Emergency Management (Diagnosis and Treatment) of Seizures in Children beyond the Neonatal Period

- Recommendations

Table 3. Recommendations
A. History taking
N	Health question	Source Guideline	Recommendations	Quality of evidence	Strength of Recommendation
A1	In infants and children of both sexes, aged from 1 month to 18 years who presents with acute seizure, what is the added value of history taking? And what items should be fulfilled?	Summary of recommendations for the management of infantile seizures: Task Force Report for the ILAE Commission of Pediatrics, 2015 Guidelines for the Evaluation and Management of Status Epilepticus, Neurocrit care, 2012) Guidelines for the Evaluation and Management of Status Epilepticus, Neurocrit care, 2012) Evidence-Based Guideline: Treatment of Convulsive Status Epilepticus in Children and Adults: Report of the Guideline Committee of the American Epilepsy Society, 2016	The first stage in clinical management is to recognize if abnormal movement or behavior has an epileptic origin Ask about prior history of epilepsy AED, AED non-compliance, or known allergies. Address history of Ingestion of a toxin or drug abuse as possible etiologies of SE.	Moderate Moderate Low Low	Strong Strong Weak (conditional) Weak (conditional)

Table 5. Recommendations
B. Clinical examination
N	Health questions	Source Guideline	Recommendations	Quality of evidence	Strength of Recommendation
B1	In infants and children of both sexes, aged from 1 month to 18 years who presents with suspected acute seizure, what is the added value of vital data recording in diagnosis of etiology, and directing management decisions?	Summary of recommendations for the management of infantile seizures: Task Force Report for the ILAE Commission of Pediatrics, 2015 Guidelines for the Evaluation and Management of Status Epilepticus, Neurocrit care, 2012)	Rule out febrile seizures Assessment of vital signs: O2 saturation, BP, HR in the immediate (0–2 min) to establish and support baseline vital signs	Moderate Very low	Strong Weak (conditional)
B2	In infants and children of both sexes, aged from 1 month to 18 years who presents with suspected acute seizures and managed, what is the added value of targeted initial clinical neurologic examination in diagnosis of etiology, and directing management decisions?	Guidelines for the Evaluation and Management of Status Epilepticus, Neurocrit care, 2012) Evidence-Based Guideline: Treatment of Convulsive Status Epilepticus in Children and Adults: Report of the Guideline Committee of the American Epilepsy Society, 2016	Neurologic exam is urgent (5–10 min) to evaluate for mass lesion, acute intracranial process Address respiratory monitoring to prevent cardiopulmonary arrest, during anticonvulsant drug treatment in status epilepticus in children.	Very low High	Weak (conditional) Strong

Table 6. Recommendations
C. Laboratory Evaluation
N	Health questions	Source Guideline	Recommendations	Quality of evidence	Strength of Recommendation
C1	In Infants and children aged 1 month to 18 years of both sexes, who are diagnosed as having acute seizure, regarding the use of laboratory investigations, in diagnostic evaluation, what are the routine laboratory investigations have to be done in all patients? Is serum AED level helpful to improve diagnosis of acute seizures?	Guidelines for the Evaluation and Management of Status Epilepticus, Neurocrit care, 2012 Treatment of convulsive status epilepticus in childhood: Recommendations of the Italian League Against Epilepsy - ITALIAN LEAGUE (LICE) 2013	I. Laboratory tests should be ordered based on individual clinical circumstances that include suggestive historic or clinical findings such as vomiting, diarrhea, dehydration, or failure to return to baseline alertness. II. For all patients, order laboratory tests: blood glucose, complete blood count, calcium (total and ionized), magnesium, AED levels.	Very low Very low	Weak (conditional) Weak (conditional)
C2	In Infants and children aged 1 month to 18 years of both sexes, who are diagnosed as having acute seizure, regarding the use of laboratory investigations, in diagnostic evaluation, is LP analysis helpful to improve diagnosis of acute seizures? Is brain imaging mandatory before it? Are arterial/ venous blood gases, liver function tests, genetic testing, helpful to improve diagnosis of acute seizures?	Guidelines for the Evaluation and Management of Status Epilepticus, Neurocrit care, 2012	III. Consider based on clinical presentation a) Lumbar puncture (LP). Should be performed in the very young child (<6 months), in the child of any age with persistent (cause unknown) alteration of mental status or failure to return to baseline, or in any child with meningeal signs. If increased intracranial pressure is suspected, the LP should be preceded by an imaging study of the head b) Comprehensive toxicology panel including toxins that frequently cause seizures (i.e. isoniazid, tricyclic antidepressants, theophylline, cocaine, sympathomimetics, alcohol, organophosphates, and cyclosporine Other laboratory tests: liver function tests, coagulation studies, arterial blood gases, and inborn errors of metabolism	Very low Very low	Weak (conditional) Weak (conditional)

