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Convulsive status epilepticus (CSE), with an incidence of 17–23 episodes per 100 000 children per year,1 is the most common medical neurological emergency in children. Since there is significant associated morbidity and mortality, which in part may be related to seizure length,2 it is essential that acute paediatric and paediatric emergency staff are comfortable and familiar with its management.
To maximise the probability of seizure termination, protocols for early appropriate treatment need to be developed. This review aims to examine the justification for early treatment and evidence supporting certain therapeutic interventions and to identify similarities and differences in protocols worldwide to identify and promote best practice.
CSE is often defined as either two or more convulsions without complete recovery of consciousness between seizures (intermittent CSE) or a single prolonged seizure lasting at least 30 min (continuous CSE) with a motor component. The motor component usually consists of tonic stiffening followed by clonic movements of all limbs, although purely tonic or clonic as well as myoclonic status epilepticus can occur.3 There has been a move towards an operational definition of CSE for treatment purposes as any seizure lasting longer than 5 min, which will be discussed later.4
The diagnosis of overt tonic-clonic seizures is usually straightforward. The main differential diagnoses are non-epileptic events (previously known as pseudoseizures) and other causes of abnormal movements such as acute dystonia, paroxysmal dyskinesia or involuntary movements associated with cerebral palsy. While uncommon, children with non-epileptic events can appear to be in CSE, but such children usually have a background of coexisting epilepsy (which may or may not have been recognised) or a family history of epilepsy.5 6 Therefore, in the acute situation it will usually be preferable to treat for CSE unless background information is available, although it is equally important …
Competing interests: Rod Scott is advising a pharmaceutical company about the licensing of buccal midazolam for the emergency treatment of seizures. If the licence is granted, his employing institution will gain financially, but he will not receive any personal benefit. None of the other authors have a conflict of interest.
Funding: This work was undertaken at GOSH/UCL Institute of Child Health which received a proportion of funding from the Department of Health’s NIHR Biomedical Research Centres funding scheme. The Centre for Paediatric Epidemiology and Biostatistics also benefits from funding support from the Medical Research Council in its capacity as the MRC Centre of Epidemiology for Child Health.
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