An Evidence-based Guideline for Pediatric Prehospital Seizure Management Using GRADE Methodology

<b>Objective</b>. The objective of this guideline is to recommend evidence-based practices for timely prehospital pediatric seizure cessation while avoiding respiratory depression and seizure recurrence. <b>Methods</b>. A multidisciplinary panel was chosen based on expertise in pediatric emergency medicine, prehospital medicine, and/or evidence-based guideline development. The panel followed the National Prehospital EBG Model using the GRADE methodology to formulate questions, retrieve evidence, appraise the evidence, and formulate recommendations. The panel members initially searched the literature in 2009 and updated their searches in 2012. The panel finalized a draft of a patient care algorithm in 2012 that was presented to stakeholder organizations to gather feedback for necessary revisions. <b>Results</b>. Five strong and ten weak recommendations emerged from the process; all but one was supported by low or very low quality evidence. The panel sought to ensure that the recommendations promoted timely seizure cessation while avoiding respiratory depression and seizure recurrence. The panel recommended that all patients in an active seizure have capillary blood glucose checked and be treated with intravenous (IV) dextrose or intramuscular (IM) glucagon if &lt;60 mg/dL (3 mmol/L). The panel also recommended that non-IV routes (buccal, IM, or intranasal) of benzodiazepines (0.2 mg/kg) be used as first-line therapy for status epilepticus, rather than the rectal route. <b>Conclusions</b>. Using GRADE methodology, we have developed a pediatric seizure guideline that emphasizes the role of capillary blood glucometry and the use of buccal, IM, or intranasal benzodiazepines over IV or rectal routes. Future research is needed to compare the effectiveness and safety of these medication routes.

<b>研究目标</b>。本指南旨在推荐基于循证依据的实践方案，以实现院前儿童癫痫发作（pediatric seizure）的及时终止，同时避免呼吸抑制及癫痫复发。<b>研究方法</b>。研究团队由具备儿童急诊医学、院前医学及/或循证指南制定经验的多学科专家组成。该团队遵循国家院前循证指南（National Prehospital EBG）模型，采用GRADE（推荐分级的评估、制定与评价）方法学开展研究，包括拟定研究问题、检索证据、评估证据质量及制定推荐意见。团队成员最初于2009年开展文献检索，并于2012年更新了检索范围。团队于2012年完成了患者救治算法草案，并提交给利益相关方组织以收集反馈，用于后续必要的修订。<b>研究结果</b>。本次指南制定过程共形成5项强推荐意见及10项弱推荐意见，除1项外，其余所有推荐均基于低质量或极低质量的证据支持。团队旨在确保推荐意见能够促进癫痫发作的及时终止，同时避免呼吸抑制与癫痫复发。团队建议，所有处于癫痫发作状态的患者均需检测毛细血管血糖（capillary blood glucose），若血糖低于60mg/dL（3mmol/L），则需给予静脉（intravenous, IV）葡萄糖或肌内（intramuscular, IM）胰高血糖素治疗。团队同时建议，对于癫痫持续状态（status epilepticus），应采用非静脉给药途径，即颊黏膜、肌内或鼻内给药途径给予苯二氮䓬类药物（benzodiazepines），剂量为0.2mg/kg，作为一线治疗方案，而非直肠给药途径。<b>研究结论</b>。本研究采用GRADE方法制定了儿童癫痫发作救治指南，该指南强调毛细血管血糖检测的重要性，并推荐优先采用颊黏膜、肌内或鼻内给药途径给予苯二氮䓬类药物，而非静脉或直肠给药途径。未来仍需开展相关研究，对比不同给药途径的临床有效性与安全性。