Table 7. Recommendations
D. EEG
N	Health questions	Source Guideline	Recommendations	Quality of evidence	Strength of Recommendation
D1	In Infants and children aged 1 month to 18 years of both sexes, who are diagnosed as having acute seizures, regarding the use of EEG in diagnostic evaluation, is standardized EEG helpful to improve diagnosis of acute convulsive seizure?	Evidence-Based Guidelines for EEG Utilization at the University Teaching Hospital (UTH) – 2011 Evidence-Based Guideline: Treatment of Convulsive Status Epilepticus in Children and Adults: Report of the Guideline Committee of the American Epilepsy Society, 2016 Guidelines for the Evaluation and Management of Status Epilepticus, Neurocrit care, 2012	I. In the PICU, An EEG is indicated in all unconscious patients suspected of non-convulsive status epilepticus or subclinical seizures. This includes comatose or obtunded inpatients of unclear etiology especially those in whom seizures preceded the onset of coma. II. EEG is recommended after a first unprovoked seizure as it might offer insights into recurrence risk and/or the need for further neuroimaging. III. In the treatment of convulsive status epilepticus in children, continuous EEG monitoring is indicated if second therapy fails to stop seizures, and treatment consideration involves the use of anesthetic doses of either thiopental, midazolam, pentobarbital, or propofol IV. The use of continuous EEG (cEEG) is usually required for the treatment of SE. V. Continuous EEG monitoring should be initiated within 1 h of SE onset if ongoing seizures are suspected VI. The duration of cEEG monitoring should be at least 48 h in comatose patients to evaluate for non-convulsive seizures. VII. The use of this cEEG is encouraged to be available at tertiary care facilities where the optimum standard of care is provided.	Very low Very low Very low	Weak (conditional) Weak (conditional) Weak (conditional) Good practice statement

Table 8. Recommendations
E. Neuroimaging (CT / MRI Brain)
N	Health questions	Source Guideline	Recommendations	Quality of evidence	Strength of Recommendation
E1	In infants and children of both sexes, aged from 1 month to 18 years who presents with acute seizures, whilst the primary assessment and resuscitation are being carried out, Regarding the added value of neuroimaging, what is the role of emergency head CT or MRI in improving diagnosis of acute convulsive seizures?	Diagnosis and Treatment of the First Epileptic Seizure: Guidelines of the Italian League Against Epilepsy, 2006 Guidelines for the Evaluation and Management of Status Epilepticus, Neurocrit care, 2012)	I. The use of a brain CT scan or MRI in the emergency room is indicated when specific interventions may be needed. II. A CT scan is strictly indicated when a structural lesion is suspected or when the etiology of the seizure cannot be easily identified. Structural lesions include, among others, post-traumatic complications, cerebral hemorrhage, brain edema, and space-occupying lesions, which may be suggested by post-ictal deficits and/or persisting impairment of consciousness. III. In the emergency room, MRI is not indicated, except for selected circumstances, to be evaluated on an individual basis. IV. The etiology of SE should be diagnosed as soon as possible and occur simultaneously and in parallel with treatment for evaluation for mass lesions, meningitis, encephalitis. V. All patients with SE should have Head computed tomography (CT) scan VI. Consider Brain magnetic resonance imaging (MRI)based on clinical presentation	Moderate Moderate	Strong Strong Good practice statement Good practice statement

Table 9. Recommendations
F. Therapies: Initial Therapy: 0 – 20 minutes: 1. Benzodiazepines
N	Health questions	Source Guideline	Recommendations	Quality of evidence	Strength of Recommendation
F1	In Infants and children aged 1 month to 18 years of both sexes, who are diagnosed as having acute seizure, what is the role of benzodiazepines as an initial therapy in pre-hospital\hospital setting?	Evidence-Based Guideline: Treatment of Convulsive Status Epilepticus in Children and Adults: Report of the Guideline Committee of the American Epilepsy Society, 2016 Treatment of convulsive status epilepticus in childhood: Recommendations of the Italian League Against Epilepsy - ITALIAN LEAGUE (LICE) 2013 Treatment of convulsive status epilepticus in childhood: Recommendations of the Italian League Against Epilepsy - ITALIAN LEAGUE (LICE) 2013 Evidence-Based Guideline: Treatment of Convulsive Status Epilepticus in Children and Adults: Report of the Guideline Committee of the American Epilepsy Society, 2016	Benzodiazepines are the most efficient group of drugs to be initially used in the treatment of acute convulsion after 5 minutes from the start of seizures I. Pre-hospital Treatment: As early as possible by Trained personal whether medical\Para medical or caretaker. • Drugs of Choice: -Midazolam (intra-muscular – buccal – nasal) -Diazepam (rectal) Only one dose, not to be repeated II. Hospital Emergency Room: • History of pre-hospital use of benzodiazepines must be considered as well as timing. • Doses given within one hour before ER presentation must be regarded as an initial dose O Midazolam • It is the most appropriate type of benzodiazepines to be used. • In the hospital the whole full dose to be given as a single dose better than broken into multiple doses. O Diazepam IV diazepam could be repeated after 5 minutes convulsion continued • Alternatively IF VENOUS ACCESS UNAVAILABLE; • Use midazolam: buccal or intranasal. • Use diazepam: rectal • Follow up for signs of respiratory depression as hypoventilation, pallor, decrease oxygen saturation Respiratory support and intubation may be needed	High Moderate Moderate High High Moderate High	Strong Strong Strong Strong Strong Strong Strong

