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Seizure Acute Management: Emergency Department v.2.1
Approval & Citation
Summary of Version Changes
Explanation of Evidence Ratings
Inclusion Criteria
· Patient presenting with
epileptic seizure
Exclusion Criteria
· Age < 1 month corrected
age
· Non-epileptic events
(pseudoseizures)
!
Confirm
medication history.
If seizing upon arrival
skip to appropriate step
!
Known epilepsy:
check outpatient
seizure plan
Definitions
Prolonged Seizure/Status Epilepticus: seizure longer than 5 minutes or
two or more seizures without a return of consciousness between seizures
General Measures
Drug Treatment
· 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
Minute 0
1st Step
· None
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
2nd Step
Drugs (1st Line)
General Measures
· Above plus
· Cardiorespiratory monitoring, blood
pressure q 5 minutes
· Correct hypoglycemia
· Prepare/obtain next medication
IV access
· Lorazepam 0.1 mg/kg max 4mg/
dose administered IV 2mg/min
No IV access v
· Midazolam 0.2mg/kg max 10mg/
dose, ½ dose in each nostril
Investigations
· Physical examination and history
· If on antiepileptic medication:
consider drug level
· Consider laboratory tests based on
individual clinical circumstances
Seizure continues
Minute 15
3rd step
Drugs (1st Line)
General Measures
· Above plus
· Capnography
· Prepare/obtain next medication
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
Investigations
· Re-confirm clinically that it is an
epileptic seizure
Seizure continues
Minute 25
4th Step
Drugs (2nd Line)
Investigations
General Measures
· Order customized treatment plan if
available. If not available, use default
below:
· 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
Age 1-2 months old
· Phenobarbital 20mg/kg IV loading
dose*
Age > 2 months old
· Fosphenytoin 20mg PE/kg IV*
· As above
· Consider CT
· Consider EEG
!
Watch for
B/P changes
in patients with
cardiac anomalies or
hemodynamic
instability
Seizure continues
Post-Ictal
Minute >40
5th Step
Drugs (2nd 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*
Investigations
General Measures
· As above
· 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
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: [email protected]
© 2016, Seattle Children’s Hospital, all rights reserved, Medical Disclaimer
Last Updated: December 2016
Next Expected Review: May 2017
Seizure
stops
Seizure Acute Management: Inpatient v.2.1
Approval & Citation
Summary of Version Changes
Explanation of Evidence Ratings
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
Confirm
medication history.
Skip to appropriate step
Definitions
Prolonged Seizure/Status
Epilepticus: seizure longer than 5
minutes or two or more seizures
without a return of consciousness
between seizures
On
Admit
Upon Admission
· Order benzodiazepine from Seizure Acute Management Plan
· Order standard second line meds from Seizure Acute Management Plan OR patient’s customized second-line meds based on
Neurology recommendations
· If patient is in ICU, discuss appropriateness of pathway inclusion with attending
Seizure occurs
General Measures
Drug Treatment
Investigations
· 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
Minute 0
1st Step
· None
· Assess risk of infection (if fever,
see Febrile Seizure Pathway)
· Investigate prior medications given
Seizure continues
st
Minute 5
2nd Step
Drugs (1 Line)
General Measures
IV access
· Lorazepam 0.1 mg/kg max 4mg/
dose administered IV 2mg/min
No IV access v
· Midazolam 0.2mg/kg max 10mg/
dose, ½ dose in each nostril
· Midazolam 0.5mg/kg buccally max
dose 10mg if nares not available
· 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
3rd Step
Drugs (1st Line)
General Measures
Investigations
· 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
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
· Re-confirm clinically that it is an
epileptic seizure
Seizure
stops
Seizure continues
Minute 25
4th Step
Investigations
General Measures
Drugs (2nd Line)
· Above plus
· Blood pressure (BP) support if
needed
· Identify and treat medical
complications
· *Decrease loading dose if patient
already established on
phenobarbital or fosphenytoin
· 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*
· As above
· Consider CT
· Consider EEG
!
