazolam is more effective and easier to administer than rectal diazepam. Phenytoin/fosphenytoin and phenobarbital administered intravenously remain the second-line treatments of choice, whilst barbiturates and midazolam as intravenous anesthetics are used for third-line treatment. Electroencephalogram monitoring is essential to evaluate the electrophysiologic treatment response and depth of anesthesia, especially in refractory status epilepticus. In the future, more individualized protocols and pathways are needed in order to optimize treatment responses. Randomized clinical trials are needed to evaluate new treatment protocols, which should not only stop the seizures more effectively but also be safer and include some neuroprotective elements to halt the cascade of neuronal injury and minimize the risk for neurologic morbidity caused by the convulsive status epilepticus.

First line management of prolonged convulsive seizures in children and adults: good practice points

Over the past decades, it has become clear that the most efficient way to prevent status epilepticus is to stop the seizure as fast as possible, and early treatment of prolonged convulsive seizures has become an integral part of the overall treatment strategy in epilepsy. Benzodiazepines are the first choice drugs to be used as emergency medication. This treatment in the early phases of a seizure often implies a 'pre-medical' setting before intervention of medically trained persons. In this paper, we propose "good practice points" for first line management of prolonged convulsive seizures in children and adults in a 'pre-medical' setting.

Are we failing to provide adequate rescue medication to children at risk of prolonged convulsive seizures in schools?

OBJECTIVE

This paper explores the issues that arise from the discussion of administering rescue medication to children who experience prolonged convulsive seizures in mainstream schools in the UK.

SITUATION ANALYSIS

Current guidelines recommend immediate treatment of children with such seizures (defined as seizures lasting more than 5 min) to prevent progression to status epilepticus and neurological morbidity. As children are unconscious during prolonged convulsive seizures, whether or not they receive their treatment in time depends on the presence of a teacher or other member of staff trained and able to administer rescue medication. However, it is thought that the situation varies between schools and depends mainly on the goodwill and resources available locally.

RECOMMENDATIONS

A more systematic response is needed to ensure that children receive rescue medication regardless of where their seizure occurs. Possible ways forward include: greater use of training resources for schools available from epilepsy voluntary sector organisations; consistent, practical information to schools; transparent guidance outlining a clear care pathway from the hospital to the school; and implementation and adherence to each child's individual healthcare plan.

IMPLICATIONS

Children requiring emergency treatment for prolonged convulsive seizures during school hours test the goals of integrated, person-centred care as well as joined-up working to which the National Health Service (NHS) aspires. As changes to the NHS come into play and local services become reconfigured, every effort should be made to take account of the particular needs of this vulnerable group of children within broader efforts to improve the quality of paediatric epilepsy services overall.

Status epilepticus in childhood

Status epilepticus (SE) remains a life-threatening condition that afflicts both adults and children, and may occur at onset of epilepsy, especially in children. Febrile SE is the most common cause in children, while other symptomatic causes are less frequent compared to adults. The aetiological workup that must be undertaken in all cases includes neuroimaging and electroencephalography. The various electroencephalographic patterns seen in patients with SE along with the out-of-hospital treatment for SE in children and treatment strategies in cases that are refractory to first-line medical treatments are discussed. Medically induced coma may be necessary in refractory cases, although the optimal agents to use and degree of electroencephalographic suppression in children remain unclear. Neurosurgery is not a well-known treatment option that could be considered for refractory cases. Although the prognosis has probably improved over the years, it remains a potential life-threatening emergency.

The administration of rescue medication to children with prolonged acute convulsive seizures in the community: what happens in practice?

This paper presents the findings of a review of existing clinical and non-clinical guidance on the management of children with prolonged acute convulsive seizures (PCS) and the administration of rescue medication in community settings. Findings are based on desk- and web-based research in 6 countries. Published clinical guidelines are mostly limited to the hospital setting and offer few explicit recommendations for community settings. Non-clinical guidance on the management of medicines at school exists at the national or regional level in all 6 countries, however rescue epilepsy medication is often not mentioned specifically. Existing legal frameworks are vague and open to interpretation. As a result, whether a child receives rescue medication at school depends primarily on the availability of a willing teacher who accepts responsibility for administering it to that child during school hours. Comprehensive guidelines are clearly needed that provide practical guidance to ensure that children with PCS are treated as quickly as possible in all community settings. Recommendations for future action include: providing clearer information on PCS and rescue medication to parents and schools; putting in place an individual healthcare plan for every child with a history of PCS at his or her school; collecting more empirical data to gain a better understanding of the experience of children with PCS at school, their parents and teachers; and finally, implementing systematic training for all carers of children with PCS. The epilepsy specialist may play an important role in ensuring that these recommendations are put into place for their patients.

