Seizure Acute Management: Emergency Department v.1.2

Seizure Acute Management: Emergency Department v.1.2 Executive Summary Test Your Knowledge Inclusion Criteria Patient presenting with epileptic seizure Explanation of Evidence Ratings Summary of Version Changes! Confirm medication history. If seizing upon arrival skip to appropriate step Exclusion Criteria Age < 1 month corrected age Non-epileptic events (pseudoseizures) Definitions Prolonged Seizure/Status Epilepticus: seizure longer than 5 minutes or two or more seizures without a return of consciousness between seizures! Known epilepsy: check outpatient seizure plan Minute 0 1 st Step Drug Treatment None General Measures Position child to avoid injury Cardiorespiratory support as needed SaO2; support respiration including provision of high concentration oxygen Make NPO/hold feeds while seizing Document seizure start time (consider using Code Blue Sheet) Check Care Plan/Care Coordination for individualized seizure care plan Prepare/obtain next medication Consider IV placement Investigations Confirm clinically that it is an epileptic seizure Assess risk for infection (if fever, see also Febrile Seizure Pathway) Investigate prior medications given Seizure continues Minute 5 2 nd Step Drugs (1 st Line) IV access Lorazepam 0.1 mg/kg max 4mg/ dose administered IV 2mg/min No IV access Midazolam 0.2mg/kg max 10mg/ dose, ½ dose in each nostril General Measures Above plus Cardiorespiratory monitoring, blood pressure q 5 minutes Correct hypoglycemia Prepare/obtain next medication Investigations Physical examination and history If on antiepileptic medication: consider drug level Consider laboratory tests based on individual clinical circumstances Seizure continues Minute 15 3 rd step Drugs (1 st Line) IV access Lorazepam 0.1 mg/kg max 4mg/ dose administered IV 2mg/min No IV access Midazolam 0.2mg/kg max 10mg/ dose, ½ dose in each nostril General Measures Above plus Capnography Prepare/obtain next medication Investigations Re-confirm clinically that it is an epileptic seizure Minute 25 4th Step Drugs (2 nd Line) Order customized treatment plan if available. If not available, use default below: Age 1-2 months old Phenobarbital 20mg/kg IV loading dose* Age > 2 months old Fosphenytoin 20mg PE/kg IV* Seizure continues General Measures Above plus Use blood pressure (BP) support if needed Identify and treat medical complications Consider PICU and Neurology consult *Decrease loading dose if patient already established on phenobarbital or fosphenytoin Investigations As above Consider CT Consider EEG! Watch for B/P changes in patients with cardiac anomalies or hemodynamic instability Seizure stops Seizure continues Minute >40 5th Step Drugs (2 nd Line) Age 1-2 months old May give additional phenobarbital 5mg/kg IV doses every 15-30 minutes until 30mg/kg maximum is met* Age > 2 months old Phenobarbital 20mg/kg IV if seizure continues 15 minutes after fosphenytoin load* May give additional phenobarbital 5mg/kg IV doses every 15-20 minutes* General Measures Above plus Off pathway, transfer to PICU In consultation with Neurology, optimize maintenance antiepileptic drug treatment *Decrease loading dose if patient already established on phenobarbital or fosphenytoin Investigations As above Post-Ictal Treatment and General Measures Ongoing vital signs q 10 minutes until stable Ongoing cardiorespiratory and SpO2 monitoring until return to baseline Family support Discuss with primary neurologist Admit Criteria Unstable cardiorespiratory or neurologic status (not returing to baseline, very somnolent) Underlying infection requiring inpatient stay Disabling parental anxiety Lack of safe home or safe transportation to home For questions concerning this pathway, contact: SeizurePathway@seattlechildrens.org 2012, Seattle Children s Hospital, all rights reserved, Medical Disclaimer Last Updated: 6/11/2013 Valid until: 6/19/2015

