Abstracts

Rationale: Childhood convulsive status epilepticus (CSE) is the most common childhood neurological emergency and is associated with significant morbidity and mortality. Childhood CSE frequently starts in the community. The purpose of emergency treatment is to minimise seizure length and to treat causes to reduce adverse outcomes but there are limited available data on optimum treatment. From the North London Convulsive Status Epilepticus in Childhood Surveillance Study (NLSTEPSS), we report the first systematic population-based data on the treatment of childhood CSE from its onset in the community. Methods: Details of the study methods have been previously described. From May 1, 2002 to April 30, 2004 data were prospectively collected on north London children with episodes of CSE. Ascertainment was estimated to be 62-84%. Decisions about treatment were made by individual carers, paramedics and doctors who enrolled patients and not by the research team. Logistic regression was used to examine factors associated with seizure termination after first and second line therapy, CSE lasting longer than 60 minutes, and respiratory depression. Factors which were univariately associated significantly with the outcomes were determined and multivariable models identified whether these associations were independent. All factors which had not previously been significant were then added to the models to identify those associated with outcome only after adjustment for other factors. All episodes were included and adjustment made for repeat episodes in individuals. Results: 240 episodes (182 children, median age 3.24 (0.16-15.98) years, 88 male) were enrolled. 5 episodes stopped without any treatment. 147 (61%) episodes received prehospital treatment of which 30 (20%) had seizure termination prior to arrival at A&E. In multivariable models, in A&E treatment with intravenous lorazepam was independently associated with a 3.7 times (95%CI 1.7, 7.9) greater likelihood of seizure termination than with rectal diazepam. As second line therapy, treatment with intravenous phenytoin was associated with 9 times (95%CI 3.0, 27.0) greater likelihood of seizure termination compared than with rectal paraldehyde. Lack of prehospital treatment (OR2.4, 95%CI 1.2-4.5) and treatment with more than 2 doses of benzodiazepines (OR 3.6 (95%CI 1.9-6.7) were associated with CSE lasting longer than 60 minutes. Treatment with more than 2 doses of benzodiazepines was also associated with respiratory depression (OR 2.9, 95%CI 1.4, 6.1). Conclusions: These data add to the debate on optimum emergency treatment of childhood CSE and support changes in treatment guidelines. Given the clinical and educational implications of our study we propose that an update of the current guidelines for the treatment of childhood CSE that incorporated a Cochrane review of the topic, would be timely.