title: Evidence-Based Guideline: Treatment of Convulsive Status Epilepticus in Children and Adults: Report of the Guideline Committee of the American Epilepsy Society.
abstract: BACKGROUND
  The optimal pharmacologic treatment for early convulsive status epilepticus is unclear.
  
  
  OBJECTIVE
  To analyze efficacy, tolerability and safety data for anticonvulsant treatment of children and adults with convulsive status epilepticus and use this analysis to develop an evidence-based treatment algorithm.
  
  
  METHODS
  Structured literature review using MEDLINE, Embase, Current Contents, and Cochrane library supplemented with article reference lists.
  
  
  METHODS
  Randomized controlled trials of anticonvulsant treatment for seizures lasting longer than 5 minutes.
  
  
  METHODS
  Individual studies were rated using predefined criteria and these results were used to form recommendations, conclusions, and an evidence-based treatment algorithm.
  
  
  RESULTS
  A total of 38 randomized controlled trials were identified, rated and contributed to the assessment. Only four trials were considered to have class I evidence of efficacy. Two studies were rated as class II and the remaining 32 were judged to have class III evidence. In adults with convulsive status epilepticus, intramuscular midazolam, intravenous lorazepam, intravenous diazepam and intravenous phenobarbital are established as efficacious as initial therapy (Level A). Intramuscular midazolam has superior effectiveness compared to intravenous lorazepam in adults with convulsive status epilepticus without established intravenous access (Level A). In children, intravenous lorazepam and intravenous diazepam are established as efficacious at stopping seizures lasting at least 5 minutes (Level A) while rectal diazepam, intramuscular midazolam, intranasal midazolam, and buccal midazolam are probably effective (Level B). No significant difference in effectiveness has been demonstrated between intravenous lorazepam and intravenous diazepam in adults or children with convulsive status epilepticus (Level A). Respiratory and cardiac symptoms are the most commonly encountered treatment-emergent adverse events associated with intravenous anticonvulsant drug administration in adults with convulsive status epilepticus (Level A). The rate of respiratory depression in patients with convulsive status epilepticus treated with benzodiazepines is lower than in patients with convulsive status epilepticus treated with placebo indicating that respiratory problems are an important consequence of untreated convulsive status epilepticus (Level A). When both are available, fosphenytoin is preferred over phenytoin based on tolerability but phenytoin is an acceptable alternative (Level A). In adults, compared to the first therapy, the second therapy is less effective while the third therapy is substantially less effective (Level A). In children, the second therapy appears less effective and there are no data about third therapy efficacy (Level C). The evidence was synthesized into a treatment algorithm.
  
  
  CONCLUSIONS
  Despite the paucity of well-designed randomized controlled trials, practical conclusions and an integrated treatment algorithm for the treatment of convulsive status epilepticus across the age spectrum (infants through adults) can be constructed. Multicenter, multinational efforts are needed to design, conduct and analyze additional randomized controlled trials that can answer the many outstanding clinically relevant questions identified in this guideline.
authors.affiliation: Division of Neurology, Comprehensive Epilepsy Center, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, OH.
authors.forename: Tracy
authors.initials: T
authors.lastname: Glauser
authors.affiliation: Departments of Neurology, Pediatrics, and Epidemiology and Population Health, and the Comprehensive Epilepsy Management Center, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY.
authors.forename: Shlomo
authors.initials: S
authors.lastname: Shinnar
authors.affiliation: CAMC Neurology Group, Charleston, WV.
authors.forename: David
authors.initials: D
authors.lastname: Gloss
authors.affiliation: School of Pharmacy, University of California, San Francisco, CA.
authors.forename: Brian
authors.initials: B
authors.lastname: Alldredge
authors.affiliation: Division of Neurology, Comprehensive Epilepsy Center, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, OH.
authors.forename: Ravindra
authors.initials: R
authors.lastname: Arya
authors.affiliation: Department of Clinical Pharmacy, University of Colorado, Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO.
authors.forename: Jacquelyn
authors.initials: J
authors.lastname: Bainbridge
authors.affiliation: Division of Neurology, Comprehensive Epilepsy Center, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, OH.
authors.forename: Mary
authors.initials: M
authors.lastname: Bare
authors.affiliation: Departments of Neurological Sciences, Neurosurgery, Medicine, and Anesthesiology, Rush University Medical Center, Chicago, IL.
authors.forename: Thomas
authors.initials: T
authors.lastname: Bleck
authors.affiliation: Departments of Neurology and Pediatrics, Washington University School of Medicine, St. Louis, MO.
authors.forename: W Edwin
authors.initials: WE
authors.lastname: Dodson
authors.affiliation: Division of Pharmacy, Cincinnati Children's Hospital Medical Center, Cincinnati, OH.
authors.forename: Lisa
authors.initials: L
authors.lastname: Garrity
authors.affiliation: Department of Emergency Medicine, Mount Sinai Hospital, Mount Sinai School of Medicine, New York, NY.
authors.forename: Andy
authors.initials: A
authors.lastname: Jagoda
authors.affiliation: Department of Neurology, University of California, San Francisco, CA.
authors.forename: Daniel
authors.initials: D
authors.lastname: Lowenstein
authors.affiliation: Division of Pediatric Neurology, Virginia Commonwealth University, Richmond, VA.
authors.forename: John
authors.initials: J
authors.lastname: Pellock
authors.affiliation: NYU Comprehensive Epilepsy Center, New York, NY.
authors.forename: James
authors.initials: J
authors.lastname: Riviello
authors.affiliation: Department of Emergency Medicine, University of Illinois at Chicago, Chicago, IL.
authors.forename: Edward
authors.initials: E
authors.lastname: Sloan
authors.affiliation: Division of Neurology, Barrow Neurological Institute, Phoenix, AZ.
authors.forename: David M
authors.initials: DM
authors.lastname: Treiman