Seizure Acute Management: Inpatient v.1.2! Confirm medication history. Skip to appropriate step Inclusion Criteria Patient presenting with seizure Patient admitted with history of epileptic seizures and risk of recurrence Exclusion Criteria Age <1 month corrected age In hospital for Video EEG Non-epileptic events (pseudoseizures) Contraindications to use of pathway medications Patient has customized seizure plan Definitions Prolonged Seizure/Status Epilepticus: seizure longer than 5 minutes or two or more seizures without a return of consciousness between seizures On Admit Minute 0 1 st Step Upon Admission Order benzodiazepine from Seizure Acute Management First-line Orderset Order either Seizure Acute Management Second-line Orderset OR patient s customized second-line meds based on Neurology recommendations If patient is in ICU, discuss appropriateness of pathway inclusion with attending Drug Treatment None Seizure occurs General Measures Position child to avoid injury Cardiorespiratory & SaO2 monitoring Support respiration including provision of high concentration oxygen Make NPO/hold feeds while seizing Document seizure start time Prepare/obtain first medication Notify Contact Provider Consider IV placement Investigations Assess risk of infection (if fever, see Febrile Seizure Pathway) Investigate prior medications given Seizure continues Minute 5 2 nd Step Drugs (1 st Line) IV access Lorazepam 0.1 mg/kg max 4mg/ dose administered IV 2mg/min No IV access Midazolam 0.2mg/kg max 10mg/ dose, ½ dose in each nostril Midazolam 0.5mg/kg buccally max dose 10mg if nares not available General Measures Above plus Assess vital signs with B/P every 5 minutes Prepare/obtain next medication Notify Contact Provider if medication given. Call MD to bedside Investigations Physical examination and history If on an antiepileptic medication: consider drug level Consider laboratory tests based on individual clinical circumstances Seizure continues Minute 15 3 rd Step Drugs (1 st Line) IV access Lorazepam 0.1 mg/kg max 4mg/ dose administered IV 2mg/min No IV access Midazolam 0.2mg/kg max 10mg/ dose, ½ dose in each nostril Midazolam 0.5mg/kg buccally max dose 10mg if nares not available General Measures Above plus Call Vascular Access Team for STAT IV access Notify Contact Provider if medication given. Call MD to bedside. Prepare/obtain next medication Call Rapid Response Team and consult Neurology Seizure continues Investigations Re-confirm clinically that it is an epileptic seizure Seizure stops Minute 25 4th Step Drugs (2 nd Line) Order customized treatment plan if available. If not available, use default below: Age 1-2 months old Phenobarbital 20mg/kg IV loading dose* Age > 2 months old Fosphenytoin 20mg PE/kg IV* General Measures Above plus Blood pressure (BP) support if needed Identify and treat medical complications *Decrease loading dose if patient already established on phenobarbital or fosphenytoin Investigations As above! Consider CT Watch for Consider EEG B/P changes in patients with cardiac anomalies or hemodynamic instability Seizure continues Minute >40 5th Step Drugs (2 nd Line) Age 1-2 months old May give additional phenobarbital 5mg/kg IV doses every 15-30 minutes until 30mg/kg maximum is met* Age > 2 months old Phenobarbital 20mg/kg IV if seizure continues 15 minutes after fosphenytoin load* May give 2 additional phenobarbital 5mg/kg IV doses every 15-20 minutes (total 30mg/kg maximum)* General Measures Above plus In consultation with Neurology, optimize maintenance antiepileptic drug treatment Off Pathway, transfer to PICU *Decrease loading dose if patient already established on phenobarbital or fosphenytoin Investigations As above Post- Ictal Treatment and General Measures Ongoing vital signs q 10 minutes until stable Ongoing cardiorespiratory & SaO2 monitoring until at baseline Family support Discuss with primary neurologist For questions concerning this pathway, contact: SeizurePathway@seattlechildrens.org 2012, Seattle Children s Hospital, all rights reserved, Medical Disclaimer Last Updated: 6/11/2013 Valid until: 6/19/2015

Definition of Prolonged Seizure A proposed Classification of Status Epilepticus according to length of seizure: 5-30 Minutes: (OR 2 or more seizures without returning to baseline): Prolonged Seizure/Early Status Epilepticus. 30-60 Minutes: Established Status Epilepticus. Greater than 60 Minutes: Refractory Status Epilepticus. [Expert Opinion (E)] (Glauser,2007; Ma, 2010; NICE, 2012) Definitions Prolonged Seizure/Status Epilepticus: seizure longer than 5 minute or two or more seizures without a return of consciousness between seizures.

