UMEM Educational Pearls

Category: Pediatrics

Title: Status epilepticus medication management in children

Keywords: Keppra, Dilantin, status epilepticus (PubMed Search)

Posted: 7/20/2019 by Jenny Guyther, MD (Updated: 12/7/2019)
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Takeaways

-Benzodiazepines alone are effective in terminating status epilepticus in 40 to 60% of pediatric patients

-The guidelines for second line agents are based on observational studies and expert opinion

-Adverse effects of phenytoin include hepatotoxicity, pancytopenia, Stevens-Johnson syndrome, extravasation injuries, hypotension and arrhythmias

- Levetiracetam has a reduced risk of serious adverse events, greater compatibility with IV fluids and can be given in 5 minutes versus 20 minutes for phenytoin.

 

Bottom line: In a recent randomized control trial they found that levetiracetam was not superior to phenytoin as a second line agent for management of convulsive status epilepticus in children.  There was no difference between efficacy or safety outcomes between the two groups.

In-Depth

Phenytoin is the second line treatment for pediatric convulsive status epilepticus after failure of first-line benzodiazepines but is only effective in approximately 60% of cases.  This study was an open label, multicenter, randomized control trial conducted in Australia and New Zealand with children aged 3 months to 16 years with status epilepticus who had failed first-line benzodiazepine treatment.  Patients were randomly assigned to to receive 20 mg/kg of phenytoin or 40 mg/kg of levetiracetam with the primary outcome being seizure resolution at 5 minutes

There were 233 children included in the study and seizure activity stopped in 60% of the patients in the phenytoin group and 50% of the patients in the levetiracetam which was not a statistically significant difference.

References

Dalziel at al.  Levetiracetam versus phenytoin for second line treatment of convulsive status epilepticus in children; an open label, multicenter, randomized control trial.  The Lancet.  Published online April 17, 2019.