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From the Division of Epilepsy and Clinical Neurophysiology and the Critical Care Neurology Service (J.J.R.), Department of Neurology, Children's Hospital, Boston, and Harvard Medical School, MA; Division of Child Neurology (S.A.), Department of Pediatrics, Loma Linda University School of Medicine, CA, CNS representative to the Quality Standards Committee; National Institute of Neurological Disorders and Stroke (D.H.), NIH, Bethesda, MD, CNS representative to the Quality Standards Committee; Comprehensive Epilepsy Center (T.G.), Children's Medical Center, Cincinnati, OH, representative of the Epilepsy Foundation of America; Albert Einstein College of Medicine (K.B.-G.), Bronx, NY, representative of the American Epilepsy Society; Children's Memorial Hospital and Northwestern Medical School (K.K.), Chicago, IL, representative of the American Epilepsy Society; Division of Child Neurology (L.D.M.), Virginia Commonwealth University, Richmond, representative of the Child Neurology Society; Children's Hospital of Orange County (S.P.), CA, representative of the American Academy of Pediatrics; Department of Emergency Medicine (E.S.), University of Illinois at Chicago School of Medicine, representative of the American College of Emergency Physicians; Departments of Neurology and Pediatrics (S.S.), Comprehensive Epilepsy Management Center, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY.
Address correspondence and reprint requests to American Academy of Neurology, 1080 Montreal Avenue, St. Paul, MN 55116; e-mail: guidelines{at}aan.com
Objective: To review evidence on the assessment of the child with status epilepticus (SE).
Methods: Relevant literature were reviewed, abstracted, and classified. When data were missing, a minimum diagnostic yield was calculated. Recommendations were based on a four-tiered scheme of evidence classification.
Results: Laboratory studies (Na++ or other electrolytes, Ca++, glucose) were abnormal in approximately 6% and are generally ordered as routine practice. When blood or spinal fluid cultures were done on these children, blood cultures were abnormal in at least 2.5% and a CNS infection was found in at least 12.8%. When antiepileptic drug (AED) levels were ordered in known epileptic children already taking AEDs, the levels were low in 32%. A total of 3.6% of children had evidence of ingestion. When studies for inborn errors of metabolism were done, an abnormality was found in 4.2%. Epileptiform abnormalities occurred in 43% of EEGs of children with SE and helped determine the nature and location of precipitating electroconvulsive events (8% generalized, 16% focal, and 19% both). Abnormalities on neuroimaging studies that may explain the etiology of SE were found in at least 8% of children.
Recommendations: Although common clinical practice is that blood cultures and lumbar puncture are obtained if there is a clinical suspicion of a systemic or CNS infection, there are insufficient data to support or refute recommendations as to whether blood cultures or lumbar puncture should be done on a routine basis in children in whom there is no clinical suspicion of a systemic or CNS infection (Level U). AED levels should be considered when a child with treated epilepsy develops SE (Level B). Toxicology studies and metabolic studies for inborn errors of metabolism may be considered in children with SE when there are clinical indicators for concern or when the initial evaluation reveals no etiology (Level C). An EEG may be considered in a child with SE as it may be helpful in determining whether there are focal or generalized epileptiform abnormalities that may guide further testing for the etiology of SE, when there is a suspicion of pseudostatus epilepticus (nonepileptic SE), or nonconvulsive SE, and may guide treatment (Level C). Neuroimaging may be considered after the child with SE has been stabilized if there are clinical indications or if the etiology is unknown (Level C). There is insufficient evidence to support or refute routine neuroimaging in a child presenting with SE (Level U).
Endorsed by the American College of Emergency Physicians on August 31, 2006; by the American Academy of Pediatrics on October 3, 2006; and by the American Epilepsy Society on October 3, 2006.
Received March 28, 2006. Accepted in final form August 4, 2006.
Approved by the Quality Standards Subcommittee on January 28, 2006; by the Practice Committee on August 5, 2006; and by the AAN Board of Directors on August 17, 2006.
Additional material related to this article can be found on the Neurology Web site. Go to www.neurology.org and scroll down the Table of Contents for the November 14 issue to find the title link for this article.
Related Article
Neurology 2006 67: 1534-1535.
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