Actively Seizing For the child that is actively seizing, obtain history of all antiseizure medications given around this seizure episode to: Prevent medication overdosing Prevent medication interactions Decide where the patient belongs on the pathway e.g., the patient that is still seizing at presentation to the ED after receiving 2 doses of benzodiazepines in the field, should proceed to second-line agents after the appropriate time interval. ED: Inpatient:

When should treatment begin? Give immediate emergency care and treatment to children, young people and adults who have prolonged (lasting 5 minutes or more) or repeated (3 or more in an hour) convulsive seizures in the community. Serious risk of immediate and long-term morbidity and mortality if convulsive seizure is not terminated by 30 minutes and therefore treatment is required urgently. [ Low quality] (NICE, 2012) Patients arriving at the hospital with a seizure can be considered as having a prolonged seizure. A pre-hospital trial showed that time from seizure onset to initiation of treatment was inversely correlated with the percentage of patients who responded to firstline therapy. Patients receiving first-line therapy within 30 minutes had >80% response rate compared to 75% within 60 minutes and 63% within 90 minutes. [ High quality] (Ma, 2010) Drug therapy for prolonged seizure Drug therapy for prolonged seizures consists of : A first-line agent PLUS A second-line agent To Pg 2

Drug therapy for prolonged seizure 1 st line Benzodiazepines are first-line agents. First dose should be given at 5 minutes after start of seizure. Dose may be repeated after 10 minutes if patient still seizing. Administer intravenous lorazepam as first-line treatment in hospital in children, young people, and adults with ongoing generalized tonicclonic seizures. Administer intranasal OR buccal midazolam if unable to secure immediate IV access. [ Low quality] (NICE, 2012) Drug therapy for prolonged seizure 1 st line Administer a maximum of two doses of the first-line treatment (including pre-hospital treatment). [ Low quality] (NICE, 2012) The first dose of the patient s second-line treatment should be requisitioned from the pharmacy immediately after giving a second dose of benzodiazepine. This gives the pharmacy adequate time to prepare the medication so that it can be given on-time if the patient continues to seize.

Drug therapy for prolonged seizure 2 nd line Second-line therapy after benzodiazepines is fosphenytoin or phenobarbital. Fosphenytoin is preferred for patients age greater than or equal to 2 months. Cardiorespiratory and blood pressure monitoring must accompany the IV administration of Fosphenytoin. [ Very low quality] (Ma, 2010) First dose of these agents should be given at 10 minutes after the second benzodiazepine dose. Dose may be repeated after an additional 15 minutes if patient still seizing.

Drug therapy for prolonged seizure 2 nd line Cautions: Fosphenytoin has direct cardiac effects which can lead to arrhythmias. Hypotension, though rare, does occur with fosphenytoin. Phenobarbital can cause hypotension from its vasodilatatory and cardiodepressant effects Phenobarbital can cause profound respiratory depression.! Watch for B/P changes in patients with cardiac anomalies

Drug therapy for prolonged seizure At Admission Order benzodiazepine from Seizure Acute Management Firstline Orderset Order either Seizure Acute Management Second-line Orderset OR patient s customized second-line meds based on Neurology recommendations All inpatients with a significant history of seizures should have as needed doses of first-line AND second line seizure rescue agents ordered as part of their admitting orders, so that they are readily available. Some patients with a history of frequent, prolonged and /or intractable seizures may use other agents other than fosphenytoin or phenobarbital for their second-line treatment. Neurology should be consulted for these patients.

General measures for acute seizure Immediately: Give high-concentration oxygen Assess cardiac and respiratory function Check blood glucose levels Secure IV access in a large vein Secure airway [Expert Opinion (E)] (NICE, 2012) If patient receives a dose of benzodiazepine, continuously monitor and manage cardio respiratory function. [Expert Opinion (E)] Check blood pressure every 5 minutes during seizure, then every 10 minutes during postictal period until stable. [Expert Opinion (E)] General Measures Position child to avoid injury Cardiorespiratory support as needed SpO2; support respiration including provision of high concentration oxygen Make NPO/hold feeds while seizing Document seizure start time (consider using Code Blue Sheet) Check Care Plan / Care Coordination for individualized seizure care plan Prepare/obtain next medication Consider IV placement Seizure Continues General Measures Above plus Cardiorespiratory monitoring, blood pressure q 5 minutes Correct hypoglycemia Prepare/obtain next medication

