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• Pre-protocol experience from Belfast.
  Michael O. Kinney
  Published on: 14 April 2016

• Published on: 14 April 2016

  Pre-protocol experience from Belfast.

  • Michael O. Kinney, Neurology registrar
  • Other Contributors:
    • Stephen Barr, Gavin McDonnell, John Craig

  We welcome the article by Jones et al, and in particular the chance to compare the protocol used in their institution with the one we hope to implement (1).

  In Northern Ireland, we are in the process of drawing up a regional protocol for the management of status epilepticus, due to wide variation in current practice. We carried out preliminary work to see where the gaps in knowledge are, so that we can create a...

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  We welcome the article by Jones et al, and in particular the chance to compare the protocol used in their institution with the one we hope to implement (1).

  In Northern Ireland, we are in the process of drawing up a regional protocol for the management of status epilepticus, due to wide variation in current practice. We carried out preliminary work to see where the gaps in knowledge are, so that we can create a relevant protocol to assist junior staff, hopefully highlighting the need for a protocol.

  We surveyed post finals - final year medical students (9 students) foundation (28 doctors) and core medical trainees (24 doctors) and got 61 responses to a questionnaire (~85% returns). Only 10% of these knew the appropriate dose and rate of administration of two first line drugs.

  Only 54% would have given an initial 4 mg dose of lorazepam, and only 36% knew the correct dose of phenytoin (15-20mg/kg); 44% acknowledged they were unaware of the dose. One third knew the appropriate initial infusion rate of phenytoin.

  Knowledge of the side effects of phenytoin was generally good, although worryingly 30% thought sedation was a side effect of phenytoin, which might lead to complacency in managing the apparently "post ictal" patient.

  It was also evident that a significant issue for junior doctors is making the actual diagnosis of status epilepticus. Without clinical experience junior doctors lack ability in making a confident and accurate diagnosis, for which they are prepared to give drugs which are sedating and are perceived to be potentially dangerous. In addition doctors in the early stages of training had limited appreciation of potentially discriminant features such as back arching, biting the tip of the tongue, open eyes during the event and the synchrony of limb movements, in making a clinical diagnosis of seizure versus non epileptic attack disorder.

  Better educational strategies that inform, everyone who manages status epilepticus, about seizure semiology (2) would go hand in hand with dissemination of treatment protocols and would therefore be useful.

  We wish to add another vitally important point to the protocol by Jones et al, and that is the clear instruction to seek immediate urgent advice from the nearest neurology service in all cases of status epilepticus.

  (1) Jones S, Pahl C, Trinka E, et al. A protocol for the inhospital emergency drug management of convulsive status epilepticus in adults. Practical neurology 2014;14:194-197

  (2) Seneviratne U, Ding C, Bower S et al. Video based training improves the accuracy of seizure diagnosis. J Neurol Neurosurg Psychiatry 2014;85:466-470

  Conflict of Interest:

  None declared

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  Conflict of Interest:
  None declared.

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