Outcome of a Lecture Before vs After Simulation-based Education on Pediatric Status Epileptics: A Randomized Controlled Pilot Trial
Phase: NA
Conditions: Medical Education, Simulation
Sponsor: University of British Columbia

 
 
 
 
 
 
 
PROTOCOL COVER PAGE 
 
 
 
 
PROTOCOL NAME: Outcome of a lecture before vs after simulation-based education on pediatric status 
epileptics: A randomized controlled pilot trial 
 
PRINCIPAL INVESTIGATOR:  
 
 
 
 
Dr. Melissa Chan 
 
BC Children’s Hospital 
4500 Oak St.  
Vancouver, BC.  
V6H 3N1 
 
Co-Investigators:   
 
 
Dr. John Ramsay 
BC Children’s Hospital 
4500 Oak St.  
Vancouver, BC.  
V6H 3N1 
Phone: 613-223-4513 
Email: ramsay.s.john@gmail.com 
 
Dr. Jonathan Duff 
Stollery Children’s Hospital 
8440 112 St. NW 
Edmonton, AB. 
T6G 2B7 
 
 
Funded By: Not applicable 
 
Current Protocol Version: Protocol Version #0.1, Aug 16, 2023 
H Number: H22-03760 
 
 
 
 

 
 
 
 
 
 
 
 
 
 
 
 
 
Protocol number: 1 
Version date: 16-Aug-23 
 
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1 
Protocol Summary  
1.1 
Synopsis 
Title: Comparing teaching before vs after simulation education on pediatric status epileptics: A 
randomized controlled trial 
Study Description: The study will test whether simulation preceding didactic teaching leads to improved 
knowledge and performance retention compared to a didactic lecture proceeding simulation. 
Participants will be randomized to one of two different groups: 1) didactic teaching followed by 
simulation or 2) simulation then didactic teaching. 
Primary Outcomes: 
1. Resuscitation performance retention score 3 months post-initial training 
Secondary Outcomes:  
2. Knowledge assessment 3 months post-initial training 
3. Learner satisfaction 
Hypothesis: 
1. Didactic teaching after simulation-based training will be more effective in maintaining retention 
of knowledge and skills in the management of pediatric status epilepticus compared to didactic 
teaching prior to simulation 
Study Population: Second year medical students from the University of British Columbia – Vancouver 
Campus 
Description of Sites: The intervention will take place at BC Children’s Hospital Simulation Centre with 
trained facilitators and high-realism simulation equipment.  
Description of Study Intervention: One arm of the study will receive a 60-minute lecture on pediatric 
status epilepticus management and then complete a simulation scenario immediately after. The second 
arm will complete a simulation scenario on pediatric status epilepticus without knowing the topic 
beforehand and will complete a 60-minute lecture immediately after the simulation session. Both 
groups will complete a knowledge test directly after the intervention. Both groups will be reassessed in 
three months with a repeat simulation scenario on pediatric status epilepticus and repeat knowledge 
test.  
Study Duration The study will enroll participants for 2 months and then complete the educational 
intervention over 3 months.  
Participant Duration: The participants will participate in one 60-minute lecture and two ten-minute 
simulation sessions and one focused 15 minute debrief over the course of four months’ time.  
1.2   Schema: 
 
 
 
 
 
 
 
 
 
Figure 1: Flow of participants through the research project 
Time:  
3 months 
n = 20 - 30 
n = 20 - 30 
1. Pre-knowledge test 
2. Lecture 
3. First Simulation 
4. Post-Knowledge test 
Recruitment 
n = 40-60 
1. Retention Knowledge 
Test 
2. Individual Assessment 
Simulation 
 
1. Pre-knowledge test 
2. First Simulation 
3. Lecture 
4. Post-Knowledge test 

 
 
 
 
 
 
 
 
 
 
 
 
 
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2  
Introduction 
2.1 
 Background Information & Rationale 
Simulation is a revolutionary tool in medical education and specifically pediatrics with the rarity of life-
threatening situations. It provides learners with the opportunity to practice high-stress crucial medical 
scenarios in a safe and supportive environment where mistakes are instead valuable teaching for future 
experiences. Simulation has been shown to be an effective teaching method in medical education 
however how best to optimize retention and patient outcomes remains unclear1–3. Medical education 
interventions are typically evaluated at one stage of Kirkpatrick’s framework for learning which include 
reaction (level 1), learning (level 2), behavior (level 3) and results (Level 4)4. Patient outcomes remains 
the strongest measure however is difficulty to effectively design projects to show this5,6. In pediatrics 
procedures and adult ACLS retention of knowledge and skills have been shown to decline by as early as 
3-months’ time in two systematic reviews7,8. In our assessment, it remains unclear what the best 
method of teaching associated with simulation is and when the best time to facilitate this teaching to 
improve retention for medical expert knowledge and resuscitation performance. 
 
