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Review of the new APLS guideline (2022): Management of the convulsing child
  1. Melody Bacon1,
  2. Richard Appleton2,
  3. Harish Bangalore3,
  4. Celia Brand4,
  5. Juliet Browning5,
  6. Richard FM Chin4,6,
  7. Satvinder Mahal3,
  8. Susana Saranga Estevan7,
  9. Kirsten McHale8,
  10. Ailsa McLellan4,
  11. Nicola Milne9,
  12. Suresh Pujar3,
  13. Tekki Rao10,
  14. Steven Short11,
  15. Stephen Warriner12,
  16. Michael Yoong1
  1. 1 Paediatric neurology, Barts Health NHS Trust, London, UK
  2. 2 Paediatric neurology, Alder Hey Children's NHS Foundation Trust, Liverpool, Merseyside, UK
  3. 3 Paediatric neurology, paediatric intensive care, Great Ormond Street Hospital for Children, London, UK
  4. 4 Paediatric neurology, Royal Hospital for Children and Young People, Edinburgh, UK
  5. 5 Paediatric neurology, University Hospitals Dorset NHS Foundation Trust, Poole, Bournemouth Christchurch, UK
  6. 6 Muir Maxwell Epilepsy Centre, The University of Edinburgh, Edinburgh, UK
  7. 7 Paediatric pharmacy, Addenbrooke's Hospital, Cambridge, Cambridgeshire, UK
  8. 8 Paediatric neurology, Royal Alexandra Children's Hospital, Brighton, Brighton and Hove, UK
  9. 9 Training and Staff Development Manager, Epilepsy Scotland, Glasgow, UK
  10. 10 Paediatrics, Luton and Dunstable Hospital NHS Foundation Trust, Luton, UK
  11. 11 Ambulance Service, Scottish Ambulance Service, Edinburgh, UK
  12. 12 Paediatrics, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
  1. Correspondence to Dr Melody Bacon, Paediatrics, Barts Health NHS Trust, London, UK; melody.bacon{at}

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Convulsive status epilepticus (CSE) (box 1) is the most common childhood medical neurological emergency, with an incidence of approximately 20 per 100 000 per year in the developed world.1 2

Box 1

Definition of status epilepticus

Status epilepticus is a condition resulting either from failure of the mechanism responsible for seizure termination or from the initiation of mechanisms, which lead to abnormally prolonged seizures (after time point t1 at 5 min).

It is a condition, which can have long-term consequences (after time point t2 after 30 min) including neuronal death, neuronal injury and alteration of neuronal networks, depending on the type and duration of seizures.

CSE can be fatal, but mortality is lower in children than in adults—at about 2%–7%.3

Adverse neurological consequences following CSE consist of subsequent epilepsy, motor deficits, and learning and behavioural difficulties. The main determinant of outcome is the underlying aetiology (box 2). There is low risk of morbidity and mortality in children with unprovoked/prolonged febrile CSE. This risk increases significantly in cases with structural or genetic causes.

Box 2

Common causes of status epilepticus

Known (ie, symptomatic)

Structural: Intracranial tumour, cerebrovascular

disease, head injury, cortical dysplasia

Infectious: CNS infection (meningitis, encephalitis), tuberculosis, cerebral malaria

Metabolic: Metabolic disturbance (electrolyte imbalance, glucose imbalance, organ failure, etc), metabolic disorders, anoxic injury, mitochondrial disorders

Toxicity or drug-related: Low or high level of antiseizure medication, withdrawal of antiseizure medication, other drug/alcohol overdose, neurotoxins and poisons

Inflammatory: Autoimmune disorders, neurocutaneous disorders

Genetic: Dravet syndrome, ring chromosome 20, Angelman syndrome, fragile X syndrome, Rett syndrome, trisomy 21

Unknown (ie, cryptogenic)

Information about the current guideline

The Advanced Life Support Group (ALSG) who run the Advanced Paediatric Life Support (APLS) programme provides internationally renowned guidance on the emergency management of common childhood emergencies. The APLS programme is also endorsed by the Royal College of Paediatrics and Child Health. Together, a professional …

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  • Contributors The authors had multiple virtual meetings to create consensus for guideline. MB drafted the algorithm and article, other authors reviewed and edited. RA provided an independent critical appraisal of the guideline.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests AM: GW Pharma - Personal payment, Honorarium; UCB - Honorarium; LivaNova - support to attend meeting; BPNA - Trustee and Professional Support Officer; Epilepsy Scotland - Co-opted Board Member; Ring 20 - Medical Advisory Board Member. NM: Veriton Supply training materials to NM's organisation including demonstration kits of midazolam oromucosal solution for use in training simulations. RFMC: GW Pharma – personal payment, Honorarium, support to attend meeting, local principal investigator in clinical trials; UCB- Honorarium; Eisai – Honorarium, personal payment, support to attend meetings; Zogenix - Honorarium, personal payment, support to attend meetings; Shares in Rize Medical Cannabis & Life Sciences. RA: Chairman of the Independent Data Safety Monitoring Committee for an NIHR HTA-funded study on mental health in children with epilepsy (the ‘MICE’ Study). 2019 – ongoing. Voluntary role.

  • Provenance and peer review Not commissioned; externally peer reviewed.