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To: Journal of PRACTICAL NEUROLOGY Letters

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Papers: R F M Chin, L Verhulst, B G R Neville, M J Peters, and R C Scott Inappropriate emergency management of status epilepticus in children contributes to need for intensive care J Neurol Neurosurg Psychiatry 2004; 75: 1584-1588 [Abstract] [Full text] [PDF]

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Inappropriate emergency management or inappropriate selection ?

Zui-Shen Yen, Chien-Chang Lee, Chiung-Yuan Hsu, and Patrick Chow-In Ko   (29 November 2004)

Inappropriate emergency management or inappropriate selection ? 29 November 2004
Zui-Shen Yen, Emergency Physician and Adjuvant Lecturer National Taiwan University Hospital, Chien-Chang Lee, Chiung-Yuan Hsu, and Patrick Chow-In Ko Send letter to journal: Re: Inappropriate emergency management or inappropriate selection ? zuishen{at}ha.mc.ntu.edu.tw Zui-Shen Yen, et al.	Dear Editor, We read the paper by Chin et al.[1] with great interest. However, we have some doubts regarding their interpretations due to the study was a observational study. A causal effect between emergency management of status epilepticus (SE) and paediatric intensive care (PIC) admission was implied by the authors. However, we believe the authors should consider disease severity before interpreting the results.. Usually, children with more severe SE would be more likely admitted to PIC. Two or more doses of benzodiazepines in the emergency pre-PIC treatment could be used in these children due to their more severe SE. However, it is not appropriate to infer that the doses of benzodiazepines contributed to PIC admission without controlling disease severity. Those children with more severe SE may be inevitably admitted to PIC no matter how they were treated in the pre-PIC stage. The severity of SE is an important confounder in the interpretation of the results. Even with appropriate doses, the number of PIC admission due to SE may not decrease. As the risk of respiratory depression is greater with larger doses of benzodiazepines, it is possible that some children with SE would not require admission to PIC, if they had been treated with lower but effective doses of benzodiazepines to control their SE. Furthermore, paraldehyde, a recommended second line antiepileptic drug, is not a FDA approved medication for treatment of pediatric seizure and may induce pulmonary edema and respiratory depression[2]. Whether the use of paraldehyde in children with SE could reduce their risks of PIC admission is not clear[3,4]. Before condemning emergency management, we would suggest that the authors include all the patients presenting in the emergency room with SE, stratify the patients according to their disease severity and then analyze the use of antiepileptic drugs. It's not easy to determine a causal effect from an observational study. Selection bias should be considered before interpreting the results. References (1). Chin RF, Verhulst L, Neville BG, Peters MJ, Scott RC. Inappropriate emergency management of status epilepticus in children contributes to need for intensive care. J Neurol Neurosurg Psychiatry. 2004;75(11):1584-8. (2). Micromedex?Healthcare Series: Thomson Micromedex, Greenwood Village, Colorado. (3). Appleton R, Martland T, Phillips B. Drug management for acute tonic-clonic convulsions including convulsive status epilepticus in children. Cochrane Database Syst Rev. 2002;(4):CD001905. (4). Townend W, Mackway-Jones K. Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. Phenytoin or paraldehyde as the second drug for convulsions in children. Emerg Med J. 2002 Jan;19(1):50.