Pre-simulation assignments may be an effective way to prime participants for learning in simulation. 
Different methods including reading, written assignments, plan of care mapping, pre-quizzes, scenario 
demonstration, virtual reality, lectures and online games have been described9–16. No method has been 
identified as superior17,18.  Pre-simulation preparation was felt to improved learning in one systematic 
review however the strength of the evidence was weak and primarily level 1 and 2 outcomes were 
assessed17,19. There remains contention in the literature with one study finding adding simulation to a 
flipped classroom teaching model improving 3-month retention though multiple studies examining a 
flipped classroom model in rapid-cycle deliberate practice models found no improvement11,20,21. New 
evidence suggests there may be better immediate knowledge gain from simulation preceding didactic 
teaching compared to didactic teaching before simulation22,23. For procedural skills it has been shown 
the practical sessions before theory-based lectures resulted in increased skill and knowledge retention 
at one month for transesophageal echocardiography24.  
 
Pediatric seizure is a common acute care pediatric scenario with numerous published simulation 
scenarios25–27 and evaluation rubrics available as well as multiple high-quality national pediatric status 
epilepticus management algorithms available28,29. The effect of pre and post simulation teaching 
remains debated in medical education literature as well as the ongoing concern of knowledge and 
performance degradation. This study aims to investigate the effect of pre and post teaching on 
knowledge degradation, and how to best optimize knowledge retention to improve medical education 
and theorized patient care. The specific objectives are to assess whether teaching before or after a 
simulation leads to medical students’ improved knowledge and resuscitation performance retention at 
two to fourth months post educational intervention for managing pediatric status epilepticus.  
 
 
 

 
 
 
 
 
 
 
 
 
 
 
 
 
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2.2 
Risk/Benefit Assessment 
2.2.1  Known Potential Risks 
As this is a medical education study there are minimal risks to the participants. The participation in 
simulation could cause increased stress to the learner but this will be minimized with structured pre-
brief and debrief sessions. 
 
2.2.2 Known Potential Benefits 
The participants will benefit from two simulation teaching sessions with a trained simulation expert and 
FRPC certified pediatric emergency medicine physician. They will also receive an additional lecture 
providing them with didactic teaching on status epilepticus.  
3 
Objectives 
The primary objective is to assess the resuscitation performance retention difference between the two 
educational intervention arms at two to four months following teaching. 
 
The secondary objectives are to assess the difference in knowledge between both study groups 
immediately after and two to four months after the educational intervention. In addition, we will 
measure the comfort of learners performing the initial simulation scenario.  
 
3.1 
 Outcome Measures 
The primary outcome will be the resuscitation performance retention assessed using the post-teaching 
the final global rating scale score (1-7 performance score) for medical management and flow during 
each simulation as well as the following “time-to” metrics; glucose check, IV access, chemistry panel 
order, first-line anti-epileptic administration30, second line anti-epileptic administration. This will be 
adjusted for baseline score.  
 
The secondary outcome measures for knowledge retention assessment will be the post-teaching  
knowledge test score assessed on a 15 Question MCQ test administered at the final assessment 
adjusted for the baseline score.   
 
Comfort/Confidence will be assessed using the change in Likert scale item after each simulation and 
debrief. 
 
4  
Study Population 
4.1. Inclusion Criteria 
1. Second year medical students at the University of British Columbia – Vancouver Campus 
4.2  
Expected Duration of Subject Participation 
A participant will already be expected to attend a 60 min teaching session on status epilepticus. They 
will also be required to participate in two 10-25 min simulation sessions which will include a 10-minute 
simulation and 15 debrief for the first and only a 10-minute simulation the second time. 
 

 
 
 
 
 
 
 
 
 
 
 
 
 
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4.3  
Recruitment and Retention 
The study participants will be recruited from the second-year medical student cohort at the University 
of British Columbia Vancouver campus. A medical student assisting in the research project will be the 
primary point for recruiting medical students and will post regularly in medical student communication 
channels including but not limited to Slack, Facebook and word of mouth. The participants names and 
contact information will be saved at this stage to allow for scheduling of the simulation and teaching 
sessions.  
 
The consent form will be emailed to participants to complete prior to participation and researchers will 
be available for questions. 
 
5  
Study Design 
5.1  
Overall Design 
This is a parallel randomized control trial in medical education that will be conducted at the BC 
Children’s Hospital. The participants will be masked to the other arm of the intervention and the 
outcome measures of the study.  
5.2    Data Collection 
The simulation sessions will be recorded to ensure accuracy in time to intervention recordings and 
global rating scales. Two experienced pediatric acute care specialists with simulation experience masked 
from the intervention arms will review the videos and determine the global rating scale for each 
simulation and they will review videos for the “time to metrics”. Time zero will be immediately after the 
scenario description is completed. 
 
The knowledge tests and anxiety/confidence assessment will be completed using a redcap-hosted 
survey. Basic demographic information including age, previous experience with simulation and a 
background in ED nursing or EMS will also be collected using a demographic survey. The names and 
contact information will not linked to the demographic or simulation information. This survey can be 
found in appendix A. 
 