Risk factors associated with death in in-hospital pediatric convulsive status epilepticus

Objective

To evaluate in-patient mortality and predictors of death associated with convulsive status epilepticus (SE) in a large, multi-center, pediatric cohort.

Patients and Methods

We identified our cohort from the KID Inpatient Database for the years 1997, 2000, 2003 and 2006. We queried the database for convulsive SE, associated diagnoses, and for inpatient death. Univariate logistic testing was used to screen for potential risk factors. These risk factors were then entered into a stepwise backwards conditional multivariable logistic regression procedure. P-values less than 0.05 were taken as significant.

Results

We identified 12,365 (5,541 female) patients with convulsive SE aged 0–20 years (mean age 6.2 years, standard deviation 5.5 years, median 5 years) among 14,965,571 pediatric inpatients (0.08%). Of these, 117 died while in the hospital (0.9%). The most frequent additional admission ICD-9 code diagnoses in addition to SE were cerebral palsy, pneumonia, and respiratory failure.

Independent risk factors for death in patients with SE, assessed by multivariate calculation, included near drowning (Odds ratio [OR] 43.2; Confidence Interval [CI] 4.4–426.8), hemorrhagic shock (OR 17.83; CI 6.5–49.1), sepsis (OR 10.14; CI 4.0–25.6), massive aspiration (OR 9.1; CI 1.8–47), mechanical ventilation >96 hours (OR9; 5.6–14.6), transfusion (OR 8.25; CI 4.3–15.8), structural brain lesion (OR7.0; CI 3.1–16), hypoglycemia (OR5.8; CI 1.75–19.2), sepsis with liver failure (OR 14.4; CI 5–41.9), and admission in December (OR3.4; CI 1.6–4.1). African American ethnicity (OR 0.4; CI 0.2–0.8) was associated with a decreased risk of death in SE.

Conclusion

Pediatric convulsive SE occurs in up to 0.08% of pediatric inpatient admissions with a mortality of up to 1%. There appear to be several risk factors that can predict mortality. These may warrant additional monitoring and aggressive management.

Management of patients with status epilepticus treated at a pediatric intensive care unit in Turkey

We investigated the etiology, treatment, and prognosis of patients treated for status epilepticus at a pediatric intensive care unit. Medical records of 89 patients admitted to a pediatric intensive care unit with status epilepticus were reviewed retrospectively. Patients ranged in age from 2 months to 18 years (mean age ± S.D., 4.7 ± 3.8 years). Seizure etiologies comprised remote symptomatic in 47 (52.7%), febrile in 15 (16.9%), acute symptomatic in 12 (13.5%), and unknown in 15 (16.9%). Seizure durations ranged from 30-60 minutes in 58 patients, whereas 31 manifested refractory seizures longer than 60 minutes. Seizure control was achieved within 30 minutes in 55 patients, from 30-60 minutes in 19, and after 60 minutes in 15. Rectal diazepam was administered to 38 (42.7%) patients before admission to the hospital. Length of intensive care unit stay increased with increasing seizure duration (P < 0.05). The total mortality rate was 3.4%. This lower mortality rate may be considered evidence of the effectiveness and reliability of the status epilepticus treatment protocol in our pediatric intensive care unit. Prehospital rectal diazepam administration and the treatment of brain edema in the intensive care unit may be useful in the management of patients with status epilepticus.

