Article Figures & Data
Figures
- Figure 1
- Clinical algorithm for treatment of CSE in children.
Tables
- Table 1
Critical appraisal of the Source CPGs by the Appraisal of Guidelines for Research & Evaluation II (AGREE II) Instrument.
CPGs AGREE-II domains scores (%) Texas 2009 NICE 2012 NCS 2012 AES 2016 Domain 1: Scope & Purpose 92 100 78 100 Domain 2: Stakeholder Involvement 47 100 41 44 Domain 3: Rigour of Development 56 98 68 69 Domain 4: Clarity & Presentation 100 97 80 92 Domain 5: Applicability 48 85 10 21 Domain 6: Editorial Independence 50 88 19 38 Overall Assessment (%) 85 100 57 75 Recommendation for CPG use Yes - 1, Yes with modifications - 1, No - 0 Yes - 1, Yes with modifications - 1, No - 0 Yes - 1, Yes with modifications - 0, No - 1 Yes - 1, Yes with modifications - 1, No - 0 The overall assessment and decision of the CPG Adaptation working group, based on the AGREE-II domain scores, was to adapt the NICE CPG and exclude the Texas, NCS, and AES CPGs. CPGs: Clinical Practice Guidelines, AGREE: Appraisal of Guidelines for Research and Evaluation, Texas: Texas Children’s Hospital Evidence-Based Outcomes Center, NICE: National Institute for Health and Care Excellence, NCS: Neurocritical Care Society, AES: American Epilepsy Society
- Table 2
Key Recommendations of the adapted CPG for management of Convulsive Status Epilepticus (CSE) in children.
Prolonged or Repeated Seizures and CSE 1.First-Line Treatment for Children with prolonged or Repeated generalized, convulsive (Tonic–Clonic, Tonic or Clonic) Seizures in the Community 1.1. Give immediate emergency care and treatment to children who have prolonged (lasting 5 minutes or more) or repeated (three or more in an hour) convulsive seizures in the community.
1.2. Only prescribe buccal midazolam or rectal diazepam for use in the community for children who have had a previous episode of prolonged or serial convulsive seizures.
1.3. Administer buccal midazolam as first-line treatment in children and young people with prolonged or repeated seizures in the community. Administer rectal diazepam if preferred or if buccal midazolam is not available
1.3. Treatment should be administered by trained clinical personnel or, if specified by an individually agreed protocol drawn up with the specialist, by family members or carers with appropriate training.
1.4. Care must be taken to secure the child airway and assess his or her respiratory and cardiac function.
1.5. Depending on response to treatment, the person’s situation and any personalized care plan, call an ambulance, particularly if:-
1.5.1. The seizure is continuing 5 minutes after the emergency medication has been administered.
1.5.2. The person has a history of frequent episodes of serial seizures or has CSE, or this is the first episode requiring emergency treatment or
1.5.3. There are concerns or difficulties monitoring the person’s airway, breathing, circulation or other vital signs.2.Treatment for Children with CSE in Hospital 2.1 For children and young people with ongoing generalized tonic–clonic seizures (CSE) who are in the hospital, immediately:
•Secure airway
•Give high-concentration oxygen
•Assess cardiac and respiratory function
•Check blood glucose levels and
•Secure intravenous access in a large vein
2.2 Administer intravenous lorazepam as first-line treatment in children, with ongoing generalized tonic–clonic seizures (CSE). Administer intravenous diazepam if intravenous lorazepam is unavailable, or buccal midazolam if unable to secure immediate intravenous access. Administer a maximum of two doses of the first-line treatment (including pre-hospital treatment).
2.3 If seizures continue, administer intravenous phenobarbital or phenytoin as second-line treatment in hospital in children with ongoing generalized tonic–clonic seizures (CSE).3.Refractory CSE 3.1. Administer intravenous midazolam or thiopental sodium to treat children with refractory CSE. Adequate monitoring, including blood levels of Antiepileptic Drugs (AEDs), and critical life systems support are required.