5.3  
Didactic Lecture and Simulation Development: 
The lecture and two simulation scenarios were developed by the primary researcher, a first-year 
pediatric emergency medicine fellow with guidance from the principal investigators, a pediatric 
intensivist and pediatric emergency medicine specialist who both have expertise in simulation and 
curriculum development. Both the lecture and simulations were peer-reviewed by a pediatric 
emergency medicine specialist with simulation expertise who was not involved with research project. 
 
The lecture was developed using existing pediatric seizure management guidelines from Trekk and the 
Canadian Pediatric Society28,29. The lecture learning objectives mirrored the research outcome measures 
and focused on acute management of pediatric seizures with supporting discussions on possible 
etiologies. It did not discuss crisis-resource management skills, long-term management or prognosis of 
seizures or other acute pediatric scenarios. The lecture can be found in PDF form in Appendix B. 

 
 
 
 
 
 
 
 
 
 
 
 
 
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The simulation scenarios were developed using published pediatric seizure scenarios as a baseline and 
set at a level appropriate for trainees with limited clinical experience.  The pediatric status epilepticus 
scenarios can be found in appendix C. 
 
5.4 
 Study Protocol: 
The participants will be randomized into two groups: Lecture-> Simulation ->  Evaluation Simulation(LS) 
and Simulation->Lecture -> Evaluation Simulation (SL) using blocked randomization with varied block 
size. The randomization allocation sequence will be completed by RedCap and the researchers will be 
masked to this. 
 
The LS group will complete the 60-minute focused lecture immediately prior to their initial simulation. 
The SL group will complete the 60-minute focused lecture immediately after their initial simulation. The 
LS group will complete a pre-intervention knowledge test prior to the lecture and the SL group will 
complete a knowledge test prior to the initial simulation. 
 
Both groups will complete the initial simulation in groups of 3-4 with one member acting as the leader 
and others acting as team members. The simulation will last for 10 minutes followed by a structure 
debrief using the +/delta method lasting up to 20 minutes. The debrief will be completed by a pediatric 
emergency medicine specialist with experience in leading simulation debrief. The leader of the group 
will be recorded for later subgroup analysis.  
 
Every individual will complete a second evaluatory simulation 3 months after the initial simulation to 
evaluate the primary outcome of resuscitation performance retention. Each participant will act as the 
simulation leader with two actors who will function as a highly trained nurse and second physician but 
will not provide advice. The simulation will be videotaped. The participants will also complete a 
knowledge test prior after the second simulation.  
 
Simulation videos will be reviewed as per the above data collection method to determine outcome 
measures. The simulations will be completed in the BCCH simulation center with a trained pediatric 
simulation expert and simulation facilitator. A high-fidelity mannequin will be used. It can seize and has 
appreciable chest rise and breath sounds. The participants will be instructed to assume all medications 
requested are drawn up in a syringe to the dose desired in the medication tray to decrease variability in 
time to metrics from difficulty in drawing up medications. 
6      Statistical Consideration 
6.1  
Sample Size Determination: 
The one paper assessing knowledge and skill retention comparing SL and LS structured teaching found a 
13.42% difference in skill performance on transesophageal echocardiography24 with the following 
means and std; LS group 71.90 (18.59) and SL group 85.32(15.63). Using a sample size calculator 
estimates a sample size of 60 with an alpha of 0.05 and power of 0.831. 
 

 
 
 
 
 
 
 
 
 
 
 
 
 
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6.2  
Statistical Analysis: 
The recorded simulation sessions will be reviewed by two separate pediatric emergency medicine and 
simulation experts who will evaluate the participants on the simulation global rating scale, a validated 
assessment tool for simulation. Inter-rater reliability will be calculated via Pearson correlation and ICC 
statistics, and the final reported value will be the mean of both reviewers. 
 
The recorded sessions will also be reviewed to the time to metrics by two reviewers with a masked co-
investigator serving as the tie breaker in times of significant discordance. Time zero for the “time to” 
metrics will be when the facilitator finishes the scenario description.  
 
The mean and 95% confidence interval of the metrics will be calculated for each group. Post 
randomization scores will be compared using a paired t-test, and with mixed effects linear models using 
pre-randomization score as a covariate.  Time-to-event measures will be displayed with Kaplan Meier 
graphs and median time, and tested with the log-rank test, and secondarily using Cox proportional 
hazards models. Regression models may include adjustment for baseline variables imbalanced between 
arms or prognostic of outcome. Secondary Likert outcomes will be assessed with a proportional odds 
model. All results will be presented with appropriate 95% confidence intervals. Statistical analysis will be 
completed with statistician support using R statistical software.  
Protocol Deviations: 
All deviations will be reported to the REB in a timely manner. 
7       Data Handling and Record Keeping: 
7.1  
Data Management Responsibilities: 
The data will be stored on a secure redcap data-server. The server will be password protected and only 
the research team will have access to the data. Participant data will only be stored de-identified. The 
video recordings will be stored on an encrypted external hard drive kept in the PI’s office locked office in 
a locked drawer. The original video data would be deleted from the simulation center.  
7.2     Record Retention 
The data will be stored for 5 years after the publication of the study following which it will be destroyed. 
The data will be stored by BCCH. 
8      Budget & Finance: 
Statistician and redcap access will be covered by the hospital/university due to being a fellow led 
project. 
9     Dissemination\Publication Plan: 
Our knowledge translation plan includes manuscript publication in a peer-reviewed journal, and 
presentation at emergency medicine and/or pediatrics focused research conferences such as the PERC 
annual meeting. 
 