Treatment of pediatric status epilepticus

OPINION STATEMENT

Status epilepticus is characterized by a prolonged, self-sustaining seizure or repeated seizures without return to baseline. The clinical manifestations of status epilepticus in children and adults range from overt generalized convulsions to more subtle behavioral manifestations, including unresponsiveness in the setting of the intensive care unit. Status epilepticus is the most common neurologic emergency of childhood. A large proportion of these episodes are the result of a prolonged febrile seizure or an acute symptomatic etiology. Fortunately, status epilepticus occurs without consequence for many children, but for others, it is correlated with long-term neurologic dysfunction or death. Treatment of status epilepticus should commence promptly upon its recognition, using predefined treatment protocols. The goal of treatment is the rapid termination of the seizure, to minimize the acute and chronic effects of this emergency and to allow for the prompt assessment and management of the underlying precipitant. Currently, the drug class of first choice in the in-hospital and out-of-hospital treatment of status epilepticus is the benzodiazepines, which may need to be quickly followed by a next-line agent, as the efficacy of the benzodiazepines is negatively correlated with seizure duration. Traditionally, these next-line agents have included phenobarbital and phenytoin, but emerging evidence supports the use of intravenous formulations of other antiepileptic drugs. If the first two agents fail, high-dose intravenous midazolam or anesthetic therapy should be rapidly initiated. This paper reviews the current treatment options and strategies for pediatric patients with status epilepticus.

Status Epilepticus in Children

Status epilepticus (SE) is a life-threatening emergency that requires prompt treatment, including basic neuroresuscitation principles (the ABCs), antiepileptic drugs to stop the seizure and identification of etiology. It results from an inability to normally abort an isolated seizure either due to ineffective inhibition, or due to abnormally persistent excessive excitation. Symptomatic SE is more common in younger children and the likely etiology depends on the age of the child. Treating the precipitating cause may prevent ongoing neurologic injury and facilitates seizure control. Benzodiapenes, phenytoin and phenobarbital form the mainstay of treatment. A systematic treatment regimen, planned in advance, is needed, including one for refractory status epilepticus (RSE). Patient education and home management of seizures is important to reduce the morbidity and mortality associated with SE.

Status epilepticus

Status epilepticus is a common neurological emergency in childhood and associated with significant morbidity and mortality. Status epilepticus (SE) has been defined as continuous seizure activity lasting more than 30 min or 2 or more seizures in this duration without gaining consciousness between them. However, the operational definition has brought the time down to 5 min. Management can be broadly divided into initial stabilization, seizure termination, and evaluation and treatment of the underlying cause. Diagnostic evaluation and seizure control should be achieved simultaneously to improve outcome. Seizure termination is achieved by pharmacotherapy. Benzodiazepines are the first line drugs for SE. Commonly used drugs include lorazepam, diazepam, and midazolam. In children without an IV access, buccal or nasal midazolam or rectal diazepam can be used. Phenytoin as a second line agent is usually indicated when seizure is not controlled after one or more doses of benzodiazepines. If the seizures continue to persist, valproate, phenobarbitone or levetiracetam is indicated. Midazolam infusion is useful in refractory status epilepticus. Thiopentone, propofol or high dose phenobarbitone are considered for treatment of refractory status epilepticus. Prolonged SE is associated with higher morbidity and mortality. Long term neurological sequelae include epilepsy, behavioural problems, cognitive decline, and focal neurologic deficits.

Outcome of status epilepticus in children treated in the intensive care unit: a study of 302 cases

PURPOSE

The aim of the study was to evaluate the outcome of status epilepticus (SE) in children and to define predictors for morbidity, mortality, and SE recurrence.

METHODS

The study included 302 children (age 2 months to less than 18 years; mean age ± SD 4.7 ± 4.2 years) with 489 episodes of SE. Etiology, treatment, and clinical and electroencephalography (EEG) features of SE and their impact on the outcome were analyzed. The outcome was classified into three categories: unchanged neurologic status, neurologic consequences, and lethal outcome. Univariate and multivariate Cox hazard regression analyses were used to define predictors of mortality, morbidity, and SE recurrence.

KEY FINDINGS

Neurologic status was unchanged in 235 children (77.8%) and neurologic consequences occurred in 39 patients (12.9%); case-fatality ratio was 9.3% and recurrence rate was 21%. Mortality was related to progressive encephalopathy, preexisting neurologic abnormalities, specific EEG findings, and generalized convulsive type of SE. Neurologic consequences were associated with younger age, progressive encephalopathy, duration of SE >24 h, prior epilepsy, and specific EEG findings. Multivariate analyses showed that etiology of SE and prior neurologic abnormalities were independent predictors of mortality, whereas younger age, etiology, and very long duration of SE were predictors of morbidity.