Laboratory evaluation for acute seizure Anti-epileptic drug (AED) levels should be considered when a child with epilepsy on AED prophylaxis develops prolonged seizure/se. [ Low quality] (Riviello, 2006) Laboratory tests (complete blood count (CBC), serum electrolytes, blood urea nitrogen (BUN), creatinine, glucose, calcium, magnesium, or stool studies) should be considered based on individual clinical circumstances that include suggestive historic or clinical findings such as vomiting, diarrhea, dehydration, or failure to return to baseline alertness. [ Very low quality] (Riviello, 2006) Investigations Confirm clinically that it is an epileptic seizure Assess risk for infection (if fever, see also Febrile Seizure Pathway) Investigate prior medications given Investigations Physical examination and history If on antiepileptic medication: consider drug level Consider laboratory tests based on individual clinical circumstances Laboratory evaluation for acute seizure Toxicology testing may be considered in children with prolonged seizure/se, when no apparent etiology is immediately identified, as the frequency of ingestion as a diagnosis was at least 3.6%. To detect a specific ingestion, suspected because of the clinical history, it should be noted that a specific serum toxicology level is required, rather than simply urine toxicology screening. [ Very low quality] (Riviello, 2006) To Pg 2

Bacterial cultures for acute seizure There is insufficient data to support or refute whether blood cultures should be done on a routine basis in children in whom there is no clinical suspicion of infection. [ Very low quality] (Riviello, 2006) There is insufficient data to support or refute whether lumbar puncture should be done on a routine basis in children in whom there is no clinical suspicion of a CNS infection. [ Very low quality] (Riviello, 2006) A lumbar puncture should be performed in any child who presents with a seizure and a fever and has meningeal signs and symptoms (e.g., neck stiffness, Kernig and/or Brudzinski signs). [ Moderate quality] (AAP, 2011)

Assess Risk of Meningitis or Intracranial Infection A lumbar puncture should be performed in any child with seizure and a fever who is felt to be at SIGNIFICANT RISK for meningitis/intracranial infection. Specific aspects of the history or exam that might suggest meningitis or intracranial infection are outlined in the table below: [ Low quality] (Baumer, 2004; Selz, 2009; Kimia, 2010; Batra, 2011; AAP, 2011; Fetveit, 2008), [Expert Opinion (E)] (AAP, 2011; BC Guideline, 2011) More detail on this subject can be found in the Febrile Seizure Learning Module. Assess Risk of Meningitis or Intracranial Infection Children with the following HISTORICAL features have an increased risk of meningitis and lumbar puncture should be CONSIDERED: A child with at least three days of illness, seen by GP in previous 24 hours, with drowsiness at home, or vomiting at home. [ Low quality] (Baumer, 2004) An infant between 6 and 12 months of age who is considered deficient in Haemophilus influenzae type b (Hib) or Streptococcus pneumoniae immunizations (i.e., has not received scheduled immunizations as recommended) or when immunization status cannot be determined because of an increased risk of bacterial meningitis. [Expert Opinion (E)] (AAP, 2011) A child who is pretreated with antibiotics, because antibiotic treatment can mask the signs and symptoms of meningitis. [Expert Opinion (E)] (AAP, 2011) History >3 days duration of illness Seen by primary MD in previous 24 hours Drowsiness or vomiting at home Infant 6-12 months old deficient in Hib or pneumococcal vaccines or immunization status cannot be determined Pretreated with antibiotics To Pg 2

