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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 Return to Home 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. Return to ED Management Return to Inpatient Management 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 Return to ED Management Return to Inpatient Management 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 Return to ED Management Return to Inpatient Management 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. Return to ED Management Return to Inpatient Management 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 To Bibliography Return to ED Management Return to Inpatient Management 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 Return to ED Management Return to Inpatient Management