SIGNIFICANCE

Outcome of SE in children is favorable in most of the cases, but mortality and morbidity rates are still high. Etiology and prior neurologic abnormalities were the main predictors of mortality, whereas the main predictor of morbidity was underlying etiology.

Medical treatment of pediatric status epilepticus

Status epilepticus (SE) is a common pediatric neurologic emergency that refers to a prolonged seizure or recurrent seizures without a return to baseline mental status between seizures. Appropriate treatment strategies are necessary to prevent prolonged SE and its associated morbidity and mortality. This review discusses the importance of a rapid and organized management approach, reviews data related to commonly utilized medications including benzodiazepines, phenytoin, phenobarbital, valproate sodium, and levetiracetam, and then provides a sample SE management algorithm.

Emergency management of paediatric status epilepticus in Australia and New Zealand: practice patterns in the context of clinical practice guidelines

AIMS

To establish current acute seizure management through a review of clinical practice guidelines (CPGs) and reported physician management in the 11 largest paediatric emergency departments in Australia (n= 9) and New Zealand (n= 2) within the Paediatric Research in Emergency Departments International Collaborative (PREDICT) network, and to compare this with Advanced Paediatric Life Support (APLS) guidelines and existing evidence.

METHODS

(i) Review of CPGs for acute seizure management at PREDICT sites. (ii) A standardised anonymous survey of senior emergency doctors at PREDICT sites investigating management of status epilepticus (SE).

RESULTS

Ten sites used seven different seizure CPGs. One site had no seizure CPG. First line management was with benzodiazepines (10 sites). Second line and subsequent management included phenytoin (10), phenobarbitone (10), thiopentone (9), paraldehyde (6) and midazolam infusion (5). Of 83 available consultants, 78 (94%) responded. First line management of SE without intravenous (IV) access included diazepam per rectum (PR) (49%), and midazolam intramuscular (41%) and via the buccal route (9%). First line management of SE with IV access included midazolam IV (50%) and diazepam IV (44%). The second line agent was phenytoin (88%); third line agents were phenobarbitone (33%), thiopentone and intubation (32%), paraldehyde PR (22%) and midazolam infusion (6%). Fourth line agents were thiopentone and intubation (60%), phenobarbitone (16%), midazolam infusion (13%) and paraldehyde (9%).

CONCLUSIONS

Initial seizure management by CPG recommendations and reported physician practice was broadly similar across PREDICT sites and consistent with APLS guidelines. Practice was variable for second/third line SE management. Areas of controversy would benefit from multi-centred trials.

The ketogenic diet improves recently worsened focal epilepsy

AIM

We observed a dramatic response to the ketogenic diet in several patients with highly refractory epilepsy whose seizure frequency had recently worsened. This study aimed to identify whether this characteristic was a useful indication for the ketogenic diet.

METHOD

From the 70 patients who received the ketogenic diet during a 3-year period at our institution, we retrospectively selected patients with focal epilepsy. There were 22 children, 13 females and nine males, aged from 5 months to 18 years 6 months (mean 6y 9mo, SD 5y 11mo). Fifteen had symptomatic and seven had cryptogenic focal epilepsy. Seizure frequency 1 week before initiating the ketogenic diet was compared with that at 1 month and at the last visit on the diet.

RESULTS

Eleven patients were responders (defined as reduction of seizures by more than 50%) at 1 month. Responders were higher (p=0.046) in the group with a recent worsening of seizures than in those with stable seizure frequency. Seven patients were still seizure-free at 6 months on the diet. Tolerability was excellent in 10 patients. Five patients stopped the diet because of early side effects.

INTERPRETATION

The ketogenic diet may be a valuable therapeutic option for children with pharmacoresistant focal epilepsy, particularly those with a recent deterioration of seizure control and neurological status. Because of its rapid effect, the ketogenic diet may be a useful support to intravenous emergency drugs in such a situation.