 

 
 
 
 
 
 
 
 
 
 
 
 
 
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10     References: 
1. Motola I, Devine LA, Chung HS, Sullivan JE, Issenberg SB. Simulation in healthcare education: A 
best evidence practical guide. AMEE Guide No. 82. Medical Teacher. 2013;35(10):e1511-e1530. 
doi:10.3109/0142159X.2013.818632 
2. Kalnow A, Davis A, Hampton Z, Gable BD. In Situ Simulation to Promote Residents as Resuscitation 
Leaders. Cureus. 13(4):e14449. doi:10.7759/cureus.14449 
3. Cook DA. If you teach them, they will learn: why medical education needs comparative effectiveness 
research. Adv in Health Sci Educ. 2012;17(3):305-310. doi:10.1007/s10459-012-9381-0 
4. Johnston S, Coyer FM, Nash R. Kirkpatrick’s Evaluation of Simulation and Debriefing in Health 
Care Education: A Systematic Review. Journal of Nursing Education. 2018;57(7):393-398. 
doi:10.3928/01484834-20180618-03 
5. Zendejas B, Brydges R, Wang AT, Cook DA. Patient Outcomes in Simulation-Based Medical 
Education: A Systematic Review. J Gen Intern Med. 2013;28(8):1078-1089. doi:10.1007/s11606-
012-2264-5 
6. Okuda Y, Bryson EO, DeMaria Jr. S, et al. The Utility of Simulation in Medical Education: What Is 
the Evidence? Mount Sinai Journal of Medicine. 2009;76(4):330-343. doi:10.1002/msj.20127 
7. Legoux C, Gerein R, Boutis K, Barrowman N, Plint A. Retention of Critical Procedural Skills After 
Simulation Training: A Systematic Review. AEM Educ Train. 2020;5(3):e10536. 
doi:10.1002/aet2.10536 
8. Yang CW, Yen ZS, McGowan JE, et al. A systematic review of retention of adult advanced life 
support knowledge and skills in healthcare providers. Resuscitation. 2012;83(9):1055-1060. 
doi:10.1016/j.resuscitation.2012.02.027 
9. Leigh G, Steuben F. Setting Learners up for Success: Presimulation and Prebriefing Strategies. 
Teaching and Learning in Nursing. 2018;13(3):185-189. doi:10.1016/j.teln.2018.03.004 
10. Luctkar-Flude M, Tregunno D, Tyerman J, et al. Feasibility and Learning Outcomes Associated with 
Preparing Nursing Students for Simulation using Virtual Simulation Games. :1. 
11. Drummond D, Delval P, Abdenouri S, et al. Serious game versus online course for pretraining 
medical students before a simulation-based mastery learning course on cardiopulmonary 
resuscitation: A randomised controlled study. European Journal of Anaesthesiology | EJA. 
2017;34(12):836-844. doi:10.1097/EJA.0000000000000675 
12. Bowyer MW, Hanson JL, Pimentel EA, et al. Teaching Breaking Bad News Using Mixed Reality 
Simulation. Journal of Surgical Research. 2010;159(1):462-467. doi:10.1016/j.jss.2009.04.032 
13. Curtin LB, Finn LA, Czosnowski QA, Whitman CB, Cawley MJ. Computer-based Simulation 
Training to Improve Learning Outcomes in Mannequin-based Simulation Exercises. AJPE. 
2011;75(6). doi:10.5688/ajpe756113 

 
 
 
 
 
 
 
 
 
 
 
 
