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Each year in the United States, there are approximately 10,000 cases of pediatric status epilepticus.1 Previous epidemiological studies of convulsive status epilepticus suggest an incidence rate in developed countries of 20 per 100,000/year with the highest occurrence in the first year of life.2 The condition is a serious medical emergency requiring urgent care and treatment in order to prevent permanent damage to neurons and life-threatening complications.  Both European and American guidelines support the use of lorazepam and diazepam as first-line options for emergent therapy.  The European guidelines place an emphasis on the use of lorazepam with diazepam listed as an alternative.3  In addition, the Neurocritical Care Society guidelines list lorazepam as a class I recommendation, while diazepam is only a class IIa recommendation.4  However, these guidelines target adult populations.  Lorazepam, for instance, lacks an FDA approved indication for use in status epilepticus management in the pediatric population.  In addition, there is a lack of safety evidence for benzodiazepine use in children.  Previous studies compared the two medications for their use in pediatric populations and hinted at potential efficacy and safety benefits to lorazepam.5-7 These studies were limited in design and generalizability, so researchers from the Pediatric Emergency Care Applied Research Network (PECARN) conducted a new double-blind, randomized clinical trial to compare lorazepam with diazepam in order to better define any differences in safety and efficacy.

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Chamberlain and colleagues enrolled patients aged between 3 months and 18 years old with generalized status epilepticus at 11 large pediatric hospitals.8  In order to be included, the seizures must have been of the tonic-clonic type and involved loss of consciousness.  Researchers used the current standard of care to define status epilepticus. Exclusion criteria included pregnancy, hypotension, cardiac dysrhythmias, emergent surgical intervention need, known contraindication to benzodiazepine use or recent benzodiazepine use (in the past 7 days, including in the ambulance).  The researchers used the Exception from Informed Consent for Emergency Research in order to include patients without a previous seizure disorder diagnosis. Pharmacists or medication nurses selected the study medication and prepared it to give doses of 0.2mg/kg diazepam (maximum dose 8mg) or 0.1mg/kg lorazepam (maximum dose 4mg).  The final volumes were made equivalent by adding diluent to lorazepam syringes, and syringes were opaque to prevent visualization in order to blind the treatment team.  The medication was given as a 1-minute IV push with the end of the push dose being defined as time 0.  A second dose at half the initial dose could be given at 5 minutes if convulsions persisted followed by phenytoin or fosphenytoin with continued seizures at 12 minutes.  Open-label treatment with clinician preference anticonvulsants was permitted at 20 minutes. The primary efficacy outcome was cessation of status epilepticus within 10 minutes and a sustained absence for 30 minutes and included all randomized patients who met the definition of generalized status epilepticus.  Secondary efficacy endpoints included time to termination of convulsion, second doses given, need ...

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