Status epilepticus in children

Status epilepticus is a common, life-threatening medical emergency in pediatric patients. Recent medical literature has focused on identifying risks and treatment options. This article highlights the epidemiology of status epilepticus, both convulsive and nonconvulsive, in children. It also reviews the recommended medications for first-line treatment of status epilepticus and refractory status epilepticus. Emphasis is placed on future pharmacotherapies and consideration of neurosurgical intervention when indicated.

Treatment of community-onset, childhood convulsive status epilepticus: a prospective, population-based study

BACKGROUND

Episodes of childhood convulsive status epilepticus (CSE) commonly start in the community. Treatment of CSE aims to minimise the length of seizures, treat the causes, and reduce adverse outcomes; however, there is a paucity of data on the treatment of childhood CSE. We report the findings from a systematic, population-based study on the treatment of community-onset childhood CSE.

METHODS

We collected data prospectively on children in north London, UK, who had episodes of CSE (ascertainment 62-84%). The factors associated with seizure termination after first-line and second-line therapies, episodes of CSE lasting for longer than 60 min, and respiratory depression were analysed with logistic regression. Analysis was per protocol, and adjustment was made for repeat episodes in individuals.

RESULTS

182 children of median age 3.24 years (range 0.16-15.98 years) were included in the North London Convulsive Status Epilepticus in Childhood Surveillance Study (NLSTEPSS) between May, 2002, and April, 2004. 61% (147) of 240 episodes were treated prehospital, of which 32 (22%) episodes were terminated. Analysis with multivariable models showed that treatment with intravenous lorazepam (n=107) in the accident and emergency department was associated with a 3.7 times (95% CI 1.7-7.9) greater likelihood of seizure termination than was treatment with rectal diazepam (n=80). Treatment with intravenous phenytoin (n=32) as a second-line therapy was associated with a 9 times (95% CI 3-27) greater likelihood of seizure termination than was treatment with rectal paraldehyde (n=42). No treatment prehospital (odds ratio [OR] 2.4, 95% CI 1.2-4.5) and more than two doses of benzodiazepines (OR 3.6, 1.9-6.7) were associated with episodes that lasted for more than 60 min. Treatment with more than two doses of benzodiazepines was associated with respiratory depression (OR 2.9, 1.4-6.1). Children with intermittent CSE arrived at the accident and emergency department later after seizure onset than children with continuous CSE did (median 45 min [range 11-514 min] vs 30 min [5-90 min]; p<0.0001, Mann-Whitney U test); for each minute delay from onset of CSE to arrival at the accident and emergency department there was a 5% cumulative increase in the risk of the episode lasting more than 60 min.

INTERPRETATION

These data add to the debate on optimum emergency treatment of childhood CSE and suggest that the current guidelines could be updated.

Closing the knowledge-performance gap: an audit of medical management for severe paediatric trauma in Flanders (Belgium)

AIMS

Considerable variability in (paediatric) trauma care has been reported. We wanted to audit current practice in Flanders (Belgium).

METHODS

The PENTA network prospectively collected data on paediatric trauma patients in a representative sample of Flemish hospitals during 2005. All cases with an ISS>or=13 and sufficient data availability were withheld for panel evaluation (n=92). Two trained experts reviewed the medical care provided in the first hours after trauma, based on available evidence and existing universal guidelines. 'Defaults' were only withheld as such if there was 100% consensus. At random, about 25% of cases were also reviewed by two other experts in order to assess interobserver variability.

RESULTS

In the 92 cases, 264 defaults were recognised. 25.4% of all defaults were thought to have a direct impact on the individual patient's outcome. Specific difficulties were observed with, e.g. cervical spine management (18/82 relevant cases), pCO2 and global respiratory management (38/92), fluid management (29/92) and analgesia (27/89). The agreement between the two panels was good for defaults identified (crude agreement 74.8%), yet only fair for the presumed impact on outcome (crude agreement 58.3%).

CONCLUSIONS

We audited paediatric trauma care in Flanders and identified several problem areas (often in basic areas of paediatric life support). The inherent degree of interobserver variability does not diminish the importance of these findings. More performance-based teaching and timely recertification may have a positive impact on the quality of the care delivered.

