Expert Consensus Recommendations on Seizure Emergencies Suitable for Rapid and Early Seizure Termination (REST) and Timing of Intervention
Jesus Eric Pina-Garza1, Michael Chez2, James Cloyd3, Lawrence J. Hirsch4, Reetta Kalviainen5, Pavel Klein6, Lieven Lagae7, Raman Sankar8, Nicola Specchio9, Adam Strzelczyk10, Manuel Toledo11, Eugen Trinka12
1The Children's Hospital at TriStar Centennial, 2Sutter Neuroscience Institute, 3College of Pharmacy, University of Minnesota, 4Yale Comprehensive Epilepsy Center, 5Epilepsy Center Kuopio University Hospital, member of EpiCARE ERN, University of Eastern Finland, 6Mid-atlantic Epilepsy and Sleep Center, 7Member of EpiCARE ERN, University Hospitals Leuven, 8David Geffen School of Medicine UCLA, University of California, 9Bambino Gesu Children's Hospital, Member of EpiCARE ERN, 10Epilepsy Center Frankfurt Rhine-Main, Goethe-University Frankfurt, 11Vall d'Hebron Hospital, Member of EpiCARE ERN, 12Department of Neurology, Christian Doppler Klinik, Paracelsus Medical University, Member of EpiCARE ERN
Objective:
To develop expert consensus recommendations for the outpatient management of certain prolonged seizures (PS) and seizure clusters (SC) to prevent progression to more severe seizure types or seizure emergencies.
Background:
Rapid and early seizure termination (REST) has been proposed as a treatment goal for early initiation of rapid treatment to terminate ongoing seizures. Although international guidance exists for status epilepticus (SE), such resources are lacking for PS and SC. We previously reported consensus recommendations on definitions for different types of PS and SC, REST, and new terminology describing acute outpatient treatments.
Design/Methods:
An expert group comprising 12 European and American pediatric/adult epileptologists, neurologists and pharmacologists employed a modified Delphi consensus methodology to develop and anonymously vote on recommendations. Consensus was defined as ≥75% (9/12) voting ‘Agree’/‘Strongly agree’.
Results:
Consensus was reached on which patients with specific seizure types warrant REST, and on advice to patients/caregivers regarding when to administer outpatient treatment. All experts agreed that all patients who have experienced PS should be offered REST medication, and all who have experienced SC should be offered medication to prevent subsequent seizures. When prescribing outpatient medication, a seizure action plan should be agreed in consultation with patients/caregivers. All experts agreed that for patients whose main seizure pattern is SC, medication to prevent subsequent seizures should be considered at first seizure onset, and 11/12 agreed that patients with a history of PS and recognizable pattern of onset should administer REST medication as early as possible.
Conclusions:
High levels of agreement were reached on recommendations for seizure types warranting treatment to terminate ongoing seizures/seizure clusters as rapidly as possible, and on advice for patients/caregivers regarding when to use outpatient medications. These expert consensus recommendations will provide clearer guidance to clinicians, patients and caregivers, and aid establishment of REST as a new paradigm for prolonged seizure management.