Assess Risk of Meningitis or Intracranial Infection Children with the following PHYSICAL EXAM features have an increased risk of meningitis and lumbar puncture should be CONSIDERED: Children with petechiae, questionable nuchal rigidity, drowsiness, convulsing on examination, weakness on examination, bulging fontanel. [ Low quality] Baumer, 2004) Some studies have suggested that abnormal neurological or mental status examinations are most predictive of meningitis/ intracranial infection: patients are described as obtunded, comatose, unresponsive, lethargic, drowsy, prolonged postictal state, agitated, combative, irritable, cranky, clingy, moaning, toxic. [ Low quality](selz, 2009; Kimia, 2010; Batra, 2011; AAP 2011) Signs of infection of the head or neck with potential for intracranial extension (such as mastoiditis, sinusitis, etc.) [Expert Opinion (E)] No evidence was found to support the suggestion that children below a certain age do not exhibit the signs of meningitis. (Baumer, 2004) Physical Signs Petechiae Questionable nuchal rigidity Drowsiness Convulsing on examination Weakness or neurological deficit on examination Signs of infection of head or neck with potential for intracranial extension (such as mastoiditis, sinusitis, etc.) Bulging fontanelle Assess Risk of Meningitis or Intracranial Infection Children with COMPLEX FEBRILE SEIZURES may have an increased risk of meningitis and lumbar puncture should be CONSIDERED There is some inconsistency in the literature regarding the approach to patients with complex febrile seizures (CFS). Two guidelines state that LP should be CONSIDERED in children with CFS. [ Low quality] (Baumer, 2004; Fetveit, 2008) One guideline RECOMMENDS lumbar puncture for all patients with CFS. [Expert Opinion (E)] (Boyle, 2011) And one guideline makes no distinction between children with CFS and children with simple febrile seizures (SFS) when assessing their risk of meningitis/intracranial infection. [Expert Opinion (E)] (BC Guideline, 2011) The PAERG systematic review looked a 4 studies from 1981-92, and found that the historic pooled rate for meningitis following febrile seizure was 2.9% overall, with a rate of 2% in SFS and 9.1% in CFS. [ Low quality] (PAERG, 2002) However, recent studies in the age of Hib and Pneumococcal vaccines have shown the rate of meningitis CFS to be very low at <1%, [ Low quality] (Selz, 2009; Kimia, 2010) and similar to the rate for SFS. [ Low quality] (Trainor, 2001) Complex Features Focal Seizures Seizure duration > 15 minutes Multiple seizures in 24 hours To Pg 3

Assess Risk of Meningitis or Intracranial Infection Children with a previous history of febrile seizures or history of pre-existing neurological abnormality may be less likely to have meningitis or intracranial infection associated with subsequent febrile seizures. [Expert Opinion (E)] Meningitis Less Likely Prior febrile seizure Pre-existing neurological findings

Urgent EEG in evaluation of acute prolonged seizure Consult neurology to discuss need for emergent EEG. In adults, nonconvulsive SE (NCSE) is present in 14% of patients in whom convulsive SE is controlled but in whom consciousness remains impaired. Although nonconvulsive SE occurs in children who present with prolonged seizure/se, there is insufficient data to support or refute recommendations regarding whether an EEG should be obtained to establish this diagnosis. [ Very low quality] (Riviello, 2006) Investigations As above Consider EEG Consider CT An EEG may be considered in a child presenting with prolonged seizure/se if the diagnosis of pseudostatus epilepticus is suspected. [ Low quality] (Riviello, 2006) Urgent CT in evaluation of acute prolonged seizure Emergent neuroimaging (CT) may be considered for the evaluation of the child with prolonged seizure/se if any of the following are present: o o o o o o Unknown etiology of seizure Acute change in neurologic exam from baseline Suspicion for non-accidental trauma Focal seizure onset Pre-disposing history (age <6 months, trauma, CSF shunt, malignancy, or neurocutaneous disorder). First seizure lasting > 30 minutes If neuroimaging is done, it should only be done after the child is appropriately stabilized. There is insufficient evidence to support or refute recommending routine neuroimaging. [ Low quality] (Riviello, 2006; Harden, 2007)

Refractory Seizure Patients are Off-Pathway Patients who continue to seize after Step 5 are OFF THE PATHWAY Further evaluation and treatment should be directed by Neurology and the Intensive Care Unit.