Pharmacokinetics and clinical efficacy of midazolam in children with severe malaria and convulsions

AIM

To investigate the pharmacokinetics and clinical efficacy of intravenous (IV), intramuscular (IM) and buccal midazolam (MDZ) in children with severe falciparum malaria and convulsions.

METHODS

Thirty-three children with severe malaria and convulsions lasting ≥5 min were given a single dose of MDZ (0.3 mg kg⁻¹) IV (n = 13), IM (n = 12) or via the buccal route (n = 8). Blood samples were collected over 6 h post-dose for determination of plasma MDZ and 1′-hydroxymidazolam concentrations. Plasma concentration–time data were fitted using pharmacokinetic models.

RESULTS

Median (range) MDZ C_max of 481 (258–616), 253 (96–696) and 186 (64–394) ng ml⁻¹ were attained within a median (range) t_max of 10 (5–15), 15 (5–60) and 10 (5–40) min, following IV, IM and buccal administration, respectively. Mean (95% confidence interval) of the pharmacokinetic parameters were: AUC(0,∞) 596 (327, 865), 608 (353, 864) and 518 (294, 741) ng ml⁻¹ h; V_d 0.85 l kg⁻¹; clearance 14.4 ml min⁻¹ kg⁻¹, elimination half-life 1.22 (0.65, 1.8) h, respectively. A single dose of MDZ terminated convulsions in all (100%), 9/12 (75%) and 5/8 (63%) children following IV, IM and buccal administration. Four children (one in the IV, one in the IM and two in the buccal groups) had respiratory depression.

CONCLUSIONS

Administration of MDZ at the currently recommended dose resulted in rapid achievement of therapeutic MDZ concentrations. Although IM and buccal administration of MDZ may be more practical in peripheral healthcare facilities, the efficacy appears to be poorer at the dose used, and a different dosage regimen might improve the efficacy.

WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT

Midazolam (MDZ), a water-soluble benzodiazepine, can be administered via several routes, including intravenously (IV), intramuscularly (IM) and buccal routes to terminate convulsions. It may be a suitable alternative to diazepam to stop convulsions in children with severe malaria, especially at peripheral healthcare facilities. The pharmacokinetics of MDZ have not been described in African children, in whom factors such as the aetiology and nutritional status may influence the pharmacokinetics.

WHAT THIS STUDY ADDS

Administration of MDZ (IV, IM, or buccal) at the currently recommended dose (0.3 mg kg⁻¹) resulted in rapid achievement of median maximum plasma concentrations of MDZ within the range 64–616 ng ml⁻¹, with few clinically significant cardio-respiratory effects. A single dose of MDZ rapidly terminated (within 10 min) seizures in all (100%), 9/12 (75%) and 5/8 (63%) children following IV, IM and buccal administration, respectively. Although IM and buccal MDZ may be the preferred treatment for children in the pre-hospital settings the efficacy appears to be poorer.

Status epilepticus: evidence and controversy

Status Epilepticus (SE) is a potential and relatively common complication of epileptic seizures. Traditionally, SE was defined as 30 minutes of continuous seizure activity or a series of seizures without return to full consciousness between the seizures. As a practical rule, it is admitted that all patients arriving at the emergency room suffering from epileptic seizures could have SE and should be treated accordingly. It is well known that the longer an attack has lasted, the more difficult it is to control in the next 5 to 10 minutes. On the other hand, once an attack has lasted for over 5 to 10 minutes, it is unlikely to cease spontaneously. Ambulatory intervention should focus on this "therapeutic interval" in acute attacks with the use of first-line drugs such as the intramuscular, rectal, oral, and/or intranasal application of benzodiazepines (BZD). Treatment of SE is a medical emergency, which should include 3 priority objectives: (1) to stop the seizures; (2) to maintain internal homeostasis; and (3) to treat possible complications. Current consensus is that a BZD, notably lorazepam or diazepam, is the initial class of drug for the treatment of SE. Phenytoin, fosphenytoin, or valproate generally is agreed upon as the next drugs to be administered. Failure to respond to optimal BZD and phenytoin loading operationally defines refractory SE.