Watch for
B/P changes
in patients with
cardiac anomalies or
hemodynamic
instability
Seizure continues
PostIctal
Minute >40
5th Step
Drugs (2nd 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
Treatment and General Measures
· Ongoing vital signs q 10 minutes until stable
· Ongoing cardiorespiratory & SaO2 monitoring until at baseline
For questions concerning this pathway,
contact: [email protected]
© 2016, Seattle Children’s Hospital, all rights reserved, Medical Disclaimer
· Family support
· Discuss with primary neurologist
Last Updated: December 2016
Next Expected Review: May 2017
Return to ED Management
Return to Inpatient Management
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.
Return to ED Management
Return to Inpatient Management
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.
Return to ED Management
ED:
Inpatient:
Return to Inpatient Management
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 – 1st 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 – 1st 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.
Return to ED Management
Return to Inpatient Management
Drug therapy for prolonged seizure – 2nd 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.
Return to ED Management
Return to Inpatient Management
Drug therapy for prolonged seizure – 2nd 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.
Return to ED Management
!
Watch for
B/P changes in
patients with
cardiac anomalies
Return to Inpatient Management
Drug Therapy For Prolonged Seizure
At Admission:
• Order benzodiazepine from Seizure Acute Management First-line Orderset
• Order standard second-line medications from Seizure Acute Management
Plan 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.
Return to ED Management
Return to Inpatient Management
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
•
•
•
•
•
•
•
•
Seizure
Continues
General Measures
•
•
•
•
Return to ED Management
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
Above plus
Cardiorespiratory monitoring, blood
pressure q 5 minutes
Correct hypoglycemia
Prepare/obtain next medication
Return to Inpatient Management
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.
Investigations
•
Confirm clinically that it is an
epileptic seizure
[ Low quality] (Riviello, 2006)
•
Assess risk for infection (if fever, see
also Febrile Seizure Pathway)
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.
•
Investigate prior medications given
[ Very low quality] (Riviello, 2006)
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)
Return to ED Management
Return to Inpatient Management
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)
To Pg 2
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
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)]
•
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
No evidence was found to support the suggestion that
children below a certain age do not exhibit the signs of
meningitis. (Baumer, 2004)
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)
Complex Features
• Focal Seizures
• Seizure duration > 15 minutes
• Multiple seizures in 24 hours
•
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)
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)]
Return to ED Management
Meningitis Less Likely
• Prior febrile seizure
• Pre-existing neurological
findings
Return to Inpatient Management
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 Unknown etiology of seizure
o Acute change in neurologic exam from baseline
o Suspicion for non-accidental trauma
o Focal seizure onset
o Pre-disposing history (age <6 months, trauma, CSF shunt,
malignancy, or neurocutaneous disorder).
o 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)
Return to ED Management
Return to Inpatient Management
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.
Return to ED Management
Return to Inpatient Management
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
Admit Criteria
ED Patients
•
•
•
•
· 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)
Return to ED Management
Return to Inpatient Management
Seizure Acute Management Approval & Citation
Approved by the CSW Seizure Acute Management for June 2012
CSW Seizure Acute Management Team:
Pathway Owner
Pathway Owner
Pathway Owner
Clinical Nurse Specialist, Emergency
Clinical Nurse Specialist, Medical
Clinical Nurse Specialist, Medical
Emergency
PharmD
Pharmacy Informatics
Clinical Effectiveness Team:
Consultant:
Project Manager:
Ron Dick, MD
Rebecca Taxier, MD
Heidi Blume, MD, MPH
Elaine Beardsley
Coral Ringer, MN
Kristi Klee, MSN, RN-BC
Stephen Cico, MD
Katherine Bridger
Karen Knudson, RPh
CE Analyst:
CIS Informatician:
CIS Analyst:
Librarian:
Jennifer Hrachovec, PharmD MPH
Ryan Leininger, BS, PMP
Asa Herrman
Suzanne Spencer, MBA, MHA
Michael Leu, MD, MS, MHS
Heather Marshall
Sue Groshong, MLIS
Executive Approval:
Sr. VP, Chief Medical Officer
Sr. VP, Chief Nursing Officer
Surgeon-in-Chief
Mark Del Beccaro, MD
Madlyn Murrey, RN, MN
Bob Sawin, MD
Retrieval Website: http://www.seattlechildrens.org/pdf/seizures-acute-management-pathway.pdf
Please cite as:
Seattle Children’s Hospital, Blume H, Dick R, Taxier R, Beardsley E, Bridger K, Cico S, Klee K,
Knudson K, Ringer C, 2012 June. Seizure Acute Management Pathway. Available from: http://
www.seattlechildrens.org/pdf/seizures-acute-management-pathway.pdf
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Value Analysis: Intranasal Midazolam
VALUE ANALYSIS TOOL
DIMENSION
BASE CASE
CARE OPTION A
CARE OPTION B
PREFERRED OPTION
DESCRIPTION OF CARE TREATMENT OPTION
Lorazepam IV
Midazolam IN
Diazepam PR
OPERATIONAL FACTORS
Percent adherence to care (goal 80%)
100%
100%
100%
NEUTRAL
Preferred
Preferred
Not preferred, requires
clothing removal
OPTION A
No difference
No difference
No difference
NEUTRAL
Effects on natural history of the disease
over equivalent time
Potential to cause harm
No difference
No difference
No difference
NEUTRAL
No difference
No difference
No difference
NEUTRAL
Palatability to patient/family
Preferred
Preferred
Preferred by a few families
but not most, requires
clothing removal
OPTION A
Population-related benefits
No difference
No difference
No difference
NEUTRAL
Care delivery team effects
BENEFITS / HARMS (QUALITY/OUTCOME)
Degree of recovery at discharge
ASSUMPTIONS MADE
A significantly lower proportion of patients receiving
rectal diazepam were seizure free within 10 minutes
compared to participants receiving intranasal
midazolam, however there is uncertainty over the
magnitude of clinical effect (Very Low quality)
No significant difference for time to cessation of
seizure (Moderate quality)
COST (Arising from Options A or B) - Average Total Cost Per Day: This represents supply + labor + non-labor costs, not charge to patient or actual cost of an item.
“ROOM RATE” ($ or time to recovery)
No difference
No difference
No difference
NEUTRAL
“Dx/Rx” costs ($)
$1
$25
$112
OPTION A LESS EXPENSIVEPlacement of an IV to give lorazepam is
not shown in cost
COST (Complications/adverse effects arising from Options A or B)- Average Total Cost Per Day: This represents supply + labor + non-labor costs, not charge to patient or actual cost of an item.
“ROOM RATE” ($ or time to recovery)
No difference
No difference
No difference
NEUTRAL
“Dx/Rx” costs ($)
No difference
No difference
No difference
NEUTRAL
BENEFIT (QUALITY & OUTCOMES)
VALUE ANALYSIS GRID
COST
A>B
A=B
A<B
Unclear
A costs more than B
Make value judgement
B
B
Do B and PDSA in 1 year
A and B costs are the same
A
A or B, operational
factors may influence
choice
B
B costs more than A
A
A
Make value judgement
A or B, operational
factors may influence
choice, PDSA in 1 year
Do A and PDSA in 1 year
VALUE STATEMENT
FINAL CSW VALUE STATEMENT
For inpatients with a history of seizures but no IV access, intranasal midazolam is preferred over rectal
diazepam because it is equivalent in effiacy, more preferable to families, less costly to administer, and
eliminates the need for an IV. This recommendation is based on moderate quality evidence. A costminimization strategy was applied.
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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
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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
Version 2.0 (5/11/2016): Added value analysis with rationale supporting use of intranasal
midazolam over rectal diazepam.
Version 2.1 (12/5/2016): Changed name of inpatient order from orderset to powerplan
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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.
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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
1 additional record identified
through other sources
7 studies added from Febrile Seizure Pathway
64 records identified through
database searching
Screening
62 records after duplicates removed
62 records screened
24 records excluded
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
Elgibility
Included
11 studies included in pathway
Flow diagram adapted from Moher D et al. BMJ 2009;339:bmj.b2535
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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
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