Criteria for Inpatient Admission Once seizures have resolved, the patient should continue to be monitored and observed until patient is returning to baseline. Addressing parental anxiety and providing parental education are often the key tasks of the medical team following a seizure. Criteria for Inpatient Admission ED Patients Admit Criteria Unstable cardiorespiratory or neurologic status (not returing to baseline, very somnolent) Underlying infection requiring inpatient stay Disabling parental anxiety Lack of safe home or safe transportation to home Children who are clinically unstable neurologically (e.g., not returning to baseline, very somnolent following doses of anti-seizure medications) should be admitted for observation and support. [Expert Opinion (E)] (Fetveit, 2008; Baumer, 2004) Children who present with an underlying infection requiring inpatient stay (e.g., severe pneumonia, infection requiring intravenous antibiotics) should be admitted. [Expert Opinion (E)] (BC, 2010) Children whose parents have "disabling" anxiety following the seizure episode may require admission for observation and further parental education and reassurance. [Expert Opinion (E)](BC, 2010; Fetveit, 2008) Children that lack a safe home or safe transportation home require admission and may require social work consultation. [Expert Opinion (E)] (Fetveit, 2008)

Executive Summary To Pg 2

Executive Summary

Self-Assessment Completion qualifies you for 1 hour of Category II CME credit. If you are taking this self-assessment as a part of required departmental training at Seattle Children s Hospital, you MUST logon to Learning Center. 1) Which of the following is FALSE regarding inclusion and exclusion criteria? a) The Seizure Acute Management pathway should be used for patients with non-epileptic seizures (a.k.a. pseudoseizures or 'spells') b) Patients less than 1 month old (44 weeks gestational age) are excluded from the pathway c) For inpatients, the Seizure Acute Management Pathway should be ordered for all patients presenting with seizure d) For inpatients, the Seizure Acute Management Pathway should be ordered for all patients with a history of epileptic seizures and risk of recurrence 2) Which of the following statements about seizures are TRUE? a) A seizure lasting 5-30 minutes or 2 or more seizures without returning to baseline is classified as: "Prolonged Seizure/ Early Status Epilepticus" b) A pre-hospital trial showed that time from seizure onset to initiation of treatment was inversely correlated with the percentage of patients who responded to first-line (benzodiazepine) therapy c) There is a serious risk of immediate and long-term morbidity and mortality if a convulsive seizure is not terminated by 30 minutes d) A patient that is still seizing at presentation to the ED after receiving 2 doses of benzodiazepines in the field should proceed to second-line agents after the appropriate time interval e) All of the above 3) It is appropriate to order the Neuro Seizure Acute Management First Line Orders (which provides p.r.n. orders for antiepileptic medications) for all patients with a history of seizures and risk of recurrence, even if they are admitted for a nonseizure related illness (asthma, dehydration, etc) a) True b) False 4) Which of the following statements are TRUE regarding seizure medications? a) Benzodiazepines are 1st line agents b) Administer a maximum of two doses of the first-line treatment c) Second-line therapy after benzodiazepines is fosphenytoin or phenobarbital d) Fosphenytoin is the preferred 2nd line therapy for patients age greater than or equal to 2 months e) Phenobarbital is preferred 2nd line therapy for patients age less than 2 months of age f) All of the above are true 5) Which of the following is a FALSE statement regarding drug therapy for prolonged seizures? a) Some patients with a history of frequent, prolonged and /or intractable seizures may use other agents other than fosphenytoin or phenobarbital for their second-line treatment. Pediatric neurology should be consulted for these patients. b) Drug therapy for prolonged seizures consists of a first line agent (benzodiazepines) and a second line agent (fosphenytoin or phenobarbital) c) There is no need for cardiac monitoring when administering fosphenytoin or phenobarbital d) Benzodiazepines may be given by the nasal route if IV access is not readily available To Self Assessment, Pg 2

