Stop the Seizure

Key contact: Dr Audrey Soo (Paediatric registrar) audrey.soo@nhs.net


Introduction

What is Epilepsy? Epilepsy is the most common significant neurological disorder in children and young people, leading to a tendency to have epileptic seizure.1 More than one in 220 children under the age of 19 years old (approximately 63,400) in the UK have epilepsy.1

What is a seizure? Normally there is electrical activity happening in the brain all the time, sending messages to various parts of the body in a coordinated manner. When a seizure happens, there is a sudden burst of intense activity, causing a temporary disruption to the way the brain normally works.

What is status epilepticus? A proportion of children who have seizures present with or develop status epilepticus. Status epilepticus is a condition resulting from:

a) the failure of the mechanisms for seizure termination or

b) the initiation of mechanisms which lead to abnormally prolonged seizures2

The prolonged seizure can have long term consequences, including brain cell death, brain cell injury and alteration of brain networks, depending on the type and duration of seizures.2


SMART objectives

To reduce the seizure duration in children/young people presenting to A&E with status epilepticus

To ensure the right medications are given and interventions made at recommended time points during status epilepticus [as per the UK Resuscitation Council’s Advanced Paediatric Life Support (APLS) guidelines or as per the child’s individual epilepsy care plan]


Progress made: What have you learned from doing this?

Results: Data was compared between paediatric status epilepticus episodes at West Middlesex Hospital during time period July2016-June2017 versus July2017-April2018. We were able to achieve a 35 minutes reduction in average seizure duration in children presenting to A&E with status epilepticus (from 108 minutes to 78 minutes). There was also a reduction in time taken from hospital arrival to Step 2 (delivering 2nd benzodiazepine) and Step 3 (administering phenytoin or phenobarbitone) by 2 minutes and 21 minutes respectively. 

There were also other positive consequences which were not anticipated from this project. This include less emergency hospital attendances with status epilepticus, less children needing intubations for status epilepticus and more proportion of children with status epilepticus having had the first benzodiazepine dose administered by parent/carer at home.

Interventions:

  1. Designing and delivering regular multidisciplinary simulation scenarios incorporating status epilepticus into in situ simulation sessions [attended by nursing and medical teams (paediatric, emergency medicine, anaesthetics)]
  2. Ensure copies of latest APLS status epilepticus algorithms are available in paediatric A&E
  3. Working with paediatric secretarial team and neurophysiology teams to identify how they can be better supported in streamlining phone calls, requests and referrals
  4. Presenting data at trust clinical governance meeting and departmental teaching sessions
  5. Improving epilepsy care locally as a whole (as per NICE guidelines and Epilepsy12 Audit standards) through education and other smaller Quality Improvement projects
  6. (In progress) Submission of business case for paediatric epilepsy clinical nurse specialist

Lessions from project: Improvements are rarely the result of a single intervention or person/team. Every intervention has marginal gains leading to overall improvement and effect. Involve every member of the MDT who might be involved in a patient’s journey (remember secretaries, nurses, administrators, managers).


What’s your take home message?

Status epilepticus is a medical emergency that requires the concerted efforts of parents/carer and health professionals to deliver the right intervention at the right time. Multiple small interventions can lead to overall larger sustainable improvements in reducing episodes of prolonged seizure or duration of seizure.


Resources?

  • Epilepsy Action – What is Epilepsy? (link here)
  • Epilepsy Action – Treatment and care for seizures that last longer than 5 minutes (link here)
  • UK Resuscitation Council Advanced Paediatric Life Support algorithm for Status Epilepticus (see page 2 – link here)
  • American guidelines for Treatment of Convulsive Status Epilepticus  (link here)

References

  1. Royal College of Paediatrics and Child Health’s 2017 State of Child Health Report – Epilepsy subsection. Accessible from here 
  2. Trinka E, Cock H, et al. A definition and classification of status epilepticus of the ILAE task force on classification of status epilepticus. 2015. Epilepsiea, 56 (10): 1515-1523

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