Tonic-clonic convulsions and convulsive status epilepticus (currently defined as a This is an update of a Cochrane Review first published in and updated in For this update, we have identified 14 further studies that meet. This emergency situation is when a seizure lasts longer than 5 minutes or when seizures occur close together without recovery in between. Seizure First Aid and Safety . Treatments for Epilepsy and other Neurologic Disorders Meeting Report · The Ketogenic Diet and Antiepileptic Drugs: A Good Mix?. In elderly patients, refractory status epilepticus (RSE) may lead to death in over A landmark meeting in Marseilles in was the first scientific meeting to be.
All except for one guideline from the Spanish Society of Neurology recommended intravenous lorazepam. Intravenous lorazepam or diazepam are efficacious and safe to use. For example, in one randomized controlled trial 21 comparing intravenous lorazepam and intravenous diazepam, In the resource-limited setting, one additional consideration with lorazepam use is the need for refrigeration of the drug, because of its degradation at high temperature.
Although both intravenous lorazepam and diazepam are included in the WHO model list of essential medicines for children, the ETAT guideline recommends intravenous diazepam in high temperature regions with no refrigeration facility.
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Interestingly, these four guidelines were published afterwhich is when Chin et al. Moreover, their study demonstrated that treatment with more than two doses of benzodiazepines was associated with respiratory depression.
Only one guideline, fromrecommended excluding consideration of prior EMS treatment, 5 and that was on the basis of possible variability in pre-hospital dosing. ED second phase anticonvulsant therapy In the second phase of therapy Fig. Comment on ED second phase anticonvulsant therapy Intravenous phenytoin was the most commonly recommended therapy for benzodiazepine-refractory SE. Together with intravenous fosphenytoin the prodrug of phenytointhey were the second phase therapy of choice in all guidelines.
There are a number of reasons why fosphenytoin should be recommended in preference to phenytoin: The evidence for using intramuscular phenobarbital is based on pediatric practice in cerebral malaria.
Three of the guidelines point out that it should be avoided or used with caution in liver disease or suspected metabolic disease and in children younger than years with uncertain seizure etiology.
Levetiracetam was recommended in four of the 11 guidelines. A randomized, pilot open study has demonstrated equivalence of effectiveness in seizure control with lorazepam, and it has less associated respiratory depression and hypotension. NCT ; due to be completed on Decemberwhich aims to determine the most effective ED treatment out of fosphenytoin, levetiracetam, and valproic acid for benzodiazepine-refractory SE, and provide information on effectiveness and safety in children.
ED third phase anticonvulsant therapy In the third phase of therapy Fig. Comment on ED third phase anticonvulsant therapy At the time of starting the third phase of anticonvulsant drug treatment, four of the 11 guidelines included the choice for repeating second phase therapy.
The Association of Child Neurology India, 12 guideline group considered the scenario when no intensive care bed is available, and recommended the following before a midazolam infusion: The Italian League Against Epilepsy guideline 10 recommended valproic acid after second phase therapy, if delay or difficulty in endotracheal intubation was expected. Finally, in regard to the choice of anesthetic agent, the guidelines do not have clear recommendations for preference between thiopental, midazolam, propofol, and pentobarbital.
Rather, specific drug selection is deferred to local expertise. It should be noted, however, that although propofol is used in adult practice of refractory SE, the risk of propofol infusion syndrome in children is unacceptable and, therefore, continuous infusion is not recommended in a number of countries.
In regard to the other anesthetic agents, the data on intensive care treatment of pediatric refractory SE are of poor quality, yet they show a hierarchy in strategies: Conclusion Managing a child who presents in an emergency with a seizure is a challenge; knowing how to best deal with acute interventions and follow-up is an important part of pediatric practice. Different routes of benzodiazepine administration are feasible in the pre-hospital EMS and first phase of ED therapy.
The choice of benzodiazepines depends on presence of intravenous access, local availability, skills of healthcare providers, and the resource setting. Valproic acid and levetiractam have better side effect profiles than phenytoin or fosphenytoin. Direct comparison of effectiveness and safety of different second phase therapy for SE awaits further clinical study. Finally, regarding the use of anesthetic agents in children, most of the experience and literature is in using midazolam and then pentobarbital by continuous infusion.
Management protocols for status epilepticus in the pediatric emergency room: J Pediatr Rio J. A definition and classification of status epilepticus - report of ILAE task force on classification of status epilepticus. Preferred reporting items for systematic reviews and meta-analyses: The status epilepticus working party, members of the status epilepticus working party. From 30 min specified in the guidelines of the Epilepsy Foundation of America's Working Group on Status Epilepticus it was reduced to to 20 min; the Veterans Affairs Status Epilepticus Cooperation Study stipulated 10 min and, most recently, a length of 5 min has been proposed.
Most seizures cease within a minute or two and if the seizure is prolonged beyond a few minutes, it is unlikely to stop by itself. Video-EEG analysis of secondarily generalized tonic—clonic seizure GTCS in 47 patients has shown that the maximum duration was s range 16— s, mean 62 s.
Primary generalized seizures were of shorter duration than secondarily generalized seizures. It appears that in SE the innate inhibitory mechanisms in the brain that put a halt to the seizure are no longer effective. A duration of 5 min probably is a reasonable cutoff to distinguish isolated seizures from SE. Numerous clinical studies have demonstrated a relation between seizure duration and mortality. Further, there is evidence that seizures may become refractory and difficult to control if treatment is delayed.
Probably any convulsive seizure that lasts more than 2 min deserves to be managed as SE. This subgroup of RSE has greater morbidity and mortality. It typically occurs in young patients 18—50 years in the setting of encephalitis. Classification of status epilepticus Semiologically and electrophysiologically there are several types of seizures; these have been broadly classified as either generalized or partial seizures by the International League Against Epilepsy.
In principle there can be as many types of SE as there are types of seizures. This has led to complex classifications of SE.
Generalized tonic—clonic SE is the most common form of SE. Myoclonic SE presents as a bilateral massive myoclonus, along with polyspike discharges on EEG, and usually carries a good prognosis. But the myoclonic status that follows severe hypoxic-ischemic insult, viral encephalitis, and prion disease is associated with poor prognosis.
This review deals predominantly with generalized tonic—clonic SE, which is the most commonly observed form of SE in clinical practice. Nonconvulsive status epilepticus Nonconvulsive SE NCSE refers to continuous or near-continuous generalized electrical seizure activity lasting for at least 30 min, but without physical convulsions. NCSE is characterized by abnormal mental status, unresponsiveness, ocular motor abnormalities, persistent electrographic seizures, and possible response to anticonvulsants.
Epidemiology It has been estimated that up tocases of SE occur annually in the US, with 55, associated deaths.
An incidence of 6. A dramatic drop in serum levels of AEDs due to noncompliance or other reasons is the most common mechanism of SE in such instances. In many patients with a preexisting seizure disorder, no obvious precipitating factor can be identified for the occurrence of SE.
SE is more common in patients with secondary generalized epilepsy than in those with idiopathic generalized epilepsy.