3.2. As the treatment pathway progresses, the expertise of an anesthetist/intensivist should be sought.
3.3. Regular AEDs should be continued at optimal doses and the reasons for status epilepticus should be investigated.
3.4. An individual treatment pathway should be formulated for children who have recurrent CSE.The recent SE definition included a seizure longer than 5 minutes or two or more seizures without a return of consciousness between seizures. Serial seizures are defined as 3 or more tonic-clonic seizures in an hour. SE can be divided into a number of subtypes, either by seizure type or response to treatment. Clinical SE can be either focal or generalized, and each of these types can be divided by duration into; (i) Early SE (5-30 minutes), (ii) Established SE (30-60 minutes), and (iii) Refractory SE (seizures persist despite treatment with adequate doses of two or three initial anticonvulsant medications) Drug Dose/administration Side effects Lorazepam IV: 0.1 mg/kg/dose (max: 4 mg/dose) slowly over 2-5 minutes; may repeat once in 5-15 minutes if needed. Hypotension Respiratory depression Diazepam IV/IO: 0.15-0.2 mg/kg/dose (max: 10 mg/dose) slowly over 2-5 minutes; may repeat once in 5-15 minutes if needed. PR: 0.5 mg/kg/dose (max: 20 mg/dose) Hypotension Respiratory depression Midazolam Buccal: 0.5 mg/kg/dose (max: 10 mg/ dose) IM: 0.2 mg/kg/dose (max: 10 mg/dose) IV Infusion: loading dose: 0.15 mg/kg (max: 8 mg/dose) over 2-3 min, followed by continuous IV infusion of 2 mcg/kg/min, titrate to effect by 2 mcg/kg/min every 10-15 min up to maximum rate of 24 mcg/kg/min. Hypotension Respiratory depression Phenytoin IV/IO: 20 mg/kg/dose (max: 1000 mg/dose) Dilute in normal saline. Infuse over 20 minutes. Administered into a large vein, using an in-line 0.22 micron filter. Flush IV catheter with normal saline to avoid local venous irritation and extravasation. Hypotension Bradycardia Arrhythmias *Use with caution in cardiac patient Phenobarbitone IV: 20 mg/kg/dose (max: 1000 mg/dose) Infusion over 20 minutes; may repeat in 10-15 minutes if needed up to max. total dose of 40 mg/kg Hypotension Respiratory depression Levetiracetam IV: 20-60 mg/kg (max: 2500 mg/dose) Infusion over 15-20 minutes Aggression Sodium valproate IV: 20-40 mg/kg (max: 3000 mg/dose) infusion over 20 minutes; an additional 20 mg/kg after 10-15 min can be used if needed, followed by a continuous IV infusion of 5 mg/kg/hour. Once patient is seizure free for 6-12 hours, reduce infusion rate by 1 mg/kg/hour every 2 hours Hyperammonemia Pancreatitis Thrombocytopenia Hepatotoxicity Thiopental IV: 3-5 mg/kg (max: 500 mg/dose) over 10 minutes, repeat dose if needed after 10-15 min (up to max. total dose of 10 mg/kg); followed by continuous IV infusion of 3-5 mg/kg/hour, titrate to effect. Hypotension Respiratory depression Arrhythmias Pentobarbital IV: 5 mg/kg over 10 minutes, may repeat the dose if needed; followed by continuous IV infusion of 0.5-5 mg/kg/hour, titrate to effect. Hypotension Respiratory depression Arrhythmias Paralytic ileus CSE - Convulsive Status Epilepticus, IV - intravenous, IO - Intraosseous, IM - intramuscular, PR - Per rectal
- Table 4
Audit data collection tool to monitor implementation of the CPG for management of CSE in children.
Items done and documented in the patient medical records Diagnosis Date of birth (DOB): - - / - - / - - - - (day/month/year) Type of patient ◻New onset seizures ◻Known patient with seizures Type of seizures ◻Generalized ◻Focal Anti-epileptic drug (AED) levels done ◻YES ◻NO ◻Not Indicated Toxicology screening done ◻YES ◻NO ◻Not Indicated Blood cultures done ◻YES ◻NO ◻Not Indicated Lumbar puncture (LP) done ◻YES ◻NO ◻Not Indicated Electroencephalography (EEG) done ◻YES ◻NO ◻Not Indicated Neuroimaging studies done: CT ◻YES ◻NO ◻Not Indicated MRI ◻YES ◻NO ◻Not Indicated Treatment Response to First-line therapy (Benzodiazepines): ◻YES ◻NO Response to Second-line therapy (Phenytoin): ◻YES ◻NO Response to Third-line therapy (Phenobarbitone): ◻YES ◻NO Response to Alternative therapy: ◻YES ◻NO Type of medication Levetiracetam ◻YES ◻NO Valproic acid ◻YES ◻NO Response to Fourth-line therapy:- Midazolam Infusion ◻YES ◻NO Thiopental Infusion ◻YES ◻NO Pentobarbital Infusion ◻YES ◻NO Admission to PICU ◻YES ◻NO Intubation/ Ventilation needed ◻YES ◻NO Length of stay (LOS) (Days/Hours):-
•Department of Emergency Medicine (DEM)
• Pediatric Intensive Care Unit (PICU)
• Inpatient ward
• Total LOS--/--
--/--
--/--
--/--Patient outcome ◻Discharged ◻Died Follow up appointment in the Pediatric Neurology Clinic provided: ◻YES ◻NO
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