 
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14. Franklin AE, Sideras S, Gubrud-Howe P, Lee CS. Comparison of Expert Modeling Versus Voice-
Over PowerPoint Lecture and Presimulation Readings on Novice Nurses’ Competence of Providing 
Care to Multiple Patients. J Nurs Educ. 2014;53(11):615-622. doi:10.3928/01484834-20141023-01 
15. Mabry J, Lee E, Roberts T, Garrett R. Virtual Simulation to Increase Self-efficacy Through 
Deliberate Practice. Nurse Educ. 2020;45(4):202-205. doi:10.1097/NNE.0000000000000758 
16. Moll-Khosrawi P, Zöllner C, Cencin N, Schulte-Uentrop L. Flipped learning enhances non-technical 
skill performance in simulation-based education: a randomised controlled trial. BMC Medical 
Education. 2021;21(1):353. doi:10.1186/s12909-021-02766-w 
17. Tyerman J, Luctkar-Flude M, Graham L, Coffey S, Olsen-Lynch E. A Systematic Review of Health 
Care Presimulation Preparation and Briefing Effectiveness. Clinical Simulation in Nursing. 
2019;27:12-25. doi:10.1016/j.ecns.2018.11.002 
18. Tyerman J, Luctkar-Flude M, Graham L, Coffey S, Olsen-Lynch E. Pre-simulation preparation and 
briefing practices for healthcare professionals and students: a systematic review protocol. JBI 
Database of Systematic Reviews and Implementation Reports. 2016;14(8):80-89. 
doi:10.11124/JBISRIR-2016-003055 
19. Birch L, Jones N, Doyle PM, et al. Obstetric skills drills: Evaluation of teaching methods. Nurse 
Education Today. 2007;27(8):915-922. doi:10.1016/j.nedt.2007.01.006 
20. Zheng Z, Liao J, Zeng L, et al. High-Fidelity Patient Simulation Incorporated Into a Flipped 
Classroom Improves Students’ Long-Term Knowledge Retention of Acute Organophosphorus 
Pesticide Poisoning. Simulation in Healthcare. 2022;17(1):e68. doi:10.1097/SIH.0000000000000566 
21. Blanie A, Shoaleh C, Marquion F, Benhamou D. Comparison of multimodal active learning and 
single-modality procedural simulation for central venous catheter insertion for incoming residents in 
anesthesiology: a prospective and randomized study. BMC Medical Education. 2022;22(1):357. 
doi:10.1186/s12909-022-03437-0 
22. Stefaniak JE, Turkelson CL. Does the Sequence of Instruction Matter During Simulation? Simulation 
in Healthcare: The Journal of the Society for Simulation in Healthcare. 2014;9(1):15-20. 
doi:10.1097/SIH.0b013e3182a8336f 
23. Zendejas B, Cook DA, Farley DR. Teaching First or Teaching Last: Does the Timing Matter in 
Simulation-Based Surgical Scenarios? Journal of Surgical Education. 2010;67(6):432-438. 
doi:10.1016/j.jsurg.2010.05.001 
24. Thampi S, Lee CCM, Agrawal RV, et al. Ideal Sequence of Didactic Lectures and Simulation in 
Teaching Transesophageal Echocardiography Among Anesthesiologists. Journal of Cardiothoracic 
and Vascular Anesthesia. 2020;34(5):1244-1249. doi:10.1053/j.jvca.2019.12.011 
25. Chua W, Burns R, Stone K, Reid J. Pediatric Emergency Medicine Simulation Curriculum: 
Hyponatremic Seizures. MedEdPORTAL. 12:10498. doi:10.15766/mep_2374-8265.10498 

 
 
 
 
 
 
 
 
 
 
 
 
 
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26. Friedman S, Tozzi M, Shakhin V, et al. Simulation of Seizures for the Pediatrics Resident. 
MedEdPORTAL. 10:9880. doi:10.15766/mep_2374-8265.9880 
27. Reid J, Stone K. Pediatric Emergency Medicine Simulation Curriculum: Seizure Scenario. 
MedEdPORTAL. 14:9794. doi:10.15766/mep_2374-8265.9794 
28. Muir K, Buttle S, Shah M, trekk, EIIC. TREKK Pediatric Status Epilepticus Algorithm. Published 
online April 2022. Accessed September 30, 2022. 
https://trekk.ca/system/assets/assets/attachments/577/original/2022-05-02_EIIC-
Trekk_Status_Epilepticus_Algorithm_Final_Version.pdf?1652215972 
29. McKenzie KC, Hahn CD, Friedman JN, Canadian Paediatric Society Acute Care Committee. 
Emergency management of the paediatric patient with convulsive status epilepticus | Canadian 
Paediatric Society. CPS.ca. Published February 1, 2021. Accessed September 30, 2022. 
https://cps.ca/en/documents//position//emergency-management-of-the-paediatric-patient-with-
convulsive-status-epilepticus/ 
30. Gaínza-Lein M, Sánchez Fernández I, Jackson M, et al. Association of Time to Treatment With 
Short-term Outcomes for Pediatric Patients With Refractory Convulsive Status Epilepticus. JAMA 
Neurology. 2018;75(4):410-418. doi:10.1001/jamaneurol.2017.4382 
31. Kane S. Sample Size Calculator. ClinCalc.com. Published July 24, 2019. Accessed October 17, 2022. 
https://clincalc.com/stats/samplesize.aspx 
 
 
 

 
 
 
 
 
 
 
 
 
 
 
 
 
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Appendix A: 
Demographics: 
Please enter your age:  
 
What is your experience with medical simulation? 
a) No experience   b) 1-5 simulation experiences c) 5-10 simulation experiences d) >10 simulation 
experiences 
 
Before entering medicine please check any roles that apply? 
-     Background in ED Nursing 
- 
Background as a paramedic or first responder? 
 
