Neurologists have proposed a ‘status epilepticus code’ after finding that hospital emergency departments rarely follow paediatric status epilepticus (SE) management guidelines.
A review of 59 SE presentations to two NSW emergency departments between 2015 and 2016 revealed the state’s ‘Infants and Children: Acute Management of Seizures—2009’ guidelines were followed only 7% of the time. The main concerns were excessive benzodiazepine use and delay in both definitive treatment of status epilepticus and in escalation from first- to second-line anticonvulsant treatment.
“This is much lower than the published overseas experience where adherence rates to guidelines ranged from 14.3% to 66%,” the authors wrote in the Journal of Paediatrics and Child Health.
The median times to first- and second-line treatments were 15 and 44 minutes from seizure onset, respectively — far beyond the recommended ≤5 and 20 minute marks.
Thirty-eight cases received three or more benzodiazepine doses, with one patient getting seven doses before moving to second-line therapy. However, patients should only receive benzodiazepine ≤5 minutes post seizure onset, and again at 10 minutes if the seizure persists, the guidelines suggest.
“Repeated administration of first-line agents can delay the institution of more effective therapy,” the authors wrote.
Benzodiazepines were only effective for the first few minutes of SE before the GABA receptors they bind to are internalised, they explained.
Additionally, prolonged seizures and/or repeated anti-epileptic medication administration, particularly with benzodiazepine, may lead to breathing complications requiring on-going respiratory support, including intubation.
In fact, although this study was too small to determine the importance of adhering to NSW clinical guidelines, “a recent systematic review [showed] poor outcomes, including increased intubation, correlating with non-adherence,” said the authors, led by Dr Preen Uppal, a paediatric neurologist at the Sydney Children’s Hospital.
Recommendations
While further studies are needed to identify whether the problem is with the guidelines, clinicians or hospital system, the researchers provided several recommendations for improving patient care.
“Ambulance staff may need further education on the futility of excessive benzodiazepine doses and consideration of midazolam doses given by the carer [as part of their seizure management plan]”, they suggested, after their study showed paramedics and hospital staff accounted for the majority of benzodiazepine over-administration.
Further, EDs should be notified of the patients’ situation while ambulances are in transit so they can prepare second-line therapies — either phenytoin, phenobarbitone or levetiracetam — for immediate administration upon arrival.
This is key for most patients, with 75% of the study cohort arriving >20 minutes after seizure onset, they said.
“The adverse effects of SE can be reduced through prompt and aggressive intervention. It would be imperative that the patient is taken to the closest ED. In fact, it may be detrimental to go to a tertiary hospital that is further away.”
Intraosseous administration of second-line therapies should be available and considered early by trained and comfortable staff, as IV use may be challenging in a seizing child, the authors suggested.
Patients may also receive sequential phenytoin and levetiracetam, which only adds 10 minutes to the treatment time versus giving phenytoin alone, and can reduce failure rate by more than 50%, they added.
This may “help prevent intubation, transfer of patients to tertiary centres and thus, necessitates consideration of changes to the current clinical practice guidelines”.
“Sequential use of two second-line agents prior to intubation has been recommended in the recent Advanced Paediatric Life Support, Australia guidelines.”
Finally, hospitals may solidify SE management with an ED ‘Status Epilepticus Code’, they concluded.