• It is important to look for a cause, as CSE can be a complication of acute illness such as encephalitis, meningitis, metabolic problems (e.g. hypoglycaemia), or can occur as a manifestation of epilepsy.
• The highest incidence is in the first year of life. Prolonged Febrile Seizure is the most common cause of Status Epilepticus

• The first step in the management of the patient who is having a seizure is to assess and support the airway, breathing and circulation.
• Timing is from onset of seizure, and not from the arrival to the Emergency Department.
• Given that most acute seizures in children stop spontaneously, usually during transit to hospital, it should be assumed that if a child is still convulsing on arrival in the Emergency Department, the seizure will continue unless treated.
• After no response to two doses of midazolam, appropriate second-line antiepileptics should be administered. Refer to the APLS Guideline for Status Epilepticus Management (or the NSW Health Guideline, once available).
• The paediatric Improvement Collaborative has also created an algorithm.
• Chapter 7 of the UK NICE guideline for Epilepsies in children, young people and adults, also provides information on treating status epilepticus, repeated or cluster seizures, and prolonged seizures.
• Prolonged seizures and/or repeated doses of anti-epileptic medications may lead to compromise of breathing requiring ongoing support including intubation. In assessing medication load, factor in dosages of benzodiazepines given by carers and ambulance personnel. However, it is thought the major reason for compromised breathing is the status epilepticus itself.

In 2019 three papers were published related to second-line treatment of convulsive status. In the studies EcLIPSE and ConSEPT, both randomised controlled trials, phenytoin and levetiracetam were compared. The primary outcome measures were not different for either drug. Adverse effects were not significantly different.

The ESETT study was a randomised trial of three anticonvulsants: levetiracetam, valproate and fosphenytoin in children and adults.  Each drug led to seizure cessation and improved alertness by 60 minutes in approximately half the patients. The three drugs were associated with similar incidences of adverse effects.

Refractory Status Epilepticus:

• Defined as a failure of response to two AEDs, including first-line therapy.
• Other drugs used in this situation include: midazolam, propofol, barbiturates.

Resources

• Patients should not be sent home without having a clear Seizure Management Plan, and Seizure Safety education.
• Consider Midazolam education for at-risk groups.   
• Article on Midazolam for Status Epilepticus (R. Smith & J. Brown, Australian Prescriber, 2017:40(1);23-25.)

• Dalziel SR, Borland ML, Furyk J, et al. Levetiracetam versus phenytoin for second-line treatment of convulsive status epilepticus in children (ConSEPT): an open-label, multicentre, randomised controlled trial. Lancet. 2019;393(10186):2135-2145. https://doi.org/10.1016/S0140-6736(19)30722-6
• Kapur J, Elm J, Chamberlain JM, et al. Randomized Trial of Three Anticonvulsant Medications for Status Epilepticus. N Engl J Med. 2019;381(22):2103-2113. https://doi.org/10.1056/NEJMoa1905795
• Lyttle MD, Rainford NEA, Gamble C, et al. Levetiracetam versus phenytoin for second-line treatment of paediatric convulsive status epilepticus (EcLiPSE): a multicentre, open-label, randomised trial. Lancet. 2019;393(10186):2125-2134. https://doi.org/10.1016/S0140-6736(19)30724-X
• Singh RK, Stephens S, Berl MM, et al. Prospective study of new-onset seizures presenting as status epilepticus in childhood. Neurology. 2010;74(8):636-642. https://doi.org/10.1212/WNL.0b013e3181d0cca2