Outcome of convulsive status epilepticus: a review

The outcome of CSE in childhood depends mainly upon the cause but length of seizure may also be important

The epidemiology of convulsive status epilepticus in children: a critical review

There is ongoing debate regarding the most appropriate definition of status epilepticus. This depends upon the research question being asked. Based on the most widely used "30 min definition," the incidence of childhood convulsive status epilepticus (CSE) in developed countries is approximately 20/100,000/year, but will vary depending, among others, on socioeconomic and ethnic characteristics of the population. Age is a main determinant of the epidemiology of CSE and, even within the pediatric population there are substantial differences between older and younger children in terms of incidence, etiology, and frequency of prior neurological abnormalities or prior seizures. Overall, incidence is highest during the first year of life, febrile CSE is the single most common cause, around 40% of children will have previous neurological abnormalities and less than 15% will have a prior history of epilepsy. Outcome is mainly a function of etiology. However, the causative role of CSE itself on mesial temporal sclerosis and subsequent epilepsy or the influence of age, duration, or treatment on outcome of CSE remains largely unknown. Future studies should aim at clarifying these issues and identifying specific ethnic, genetic, or socioeconomic factors associated with CSE to pinpoint potential targets for its primary and secondary prevention.

Childhood convulsive status epilepticus: epidemiology, management and outcome

Convulsive status epilepticus (CSE) in childhood is a medical emergency and its aetiology and outcome mean that it should be studied separately from adult CSE. The incidence in developed countries is between 17 and 23/100,000 with a higher incidence in younger children. Febrile CSE is the commonest single group with a good prognosis in sharp distinction to CSE related to central nervous system infections which have a high mortality. The aim of treatment is to intervene at 5 min and studies indicate that intravenous (i.v.) lorazepam may be a better first-line treatment than rectal diazepam and i.v. phenytoin a better second-line treatment than rectal paraldehyde. An epidemiological study strongly supports the development of prehospital treatment with buccal midazolam becoming a widely used but unlicensed option in the community. More than two doses of benzodiazepines increase the rate of respiratory depression without obvious benefit. The 1 year recurrence rate is 17% and the hospital mortality is about 3%.

Aetiology, course and outcome of children admitted to paediatric intensive care with convulsive status epilepticus: a retrospective 5-year review

A retrospective case note study of the aetiology and course of children in convulsive status epilepticus (CSE) admitted to a large paediatric intensive care unit (PICU) was undertaken between January 1999 and April 2004. Status epilepticus was defined as a prolonged (>30 min) tonic-clonic seizure irrespective of whether the seizure had stopped prior to admission to PICU. During this period, 137 (74 male) children aged 1 month to 15 years were admitted to PICU with 147 episodes of status epilepticus. Forty-seven of the 137 children (34%) were admitted following a prolonged febrile seizure. Thirty-eight of the 137 children (28%) had a remote symptomatic cause for the CSE, 24 (18%) were admitted for an acute symptomatic cause and 15 (11%) were admitted with an acute exacerbation of a pre-existing idiopathic/cryptogenic epilepsy. Six children had a progressive encephalopathy and no cause was identified in the remaining 7 of the 137 children (5%). Forty-nine (36%) of the 137 children had pre-existing epilepsy. The mean duration of CSE was 44 min. Forty-nine (36%) children admitted to PICU who had received a benzodiazepine with either phenobarbital or phenytoin, required further treatment to terminate the presenting episode of CSE. Forty-two of these 49 were treated with thiopentone anaesthesia and the remaining 7 with a continuous infusion of midazolam, successfully terminating status in all. No child died. Of the 70 children considered to be previously neurologically and developmentally normal prior to admission, only 1 child demonstrated a new gross neurological abnormality at the time of latest follow-up. Seven patients (5%) developed new or de novo epilepsy.

Outcome of paediatric convulsive status epilepticus: a systematic review

We did a systematic review on the outcome of paediatric convulsive status epilepticus (CSE) and investigated the role of biological and non-biological variables in reported outcomes. The methodological quality of the 63 studies that met our inclusion criteria was assessed. Study design, type of study, and length of follow-up influenced the outcome. The studies with highest methodological quality are associated with better outcome: short-term mortality between 2.7% and 5.2% and morbidity other than epilepsy less than 15%. The incidence of subsequent epilepsy is not increased after cryptogenic CSE. Causal factor is the main determinant of outcome and the effect of age or duration is difficult to separate from the underlying cause. The risk of sequelae in unprovoked and febrile CSE is low. There is some evidence that CSE, especially febrile CSE, might cause hippocampal injury, although its role in the development of mesial temporal sclerosis is unknown.