Confidence Quiz: 
Please rate your anxiety in the simulation experience from 1 to 5? 
1 – Extremely anxious  5 – Not anxious at all 
 
Please rate your confidence in managing pediatric seizures in the future? 
1 – Not confident at all, 5 – extremely confident 
 
Please rate your satisfaction with the educational experience (Simulation + Debrief + Lecture)? 
1 – extremely dissatisfied , 5 extremely satisfied  
 
 
 
 
 

 
 
 
 
 
 
 
 
 
 
 
 
 
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Appendix B
 
Pediatric 
Status 
Epilepticus 
John Ramsay – 2023
Case Presentation
You are working in the ED and a 4 year old girl is brought in who has 
been having generalized tonic-clonic movements and head deviation 
for the past 10 minutes. 
• What is the diagnosis? 
• What might be the underlying cause?
• How do you stabilize this patient?
• What’s the best way to stop this seizure?
• Are there any tests or investigations you need to think about?
What is status Epilepticus?
Typ es o f Seizures (Epilep sy #2) (2007) Yo uTu be. YouTube. Available at: https://www.youtube.com/watch?v=CDccChHrgRA (Accessed: December 21, 2022).
Early Status Epilepticus: >5 mins and ongoing seizure
Status epilepticus: Longer than 30 minutes, can start to have permanent neurologic damage
Differential for Seizures
Underlying Differential
Infection
Encephalitis
Meningitis
Febrile Seizure
Hypoxia
Trauma
Drug Related
AED Non-compliance
Toxic Ingestion
Stroke
Epilepsy
Metabolic 
abnormalities
Hypoglycemia
Hyponatremia
Hypocalcemia
Important aspects to consider:
• EMS handover
• SAMPLE History:
• Signs & Symptoms
• Fever
• head injuries
• Allergies
• Medications
• Taking
• Medication at home
• Past Medical History
• Last meal
• Events leading up to presentation
What are your priorities?

 
 
 
 
 
 
 
 
 
 
 
 
 
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Stabilization
Primary Survey – A - Airway
1. Lloyd, G. (2021) B asic airw ay m an agem en tGa v, RCEM Learnin g. Available at: https://www.rcemlearning.co.uk/reference/basic-airway-management/#1568196731191-ffef3f4f-1a10 (Accessed: January 11, 2023).
2. Strido r - Lung Sounds - M EDZCO O L (2018) YouTub e. YouTube. Available at: https://www.youtube.com/watch?v=JSdEK79J4dw (Accessed: January 11, 2023).
Recognize
Assess for
Manage
Airway Obstruction
•
Position (hyper/hypo extension)
•
Patency (Blood, Vomiting)
•
Need for protection
•
Oral Suction
•
Sniffing Position
•
Oral Airway
•
Jaw thrust
•
Bag-mask ventilation
A
Primary Survey – B - Breathing
Recognize
Assess for
Manage
Respiratory Failure
•
Apnea/poor effort
•
Increased work of breathing
•
Air entry
•
Added Sounds: Wheeze/Crackles
•
SpO2, RR, End-tidal CO2
•
Bag-mask ventilation
•
Positive Pressure (HFNC, CPAP, BiPAP)
•
Prepare for intubation if needed
•
Medications for respiratory distress (Asthma)
•
Pneumothorax – Needle decompression, Chest tube
B
Respiratory issues are typically secondary to airway 
compromise in seizures
Primary Survey – C - Circulation
Recognize
Assess for
Manage
Shock
•
Tachycardia, Bradycardia
•
Cap Refill (Fast/Slow)
•
Pulses
•
Hypotension (late sign)
•
Hepatomegaly
•
Check pelvis stability
•
Think about access - IV, IO, Central Line
•
Isotonic Fluid Bolus – 10-20ml/kg at a time
•
Consider epinephrine or norepinephrine
C
Seizing patients should be tachycardic 
and normotensive or slightly 
hypertensive. 
Hypotension and/or bradycardia is 
very concerning.
New bo rn physical exam (May 15, 2016) Stepwa rds. Available at: https://www.stepwards.com/?page_id=4152 (Accessed: January 12, 2023).
Primary Survey – D - Disability
Recognize
Assess for
M anage
•
Severe Head injury
•
Raised ICP
•
Seizure
•
GCS less than or equal to 8
•
Respond only to pain/unresponsive
•
Cushing's Triad (Bradycardia, 
Hypertension, Irregular resp)
•
Head of bed elevation, head midline
•
Intubation/Sedation
•
3% hypertonic saline – 5ml/kg
•
Hyperventilation if herniation (Blown Pupil)
•
Neurosurgery consult
D
AVPU: Alert
Verbal
Pain
Unresponsive
1.
(2021) Tw itter. Metrolina Trauma Advisory Committee, 30 August. Available at: https://twitter.com/metrolinatrauma/status/1432353465758531588 (Accessed: January 12, 2023).
2.
Gary Heiting, O.D. (2019) Dilated pu pils: Cau ses and  con cern s, All Ab out Vision. All About Vision. Available at: https://www.allaboutvision.com/conditions/dilated-pupils.htm (Accessed: January 12, 2023).

