SGEM#265: Total EcLiPSE of the Seizure – What a ConSEPT

Date: September 5th, 2019 Reference: Dalziel et al. Levetiracetam versus phenytoin for second-line treatment of convulsive status epilepticus in children (ConSEPT): an open-label, multicentre, randomised controlled trial. The Lancet May 2019 Guest Skeptic: Dr. Tessa Davis is a Paediatrician specializing in Paediatric Emergency Medicine and currently practicing at the Royal London Hospitals. She is also the co-founder of Don’t Forget the Bubbles and on the FeminEM Speaker Bureau. Case: Julia is a 4-year-old girl with a history of seizures and developmental delay. She presents the emergency department with another seizure for more than five minutes and has not been aborted with two doses of midazolam intramuscularly.You know the guidelines recommend phenytoin as a second line agent, but the junior doctor asks you if levetiracetam would work faster with less side effects. Background: Convulsive status epilepticus can be defined as a single seizure lasting greater than 20 to 30 minutes, or recurrent shorter seizures without recovery of consciousness between seizures. Status epilepticus is a common paediatric emergency with significant consequences for the patients. Our focus on management of status is to stop the seizures quickly to avoid any complications. Guidelines recommend benzodiazepines as the first line treatment, and we have plenty of evidence to back this up. Most guidelines recommend phenytoin or fosphenytoin as a second-line treatment, but the evidence base for its use is much weaker. CPS - Emergency management of the paediatric patient with generalized convulsive status epilepticus APLS - Advanced Life Support Group. Advanced paediatric life support: a practical approach to emergencies, 6th edn. Hoboken: Wiley-Blackwell, 2016. NICE - Epilepsies: diagnosis and management. London: National Institute for Health and Care Excellence, 2012. AES - Glauser T, Shinnar S, Gloss D, et al. Evidence-based guideline: treatment of convulsive status epilepticus in children and adults: report of the Guideline Committee of the American Epilepsy Society. Epilepsy Curr 2016 Phenytoin is linked to many adverse events including liver damage, Steven-Johnson syndrome, extravastion, pancytopenia, hypotension, arrhythmias, and death due to dosing errors. Levetiracetam is an alternative to phenytoin for second line treatment of convulsive status epilepticus. It can be given more quickly, is more compatible with intravenous fluids, has less drug interactions, and has a lower risk of adverse events. Although small studies suggest that levetiracetam is effective, there have been no comparison studies until now. Clinical Question: Is levetiracetam superior to phenytoin as a second-line treatment for convulsive status epilepticus in children? Reference: Dalziel et al. Levetiracetam versus phenytoin for second-line treatment of convulsive status epilepticus in children (ConSEPT): an open-label, multicentre, randomised controlled trial. The Lancet May 2019 Population: Children aged three months to 16 years of age presenting to 13 emergency departments in Australia and New Zealand in status epilepticus. Convulsive status epilepticus was defined as having a seizure for more than five minutes or two or more recurrent seizures without recovery of consciousness between seizures. Or three or more seizures within the preceding hour and a current seizure. They also had to have received two doses of benzodiazepines. Exclusions: Being on regular phenytoin or levetiracetam; having already had a second-line treatment; known to be refractory to the medication; allergy; seizures secondary to a head injury; or seizure due to eclampsia in late pregnancy. Intervention: Levetiracetam 40mg/kg (max 3g) IV or IO over five minutes. Five minutes after the infusion finished, patients were assessed to see if the seizures had stopped. If the patient was still convulsing, then the other drug was given.