Related Experiment Video
Updated: Oct 23, 2025
Author Spotlight: Advancing Pediatric Epilepsy Surgery in Children Through Novel Biomarkers and Enhanced Localization
Published on: September 20, 2024
Benzodiazepine administration patterns before escalation to second-line medications in pediatric refractory
Theodore Sheehan1, Marta Amengual-Gual1,2, Alejandra Vasquez1,3
1Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
Insights
Benzodiazepine (BZD) administration patterns in pediatric refractory convulsive status epilepticus (rSE) show delays in transitioning to non-BZD antiseizure medications (ASMs). Out-of-hospital onset is linked to more BZD doses and delayed escalation, highlighting the need for pre-hospital treatment and smoother transitions.
Area of Science:
- Pediatric Neurology
- Emergency Medicine
- Pharmacology
Background:
- Refractory convulsive status epilepticus (rSE) in children requires prompt and effective treatment.
- Benzodiazepines (BZDs) are first-line agents, but transition to non-BZD antiseizure medications (ASMs) is crucial for refractory cases.
- Understanding BZD administration patterns is key to optimizing treatment protocols.
Purpose of the Study:
- To evaluate benzodiazepine (BZD) administration patterns before transitioning to non-BZD antiseizure medication (ASM) in pediatric patients with refractory convulsive status epilepticus (rSE).
Main Methods:
- Retrospective, multicenter observational study of pediatric patients with rSE in the US and Canada (2011-2020).
- Analysis of BZD doses administered before the first non-BZD ASM, and timing of BZD administration relative to seizure onset.
- Comparison of treatment patterns based on seizure onset location (in-hospital vs. out-of-hospital) and seizure type (intermittent vs. continuous).
Main Results:
- 36% of patients received more than two BZDs before escalating.
- Delayed treatment initiation after seizure onset was associated with fewer BZD doses before transition.
- Patients with out-of-hospital onset were more likely to receive multiple BZD doses beyond 30 and 45 minutes and often did not receive pre-hospital treatment.
- Intermittent SE was a risk factor for more BZDs administered beyond 45 minutes.
Conclusions:
- Failure to escalate from BZDs to non-BZD ASMs is common in out-of-hospital rSE onset.
- Initiating treatment before hospital arrival and facilitating a timely transition to non-BZD ASMs after two BZD doses during handoffs can reduce treatment delays.
Objective:
This study was undertaken to evaluate benzodiazepine (BZD) administration patterns before transitioning to non-BZD antiseizure medication (ASM) in pediatric patients with refractory convulsive status epilepticus (rSE).
Methods:
This retrospective multicenter study in the United States and Canada used prospectively collected observational data from children admitted with rSE between 2011 and 2020. Outcome variables were the number of BZDs given before the first non-BZD ASM, and the number of BZDs administered after 30 and 45 min from seizure onset and before escalating to non-BZD ASM.
Results:
We included 293 patients with a median (interquartile range) age of 3.8 (1.3-9.3) years. Thirty-six percent received more than two BZDs before escalating, and the later the treatment initiation was after seizure onset, the less likely patients were to receive multiple BZD doses before transitioning (incidence rate ratio [IRR] = .998, 95% confidence interval [CI] = .997-.999 per minute, p = .01). Patients received BZDs beyond 30 and 45 min in 57.3% and 44.0% of cases, respectively. Patients with out-of-hospital seizure onset were more likely to receive more doses of BZDs beyond 30 min (IRR = 2.43, 95% CI = 1.73-3.46, p < .0001) and beyond 45 min (IRR = 3.75, 95% CI = 2.40-6.03, p < .0001) compared to patients with in-hospital seizure onset. Intermittent SE was a risk factor for more BZDs administered beyond 45 min compared to continuous SE (IRR = 1.44, 95% CI = 1.01-2.06, p = .04). Forty-seven percent of patients (n = 94) with out-of-hospital onset did not receive treatment before hospital arrival. Among patients with out-of-hospital onset who received at least two BZDs before hospital arrival (n = 54), 48.1% received additional BZDs at hospital arrival.
Significance:
Failure to escalate from BZDs to non-BZD ASMs occurs mainly in out-of-hospital rSE onset. Delays in the implementation of medical guidelines may be reduced by initiating treatment before hospital arrival and facilitating a transition to non-BZD ASMs after two BZD doses during handoffs between prehospital and in-hospital settings.
More Related Videos
06:58Non-restraining EEG Radiotelemetry: Epidural and Deep Intracerebral Stereotaxic EEG Electrode Placement
Published on: June 25, 2016
05:54Stereo-Electro-Encephalo-Graphy SEEG With Robotic Assistance in the Presurgical Evaluation of Medical Refractory Epilepsy: A Technical Note
Published on: June 13, 2016
Related Concept Videos
01:19Sedatives and Hypnotics Drugs: Benzodiazepines
Benzodiazepines work by enhancing the effects of the inhibitory neurotransmitter GABA. They bind to the GABAA receptor, increasing its affinity for GABA, which opens chloride...
01:14CNS Depressants: Barbiturates and Benzodiazepines
01:18Antiepileptic Drugs: GABAergic Pathway Potentiators
The key GABA pathway potentiators used in epilepsy management are as follows.
Benzodiazepines are a well-known class of drugs used for...
01:29Anxiolytic Drugs: Benzodiazepines and Buspirone
01:23Sedatives and Hypnotics: Overview
Sedative-hypnotics are categorized into barbiturates, benzodiazepines (BZDs), and non-benzodiazepines or Z-drugs. These drugs work by suppressing central nervous system activity, and this suppression is dose-dependent. Older sedative medications, like barbiturates, follow a linear curve in...
01:20Sedatives and Hypnotics Drugs: Barbiturates