[Refractory status epilepticus: diagnosis, therapy, course, and prognosis]

Status epilepticus (SE) is a frequent neurological emergency with an annual incidence of 10-20/100,000 individuals. The overall mortality is about 10-20%. Patients present with long-lasting fits or series of epileptic seizures or extended stupor and coma. Furthermore, patients with SE can suffer from a number of systemic complications possibly also due to side effects of the medical treatment. In the beginning, standardized treatment algorithms can successfully stop most SE. A minority of SE cases prove however to be refractory against the initial treatment and require intensified pharmacologic intervention with nonsedating anticonvulsive drugs or anesthetics. In some partial SE, nonpharmacological approaches (e.g., epilepsy surgery) have been used successfully. This paper reviews scientific evidence of the diagnostic approach, therapeutic options, and course of refractory SE, including nonpharmacological treatment.

Incidence, cause, and short-term outcome of convulsive status epilepticus in childhood: prospective population-based study

BACKGROUND

Convulsive status epilepticus is the most common childhood medical neurological emergency, and is associated with significant morbidity and mortality. Most data for this disorder are from mainly adult populations and might not be relevant to childhood. Thus we undertook the North London Status Epilepticus in Childhood Surveillance Study (NLSTEPSS): a prospective, population-based study of convulsive status epilepticus in childhood, to obtain a uniquely paediatric perspective.

METHODS

Clinical and demographic data for episodes of childhood convulsive status epilepticus that took place in north London were obtained through a clinical network that covered the target population. We obtained these data from anonymised copies of a standardised admission proforma; accident and emergency, nursing, ambulance, and intensive-care unit notes; and interviews with parents, medical, nursing, and paramedic staff. We investigated ascertainment using capture-recapture modelling.

FINDINGS

Of 226 children enrolled, 176 had a first ever episode of convulsive status epilepticus. We estimated that ascertainment was between 62% and 84%. The ascertainment-adjusted incidence was between 17 and 23 episodes per 100,000 per year. 98 (56%, 95% CI 48-63) children were neurologically healthy before their first ever episode and 56 (57%, 47-66) of those children had a prolonged febrile seizure. 11 (12%, 6-18) of children with first ever febrile convulsive status epilepticus had acute bacterial meningitis. Conservative estimation of 1-year recurrence of convulsive status epilepticus was 16% (10-24%). Case fatality was 3% (2-7%).

INTERPRETATION

Convulsive status epilepticus in childhood is more common, has a different range of causes, and a lower risk of death than that in adults. These paediatric data will help inform management of convulsive status epilepticus and appropriate allocation of resources to reduce the effects of this disorder in childhood.

Update on the acute management of status epilepticus in children

PURPOSE OF REVIEW

Status epilepticus is the most common neurologic emergency in children. The understanding of its less recognizable forms, its pharmacologic management, the role of electroencephalography and the long-term morbidity and mortality as a result of status epilepticus are consistently evolving. This review frames the current understanding of several issues as they apply to acute management in the emergency department.

RECENT FINDINGS

Researchers are working to define less recognizable forms of status epilepticus such as nonconvulsive, autonomic and psychogenic. Buccal and intranasal forms of midazolam are emerging as suitable alternatives to rectal diazepam in the initial treatment of status epilepticus. Valproic acid, chloral hydrate and newer-generation antiepileptics are being proposed as safe and effective alternatives to the traditional drugs used to treat status epilepticus. The role of electroencephalography in diagnosis is being elucidated. Risk factors for neurologic sequelae and mortality after status epilepticus remain an area of research with conflicting findings and no real consensus.

SUMMARY

The understanding of different types of status epilepticus, the options for pharmacologic treatment, the tools for diagnosis and the morbidity and mortality of the disease are still evolving. As a result, several areas for further research remain that will help clinicians in their approach to this complex condition.