Seizure 2018, Vol 58, Editor’s Choice: Outcomes of deviation from treatment guidelines in status epilepticus: A systematic review and Towards acute pediatric status epilepticus intervention teams: Do we need “Seizure Codes”?
This time I have selected two articles from the current issue of Seizure as Editor’s Choices. Both focus on the management of convulsive status epilepticus (CSE).
There are many unanswered medical questions and serious conditions which we lack effective treatment for. Being diagnosed with such a condition will obviously cause distress, but most patients realise that medical knowledge only advances gradually and that there is much we simply do not understand. This may leave them sad or angry, but usually they will accept their fate and do their best to cope with the challenge life has thrown at them.
What is much harder to accept – for patients and health professionals alike – is when we know what to do, when highly effective treatments are available, but are simply not administered in an appropriate or timely fashion.
Status epilepticus is an example of such a scenario. Benzodiazepines can control convulsive status epilepticus (CSE) successfully in over two thirds of cases. Second line drugs achieve acute seizure control in a further 10-20%. Earlier control of CSE is associated with better outcomes in terms of survival, recovery time and cognitive function. However, while it has been known for many years that “time is brain” in CSE and that the responsiveness to benzodiazepines diminishes significantly after 20 minutes, CSE is often treated poorly. Medications are given too late or in inadequate doses. Another common error is the repeated administration of insufficient doses of benzodiazepines until clinicians loose sight of how much medication they have given. Although protocols and guidelines exist in many treatment centres, deviations from the protocols are almost the rule rather than the exception.
The systematic review by Preena Uppal et al., my first Editor’s Choice paper, summarises the findings of studies comparing outcomes of CSE treatments in which clinicians adhered or deviated from treatment protocols. It clearly demonstrates the dangers of a non-methodical approach. The commonest problem was the administration of excessive doses of benzodiazepines. This was associated with an almost six fold increase of the risk of respiratory depression, need for intubation or intensive care admission.
My second Editor’s Choice paper, a narrative review by Coral Stredny et al. focuses especially on the gap between what is known about best and common practice in the treatment of paediatric CSE. Thirty years ago, the acute treatment of myocardial infarction was revolutionised by the introduction of clear treatment algorithms. Over the last ten years, the emergency treatment of patients presenting with strokes has benefited from the same approach. These are good models to follow if we want to achieve a similar revolution in the outcome of CSE.
(1) Uppal P, Cardamone M, Lawson J. Outcomes of deviation from treatment guidelines in status epilepticus: A systematic review. Seizure 2018, 58, 147-153.
(2) Stredny C, Abend N, Loddenkemper T. Towards acute pediatric status epilepticus intervention teams: Do we need “Seizure Codes”? Seizure 2018, 58, 133-140.