When benzodiazepines fail: how effective is second line therapy for status epilepticus in children?

To define the characteristics and management of children presenting to the ED of a major tertiary paediatric hospital with convulsive status epilepticus (CSE). To determine the timing and efficacy of therapeutic interventions in this group and to identify factors that influence the effectiveness of treatment.

A retrospective audit of all children who presented to an ED of a tertiary paediatric hospital in CSE over a 3 year period.

Thirty-seven cases were identified. Prehospital treatment had been administered in 51%. Uncomplicated seizure control was achieved in 30% with the combination of first and second line therapy. Rapid sequence induction (RSI) of anaesthesia was required in 70% for the control of ongoing seizure activity (21 cases) or to support severe respiratory depression (five cases). This requirement for RSI was increased to 85% in those with seizure duration in excess of 30 min and 89% of those who received prehospital treatment. Of those who required RSI, 35% were treated for periods in excess of 60 min before this intervention was performed.

Standard second line anticonvulsant treatment was relatively ineffective in terminating seizures in children who presented in CSE not responsive to benzodiazepines. Failure to respond to prehospital treatment and prolonged seizure duration at presentation both predict poor therapeutic response. Third line treatment with RSI of anaesthesia is often delayed while waiting for second line treatment to work.