Status epilepticus treatment guidelines

Status epilepticus (SE) is an underrecognized medical emergency that requires rapid and aggressive treatment to prevent neuronal damage, systemic complications, and death. The incidence of SE is 20 per 100,000 person years (DeLorenzo et al., 1996; Knake et al., 2001; Metsäranta et al., 2004). Mortality still remains approximately 20% and the risk of cognitive decline and development of epilepsy are increased (DeLorenzo et al., 1996; Knake et al., 2001; Metsäranta et al., 2004). Standardized guidelines are believed to improve the quality of emergency care and outcome. The treatment of SE in the 1970s involved administering 1,000 mg of phenytoin, regardless of body weight, at no specified rate, and without guidelines for monitoring this infusion. During this time period, mortality from SE surpassed 50%, partially because of unmonitored intravenous infusion rates. A classical clinical study with intravenous phenytoin (Cranford et al., 1978) set the standards for monitoring blood pressure and electrocardiograms during SE treatment, demonstrated that phenytoin infusions should be no faster than 50 mg/min and in general a dose of 18 mg/kg was needed. Until late 1980s there was large variation in patient stabilization procedures, laboratory measures, and sequence of medications in the management of SE. In the year 1993, the Epilepsy Foundation of America convened a working group on SE. They published guidelines and a treatment protocol (EFA Working Group on Status Epilepticus, 1993), which was based on a literature review and input from expert reviewers and a professional advisory board. Some key treatment principles of this guideline still remain valid: utilize an agreed-upon treatment protocol, serially provide antiepileptic drugs (AEDs) quickly in maximal mg/kg doses, and consider EEG when the diagnosis of nonconvulsive or subtle SE must be excluded. They stated that both clinical and electrical seizure activity must be stopped quickly to optimize outcome. The longer the SE endures, the more difficult it is to control and CNS injury is more likely. Thus, treating early and aggressively was the recommended approach. EFA-guideline was launched with impressive educational program including article with reprints and a slide set for the use of educators worldwide. The Status Epilepticus Working Party (Appleton et al., 2000) published a widely cited four-step guideline which was based on a comprehensive computer based literature search and consequent consensus statement by the group. The National Institute for Health and Clinical Excellence (NICE)-guideline form UK (2004), the Scottish Intercollegiate Guidelines Network (SIGN)-guideline from Scotland (2003), and guidelines of the Italian League Against Epilepsy (Minicucci et al., 2006) are examples of national guidelines. The Finnish Evidence Based Guidelines for Prolonged Seizure and Status Epilepticus (2005) tries to integrate the treatment of SE to the first aid given by nonmedical personnel in the premonitory phases of SE (Table 1, use of phenytoin added to Finnish guidelines). Last comprehensive guideline for SE was published by the European Federation of Neurological Societies (EFNS) (Meierkord et al., 2006). Recommendations are based on literature search and group discussions (informative consensus approach). Where there was a lack of evidence but consensus was clear, the group has stated its opinion as good practice points (GPP). Guidelines for the management of SE have been in the literature for many years, yet retrospective studies have confirmed that management often fails to reflect these guidelines (Walker et al., 1996; Salmenperä et al., 2000; Cascino et al., 2001; Cock and Schapira, 2002). SIGN-guidelines have been studied in general to determine the effectiveness implementation strategies (Davis et al., 2004). None of the intervention strategies led to improvements in patient quality of life or quality of epilepsy care. The problems of guideline implementation in medicine in general are recognized and documented both within hospital (Marshall et al., 1999; Costantini et al., 2001) and community practice (Loeb et al., 2001). There have been few systematic studies of factors contributing to poor guideline adherence, but a variety of barriers to guideline implementation are recognized in the emergency setting. The key reason for the lack of implementation of the SIGN epilepsy guideline was an established pattern of staff behavior, with which there was little perceived need to change (Williams et al., 2007). Secondary to this there was lack of knowledge of the existence and/or content of the guideline and perceived difficulties in implementing them in clinical practice stemming from resource constraints. Moreover, the high turnover of treating (largely junior) medical staff in emergency units requires very regular reinforcement of guidelines if they are to be maintained (Cock and Schapira, 2002). The implementation of evidence based medicine finds its most receptive ground when there are local opinion leaders who are supportive, there is accessibility through user friendly information technology, and the guidelines are focused and dictate specific actions. However, recent findings from implementation studies show that guidelines may not be even looked at if they are regarded as unnecessary. On the other hand guidelines are more likely to be implemented where there are perceived problems with current service delivery. Therefore, it is necessary to take that a feedback system is in place at participating levels of care and they have to participate in gathering the evidence supporting the need for the guidelines. Clinical scenarios should be examined and followed for noncompliance of the guideline and the guidelines should be corrected accordingly if practice shows better ways of doing things. Secondly, as treating early and aggressively is the recommended approach, it is critical to start the protocols from home and public education and from the prehospital setting, not from the hospital and integrate all parts of the critical treatment pathway. Prehospital emergency response systems must train personnel to correctly identify patients with prolonged seizures and SE and work closely with hospital emergency departments to transport these patients rapidly to appropriate centers. Emergency departments must have specialized protocols in place for identifying SE patients and treating those who require therapy within a narrow therapeutic time window. Response systems, including optimal time frames, must be established, maintained, and monitored in all emergency departments. Hospitals must develop local status epilepticus guidelines and protocols that define the specialized roles of nursing staffs, diagnostic units, neurological and intensive care teams, and other treatment services such as pharmacy and rehabilitation. Public education is critically important in ensuring that all of the efforts cited above are successful. The public must learn that a prolonged seizure is a medical emergency, that a treatment is now available, and that this treatment is only effective when given rapidly after the onset of symptoms. Lay people programs and first responder programs with police officers, etc. are very important. These should include protocol guidelines for the first aid management of epileptic seizures, including the advice when to call ambulance. Morbidity and mortality in SE increase with prolonged seizure activity. Early and aggressive intervention is the hallmark of successful treatment of SE. Guidelines need to be developed for pathways from home to intensive care unit and we need to raise the awareness of the current problems like that of treatment delay and motivate the community to implement the guidelines to overcome problems.