Self-Assessment If you are taking this self-assessment as a part of required departmental training, you will need to logon to the Learning Center to receive credit. Completion also qualifies you for 1 hour of Category II CME credit. 6) Immediate general measures for acute seizures should include: a) Giving high-concentration oxygen b) Assess cardiac and respiratory function c) Check blood glucose levels d) Securing IV access in a large vein e) Securing airway f) Cardiorespiratory monitoring for all patients receiving an antiepileptic medication g) Checking blood pressures every 5 minutes during seizure and then every 10 minutes during the postictal period until stable h) All of the above 7) Which of the following statements is FALSE? a) Anti-epileptic drug (AED) levels should be considered when a child with epilepsy on AED prophylaxis develops prolonged seizure/se. b) In the setting of a febrile seizure, a lumbar puncture is not necessary even if the patient has meningeal signs c) Laboratory tests (complete blood count (CBC), serum electrolytes) should be considered based on individual clinical circumstances that include suggestive historic or clinical findings such as vomiting, diarrhea, dehydration, or failure to return to baseline alertness d) Toxicology testing may be considered in children with prolonged seizure/se, when no apparent etiology is immediately identified 8) Which of the following statements regarding admission criteria are TRUE? a) Children who are clinically unstable neurologically (e.g., not returning to baseline, very somnolent following doses of anti-seizure medications) should be admitted for observation and support. b) Children who present with an underlying infection requiring inpatient stay (e.g., severe pneumonia, infection requiring intravenous antibiotics) should be admitted. c) Children whose parents have "disabling" anxiety following the seizure episode may require admission for observation and further parental education and reassurance. d) Children that lack a safe home or safe transportation home require admission and may require social work consultation. e) All of the above 9) Which of the following statements regarding nonconvulsive status epilepticus (NCSE) is TRUE? a) In adults, NCSE is present in 14% of patients in whom convulsive SE is controlled but in whom consciousness remains impaired. b) Although NCSE occurs in children who present with prolonged seizure/se, there are insufficient data to support or refute recommendations regarding whether an EEG should be obtained to establish this diagnosis. c) An EEG may be considered in a child presenting with prolonged seizure/se if the diagnosis of pseudostatus epilepticus is suspected. d) All of the above 10) Which of the following statements is FALSE? a) In children with prolonged seizure/se when no apparent etiology is immediately identified, the frequency of ingestion of a toxic substance is approximately 3.6% b) If the patient has ingested a known toxic substance, a urine toxicology screening test is sufficient for detection c) Neuroimaging should be considered if there is suspicion for non-accidental trauma, a focal seizure at onset, a first seizure lasting >30 minutes, or if there is an acute change in the neurologic exam from baseline. d) Children seizing for >40 minutes are off pathway Back View Answers

Answer Key 1) The correct answer is (a), non-epileptic seizures should not be treated with benzodiazepines, or other antiepileptic medications. 2) The correct answer is (e), all of the above statements are true. 3) The correct answer is (a). Ordering the Neuro Seizure Acute Management First Line Orders for all patients with a history of epileptic seizures is appropriate because one should anticipate the need for a possible seizure episode while hospitalized 4) The correct answer is (f), all of the above are true statements 5) The correct answer is (c). Cardiorespiratory monitoring is recommended when using 2nd line agents. Fosphenytoin has direct cardiac effects which can lead to arrhythmias and phenobarbital can cause hypotension from its vasodilatatory and cardiodepressant effects. 6) The correct answer is (h). All of the above are correct. 7) The correct answer is (b). A lumbar puncture should be performed in any child who presents with a seizure and a fever and has meningeal signs and symptoms (e.g., neck stiffness, Kernig and/or Brudzinski signs). 8) The correct answer is (e). All of the above statements are true. 9) The correct answer is (d). All of the above statements are true 10) The correct answer is (b). If a specific ingestion is being considered as a possible etiology of the seizure, serum toxicology testing should be ordered. Urine toxicology screening may not be sufficient.

Evidence Ratings We used the GRADE method of rating evidence quality. Evidence is first assessed as to whether it is from randomized trial, or observational studies. The rating is then adjusted in the following manner: Quality ratings are downgraded if studies: Have serious limitations Have inconsistent results If evidence does not directly address clinical questions If estimates are imprecise OR If it is felt that there is substantial publication bias Quality ratings can be upgraded if it is felt that: The effect size is large If studies are designed in a way that confounding would likely underreport the magnitude of the effect OR If a dose-response gradient is evident Quality of Evidence: High quality Moderate quality Low quality Very low quality Expert Opinion (E) Reference: Guyatt G et al. J Clin Epi 2011: 383-394 To Bibliography

Summary of Version Changes Version 1 (6/19/2012): Go live Version 1.1 (6/24/2012): Adaptation for android use Version 1.2 (6/11/2013): Exclusion criteria updated; patients in ICU may be on pathway at discretion of attending MD