Table 10. Recommendations
G. Therapies: Initial Therapy: 0 – 20 minutes: 2. Non Benzodiazepine Therapy 2.1 Phenytoin and Phenobarbitone: First Phase therapy : 5 - 20 minutes
N	Health questions	Source Guideline	Recommendations	Quality of evidence	Strength of Recommendation
G1	In Infants and children aged 1 month to 18 years of both sexes, who are diagnosed as having acute seizure, what is the role of Phenobarbitone and phenytoin, as an initial and second line therapy?	Guidelines for the Evaluation and Management of Status Epilepticus, Neurocrit care, 2012) Treatment of convulsive status epilepticus in childhood: Recommendations of the Italian League Against Epilepsy - ITALIAN LEAGUE (LICE) 2013 Evidence-Based Guideline: Treatment of Convulsive Status Epilepticus in Children and Adults: Report of the Guideline Committee of the American Epilepsy Society, 2016 Guidelines for the Evaluation and Management of Status Epilepticus, Neurocrit care, 2012). Treatment of convulsive status epilepticus in childhood: Recommendations of the Italian League Against Epilepsy - ITALIAN LEAGUE (LICE) 2013. Evidence-Based Guideline: Treatment of Convulsive Status Epilepticus in Children and Adults: Report of the Guideline Committee of the American Epilepsy Society, 2016	Both phenytoin and phenobarbital are recommended Phenytoin followed by phenobarbital is recommended if benzodiazepines fail Phenobarbital is recommended in the absence of benzodiazepines Second phase therapy: 20 - 40 minutes • Phenytoin and Phenobarbital are recommended • They are not used sequentially, but alternating. Generally, phenytoin precedes phenobarbital on account of a better safety profile	High Moderate High Moderate Moderate	Strong Strong Strong Strong Strong

Table 11. Recommendations
2.2 Valproate
N	Health question	Source Guideline	Recommendations	Quality of evidence	Strength of Recommendation
H1	In infants and children of both sexes, aged from 1 month to 18 years who are diagnosed as having acute seizure, regarding the use of sodium valproate in the treatment, what is the role of sodium valproate, as a third line therapy?	Evidence-Based Guideline: Treatment of Convulsive Status Epilepticus in Children and Adults: (AES guidelines. Epilepsy Currents, Vol. 16, No. 1 (January/February) 2016 pp. 48–61: Treatment of convulsive status epilepticus in childhood: Recommendations of the Italian League Against Epilepsy - ITALIAN LEAGUE (LICE) 2013	· IV Sodium valproate is an option in the second-therapy phase and should begin when the seizure duration reaches 20 minutes. · The use of IV Sodium valproate is dependent on its availability especially in tertiary care centers where optimum care is provided. Valproic acid offers a valid alternative to phenytoin and phenobarbital. It should be used with extreme caution, however, particularly in young children, when a possible metabolic etiology has not been ruled out.	Moderate Moderate	Strong Good practice statement Strong

Table 12. Recommendations
2.3 Pyridoxine
N	Health questions	Source Guideline	Recommendations	Quality of evidence	Strength of Recommendation
I1	In infants and children of both sexes, aged from 1 month to 18 years who are diagnosed as having acute seizures and transferred to PICU with convulsive status epilepticus not adequately responding to first, second and third line medications, what is the role of levetiracetam?	Summary of recommendations for the management of infantile seizures: Task Force Report for the ILAE Commission of Pediatrics, 2015 Guidelines for the Evaluation and Management of Status Epilepticus, Neurocrit care, 2012) Evidence-Based Guideline: Treatment of Convulsive Status Epilepticus in Children and Adults: Report of the Guideline Committee of the American Epilepsy Society, 2016 Treatment of convulsive status epilepticus in childhood: Recommendations of the Italian League Against Epilepsy - ITALIAN LEAGUE (LICE) 2013	Consider vitamin-dependent diseases (pyridoxine or pyridoxal-phosphate) in the early myoclonic epilepsy group Young children with epilepsy (under 3 years) who develop SE lasting 30 minutes, especially if myoclonic should receive pyridoxine trial in case they have pyridoxine dependent/responsive seizures. IV Levetiracetam or oral through a nasogastric tube could be given in the second phase therapy for SE This drug can be used for continued oral therapy, does not cause significant side effects, and needs no preliminary check of renal function.	Low Very low Very low	Good practice statement Weak (conditional) Weak (conditional) Weak (conditional)