 
 
 
 
 
 
 
 
 
 
 
 
 
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Primary Survey – E - Exposure
Recognize
Assess for
Manage
•
Rashes
•
Signs of Trauma
•
Purpura
•
Bruising
•
Abrasions
•
Maintain Normothermia
E
Not always a core component of seizure 
assessment but may give clues to etiology
Estimating your patients weight
Practical Estimation based on Age:
•
Infants <12mo: (age in months + 9)/2
•
Children 1-5: (age + 5) x 2
•
Children 5-14: Age x 4
Breslow Tape
First line Treatment
Benzodiazepines – First Line
Side Effects of too many Benzodiazepines
• Respiratory depression
• Hypotension
• Sedation
MAX DOSES: TWO
Intraosseous
Intranasal
BUCCAL

 
 
 
 
 
 
 
 
 
 
 
 
 
Protocol number: 1 
Version date: 16-Aug-23 
 
Page 15 of 27  
 
 
Second Line Treatment
Equal Efficacy of all options
Levetiracetam can be given the fastest with the best side effect profile
Repeat one different second line 
medication 5 mins after infusion 
Hypoglycemia
POCT BG < 3.3mmol/L
Conscious & Asymptomatic
Impaired consciousness or seizure
• Confirm symptoms if possible
• 15g or rapid acting carbohydrates
• ~125ml of juice
• Recheck glucose 15-30min post
• Dextrose bolus: rule of 50
• 5ml/kg of D10 – up to 250ml
• 4ml/kg of D12.5
• 2ml/kg of D25
• Repeat glucose q5 min until normal
• Repeat bolus as needed
• D5-10NS @ maintenance
< 2.8 mmol/L send a Critical Sample
Normal Range:
3.9 – 5.5 mmol/L
No response 
or
Refuses PO
Hyponatremia
Hyponatremia:  < 135mEq/L
Is sodium less than:  < 120mEq/L
NO
YES
Normal Range:
135 – 145 mmol/L
3% Hypertonic Saline
• 5ml/kg bolus over 10-15 mins
• Will raise sodium by  ~5mEq/L
Unlikely to be cause of seizure
• Consider hypertonic saline if not 
improving

 
 
 
 
 
 
 
 
 
 
 
 
 
Protocol number: 1 
Version date: 16-Aug-23 
 
Page 16 of 27  
 

 
 
 
 
 
 
 
 
 
 
 
 
 
Protocol number: 1 
Version date: 16-Aug-23 
 
Page 17 of 27  
 
Raised ICP/Trauma/Stroke
Necessary Investigations:
•
Non-Contrast CT Scan
Band-Aids:
•
Head of bed elevation
•
Sedation
•
Hypertonic saline
•
Mannitol
•
Hyperventilation
Managing secondary brain injury:
•
Normothermia
•
Normotension
•
Normoglycemia
Definitive Management – NEUROSURGERY
Infection
Febrile Seizure:
•
Between 6 months and 6 year with a temp >38.0C 
•
Absence of CNS infection/Inflammation and no acute systemic abnormalities
•
Seizures typically 5-10 mins with shorter post-ictal period of 5-10 mins.
Febrile Status Epilepticus 
Consider Meningitis/Encephalitis
•
Blood Culture
•
Urine Culture
•
Consider LP/CSF if stable
Start antibiotics as soon as possible 
If very sick: Don’t delay antibiotics for cultures
Blood culture is still typically able to be obtained with IV
Disposition
Children should be admitted to the hospital if they have prolonged seizures, refractory 
seizures or do not return to their baseline within 4-6 hours.
Discharging:
•
Ensure neurology follow up
•
Outpatient EEG
•
+/- Outpatient MRI
Brief Febrile Seizure – No further investigations needed
Admission Investigations:
•
Neurology Consult
•
MRI Brain
•
Lumbar Puncture
•
EEG
•
Metabolic Workup
Resources
References
•
(2021) Twitter. Metrolina Trauma Advisory Committee, 30 August. Available at: 
https://twitter.com/metrolinatrauma/status/1432353465758531588 (Accessed: January 12, 2023).
•
Gary Heiting, O.D. (2019) Dilated pupils: Causes and concerns, All About Vision. All About Vision. Available at: 
https://www.allaboutvision.com/conditions/dilated-pupils.htm (Accessed: January 12, 2023).
•
Lloyd, G. (2021) Basic airway managementGav, RCEMLearning. Available at: https://www.rcemlearning.co.uk/reference/basic-airway-
management/#1568196731191-ffef3f4f-1a10 (Accessed: January 11, 2023).
•
New born physical exam (no date) Stepwards. Available at: https://www.stepwards.com/?page_id=4152 (Accessed: January 12, 2023).
•
Stridor - Lung Sounds - MEDZCOOL (2018) YouTube. YouTube. Available at: https://www.youtube.com/watch?v=JSdEK79J4dw 
(Accessed: January 11, 2023).
•
Chua W, Burns R, Stone K, Reid J. Pediatric Emergency Medicine Simulation Curriculum: Hyponatremic Seizures. M edEdPORTAL. 
12:10498. doi:10.15766/mep_2374-8265.10498
•
Friedman S, Tozzi M, Shakhin V, et al. Simulation of Seizures for the Pediatrics Resident. MedEdPORTAL. 10:9880. 
doi:10.15766/mep_2374-8265.9880
•
Reid J, Stone K. Pediatric Emergency Medicine Simulation Curriculum: Seizure Scenario. MedEdPORTAL. 14:9794. 
doi:10.15766/mep_2374-8265.9794
•
Muir K, Buttle S, Shah M, trekk, EIIC. TREKK Pediatric Status Epilepticus Algorithm. Published online April 2022. Accessed September 
30, 2022. https://trekk.ca/system/assets/assets/attachments/577/original/2022-05-02_EIIC-
Trekk_Status_Epilepticus_Algorithm_Final_Version.pdf?1652215972
•
McKenzie KC, Hahn CD, Friedman JN, Canadian Paediatric Society Acute Care Committee. Emergency management of the paediatric
patient with convulsive status epilepticus | Canadian Paediatric Society. CPS.ca. Published February 1, 2021. Accessed September 30, 
2022. https://cps.ca/en/documents//position//emergency-management-of-the-paediatric-patient-with-convulsive-status-epilepticus/
QUESTIONS?
Contact Info: John Ramsay – ramsay.s.john@gmail.com
The quiz answers will be available at the end of the study should you be interested.

