Steve Meek wanted some clarification on some points from someone from the
APLS
working group on the new status epilepticus protocol ,so here goes although
I think most of what I'd say has already been suggested in the
correspondence.....
The guidelines recently implemented by APLS for status epilepticus in
children are evidence based and were developed by A and E and Paediatric
Neurologists together over a two year period. They were then adopted for
APLS by the working group -so we didn't write them ourselves!
Lorazepam has been shown in trials to be as or slightly more effective than
diazepam with less respiratory depression and less risk of accumulation.
Although the onset of action is slower the duration of action is longer - as
it would be very unusual to want to discharge a child who has come in in
status
epilepticus immediately, this should not be a problem and should in fact be
helpful (in preventing a recurrence). Rectal diazepam has been kept in the
protocol where there is no IV access as the absorption of lorazepam rectally
is erratic, but paraldehyde, rather than repeating the diazepam, is
recommended if it doesn't work after the first dose, as there is less risk
of
respiratory depression. Clinical experience (few studies) have shown it to
work.
Before giving phenytoin /fosphenytoin we recommend getting senior assessment
to make sure the diagnosis is correct (may be an acute movement disorder,
decerebrate posturing etc etc)as phenytoin is effective but care should be
taken with toxicity which really does sometimes occur. (I gave some at a
rate of 'over not less than 20 mins' once and the patient went into VT -
turned
out subsequently to have had a low K we didn't know about at the time, did
fine eventually, but it certainly made me aware of the dangers!).
Fosphenytoin is less cardiovascularly toxic and has fewer problems with
extravastation, but acts no faster.
The guidelines do not apply to neonates in whom diazepam +/- phenobarb is
usually used. Their fits often have a different aetiology. Phenobarb may
also be preferable instead of phenytoin in those already on phenytoin
because of toxicity problems. They are equally effective but phenytoin is
less respiratory depressant.
The guidelines are not intended for prehospital use. (I too would like to
see a prehospital study using buccal midazolam.)
Hope this is of help - if you want refs please let me know and I'll do my
best, but it may take a while.
Fiona Jewkes
APLS Working Group member
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