Commentary on ‘Drug management for acute tonic-clonic convulsions including convulsive status epilepticus in children’, with a response from the review authors

Pusic, Martin; Dayan, Peter; McGillivray, David

Commentary by David McGillivray, Peter Dayan and Martin Pusic The treatment of an acute convulsion can be a lifesaving intervention, especially in cases where the convulsion is likely to be prolonged or leaves the patient susceptible to aspiration or permanent neurologic damage. There is wide practice variation in the medications used to abort persistent tonic-clonic convulsions (we leave aside the treatment of partial complex status epilepticus).The ambitious Cochrane review completed by Appleton et al. starts out by stating that ‘benzodiazepines (midazolam, diazepam, lorazepam), phenobarbitone, phenytoin and paraldehyde may all be regarded as drugs of first choice in the management of acute tonic-clonic convulsions in children’. The task is then to determine which medication and route of administration leads to seizure cessation most rapidly without adverse side effects. The question is complicated given that six medications are considered along with multiple routes of administration that can change the pharmacokinetics of the medication. Further complicating study design is that fact that seizures with different clinical features may respond differently to medications. An investigator must consider whether to include patients with a narrow spectrum of seizure etiologies (e.g. febrile seizures) as opposed to including ‘all-comers’. Additionally, efficacy and adverse event outcomes are not well standardized.



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Cochrane Database of Systematic Reviews

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March 13, 2013