Convulsive status epilepticus in children: Etiology, treatment protocol and outcome

Abstract

This study aimed to determine the etiology, treatment protocol and outcome of convulsive status epilepticus (SE) in children. An institutional treatment protocol using benzodiazepines (diazepam and midazolam) was assessed in a retrospective case study. The treatment protocol (Ege Pediatric Status Epilepticus Protocol or EPSEP) was developed based on an operational definition of pediatric SE according to the duration of seizure activity. Pediatric SE is divided into three categories: initial SE (20-30 min), established SE (30-60 min) and refractory SE (>60 min). Eight (30%) of the studied episodes were initial SE, 10 (37%) were established SE, and 9 (33%) were refractory SE. With respect to the etiological spectrum of SE, 11 (40%) children had meningitis or encephalitis. Febrile SE was identified in 7 (26%) patients. Only 2 episodes of initial SE (7.5%) were controlled with first step of the protocol (two concomitant-doses of rectal diazepam). Midazolam bolus and infusions (up to 1.2 μg/kg/min) were used to treat 22 episodes of SE (9 refractory SE, 10 established SE and 3 initial SE). Complete arrest of convulsive SE was achieved in 21 of 22 (95%) episodes with midazolam infusion. We concluded that the combined use of benzodiazepines (diazepam+midazolam) was safe and effective in the treatment of convulsive SE in children.

Quality assurance evaluation of a simple linear protocol for the treatment of impending status epilepticus in a pediatric emergency department 2 years postimplementation

“…[2][3][4] Our results are comparable to those reported in the literature assessing the use of midazolam for seizure control in the emergency setting and reporting success rates of 56 to 96.7%. 3,5,8,10,11,[13][14][15][16][17] To our knowledge, there are no studies comparing IV midazolam to either lorazepam or diazepam IV in the ED setting. Silbergleit and colleagues published a double-blind, randomized, noninferiority trial comparing the efficacy of IM midazolam to that of IV lorazepam: IM midazolam was at least as safe and effective as IV lorazepam.…”

“…Using the same dosage for both IV and IM routes makes the protocol easier to use. Despite the protocols written by Brevoord and colleagues, Papavasiliou and colleagues, and Friedman (CPS) recommending a lower dosage (0.1 mg/kg) for the IV 3,22 We intend to emphasize the need for titrating the IV dose to effect to possibly prevent dose-related adverse effects in future versions. This study's main limitation is that it was a retrospective study.…”

“…2 The mortality rate is nearly 10 times higher for seizures longer than 30 minutes than for those 10 to 29 minutes. 3 Associated morbidity is also high; new neurologic disorders or sequelae occur in 15% of cases. 1 Given that prompt treatment is more likely to succeed, physicians recognize the need for early treatment.…”

“…12 Multiple studies have proven that midazolam is at least as effective as diazepam in terms of safety and risk of recurrence, with the advantage of providing a faster initiation of treatment, leading to more rapid seizure cessation. 3,5,8,10,11,[13][14][15][16][17][18][19] Midazolam has emerged as a highly efficacious drug in the treatment of impending SE, with several routes of administration exhibiting high bioavailability. 19 In a recent article proposing evidence-based and expert consensus practice guidelines, the Neurocritical Care Society lists midazolam as Class I, Level A for the emergent treatment of SE, as Class IIB, Level B for urgent treatment (continuous infusion), and as Class IIa, Level B for refractory treatment using the evidence rating system of the American Heart Association. )…”

“…as a choice in their algorithms for the treatment of SE, but neither of these protocols has been studied. 21,22 Two midazolam-based protocols were studied in pediatric intensive care units (PICUs), 2,3 and one was studied in known epileptic patients who were admitted. 4 Midazolam was successful in these three studies.…”