Medical Disclaimer Medicine is an ever-changing science. As new research and clinical experience broaden our knowledge, changes in treatment and drug therapy are required. The authors have checked with sources believed to be reliable in their efforts to provide information that is complete and generally in accord with the standards accepted at the time of publication. However, in view of the possibility of human error or changes in medical sciences, neither the authors nor Seattle Children s Healthcare System nor any other party who has been involved in the preparation or publication of this work warrants that the information contained herein is in every respect accurate or complete, and they are not responsible for any errors or omissions or for the results obtained from the use of such information. Readers are encouraged to confirm the information contained herein with other sources. For questions concerning this pathway, contact:seizurepathway@seattlechildrens.org Last Updated: 5/7/2012 Valid until: 5/7/2012

Bibliography Search Methods, Seizures - Acute Management Studies were identified by searching electronic databases using search strategies developed and executed by a medical librarian, Jamie Graham. Searches were performed in February 2012. The following databases were searched - on the Ovid platform: Medline (2002 to date), Cochrane Database of Systematic Reviews (2005 to date; elsewhere - Embase (2002 to date), Clinical Evidence, National Guideline Clearinghouse, and TRIP. Retrieval was limited to children older than neonates and English language. In Medline and Embase, appropriate Medical Subject Headings (MeSH) and Emtree headings were used respectively, the search strategy was adapted for other databases using their controlled vocabularies, where available, along with text words. Concepts searched were status epilepticus. All retrieval was further limited to certain evidence categories, such as relevant publication types, guidelines, and index terms for study types and other similar limits. Jamie Graham, MLS June 1, 2012 Identification 64 records identified through database searching 1 additional record identified through other sources 7 studies added from Febrile Seizure Pathway Screening 62 records after duplicates removed 62 records screened 24 records excluded Elgibility 38 full-text articles assessed for eligibility 34 full-text articles excluded, 1 did not answer clinical question 7 older study 26 did not meet quality threshold Included 11 studies included in pathway Flow diagram adapted from Moher D et al. BMJ 2009;339:bmj.b2535 To Bibliography

Bibliography (AAP), Subcommittee on Febrile Seizures, American Academy of Pediatrics. Neurodiagnostic evaluation of the child with a simple febrile seizure. Pediatrics [IBD]. 2011;127(2):389-394. Baumer, JH. (2004). Evidence based guideline for post-seizure management in children presenting acutely to secondary care. Arch Dis Child; 89:278-280. (BC), Febrile seizures. (2010). Clinical Practice Guidelines and Protocols in British Columbia Batra, P., Gupta, S., Gomber, S., & Saha, A. (2011). Predictors of meningitis in children presenting with first febrile seizures. Pediatric Neurology, 44(1), 35-39. Fetveit, A. (2008). Assessment of febrile seizures in children.european Journal of Pediatrics, 167(1), 17-27. Harden, C., Huff,J., Schwartz,T., et.al. ((2007). Reassessment: Neuroimaging in the emergency patient presenting with seizure (an evidence-based review). Neurology 2007;69:1772-1780. Kimia, A., Ben-Joseph, E. P., Rudloe, T., Capraro, A., Sarco, D., Hummel, D., et al. (2010). Yield of lumbar puncture among children who present with their first complex febrile seizure.pediatrics, 126(1), 62-69. Ma, L., Yung, A., Kwong, K., et al. (2010). Clinical Guidelines on Management of Prolonged Seizures, Serial Seizures and Convulsive Status Epilepticus in Children. HK J Paediatr (new seeries) 2010; 15: 52-63. NICE clinical guideline 137 (2012). The epilepsies: the diagnosis and management of the epilepsies in adults and children in primary and secondary care. www.nice.org.uk/cg137 Riviello, JJ., Ashwal,S., Hirtz, D., et. al. (2006). Practice Parameter: Diagnostic assessment of the child with status epilepticus (an evidence-based review). Neurology 2006;67:1542-1550. Seltz LB, Cohen E, Weinstein M. Risk of bacterial or herpes simplex virus meningitis/encephalitis in children with complex febrile seizures. Pediatr Emerg Care. 2009;25(8):494-497