 
 
 
 
 
 
 
 
 
 
 
 
 
Protocol number: 1 
Version date: 16-Aug-23 
 
Page 18 of 27  
 
Appendix C 
Scenario 1 
Case Title: Status epilepticus in an 8-year-old child 
 
 
 
Author: John Ramsay  
Date Last Updated: 2022-11-30 
Reason for Development: Simulation research scenario  
Target Population: 2nd year medical students 
Target Duration: 10 minute simulation 
Learning Objectives: 
1. ABC approach in a sick child 
2. Initiation of seizure management and review of Trekk Algorithm  
3. Initiation of basic seizure investigations 
 
Core Competencies Checklist: 
Medical Expert: ☒   Professional: ☒   Communicator: ☒   Collaborator: ☐   Leader: ☒   Health Advocate: ☐   Scholar: ☐ 
 
 
Crisis Resource Management Skills: 
Know Environment: ☒   Anticipate & Plan: ☒   Call for help early: ☒   Distribute workload: ☐   Exercise leadership & Followership: ☐    
Mobilize all available resources: ☐   Use all information: 
 ☒   Re-evaluate case: ☒   Prevent & Manage Fixation errors: ☐    Use good teamwork: ☒  
Communicate effectively: ☒   Allocate attention: ☒   Set priorities dynamically ☒ 
Scenario Setup: 
Clinical Setting: 
 
ED Resus Room: ☐ 
 
Sim Lab: ☒ 
 
Other: ☐ Ward 
System:  
 
Low fi infant: ☐ 
 
Low-fi Child: ☒ 
 
High-Fi Infant: ☐ 
High-fi Child: ☒ 
Equipment Needs:
☒ Bed  
☒Medication Cart 
☐ IV Pump + Pole 
☐ Defibrillator/Pacer/ECG Leads 
☒ O2 delivery (NP, NRB mask, BVM) 
☐ Airway cart (Laryngoscope, ETT, etc) 
☒ IV Catheters 
☒ Vitals: chest leads, pulse ox, Bp cuff 
☐ PPE 
☐ IO Setup 
☐ Chest tube set up 
☐ Three-way stopcock 
☐ Foley Catheter
Adjuncts Needed:
ECG: ☐  
Imaging: ☐  
Bloodwork: ☒ Appendix A 
Videos/Photos: ☐  
Guidelines: ☒ Appendix B 
Flowsheets: ☐ 
 
 

 
 
 
 
 
 
 
 
 
 
 
 
 
Protocol number: 1 
Version date: 16-Aug-23 
 
Page 19 of 27  
 
 
Age: 8 yrs 
 
 
 
 
 
 
 
Sex: Male 
 
 
 
 
 
 
 
Wt: 30kg 
Case Summary (For Facilitator): 
8-year-old male presenting to the ED who has been having seizure for the past 10 minutes. His seizures will resolve following the administration of a 
second line anti-epileptic. The scenario is complicated by inability to obtain IV access for the first dose and worsening airway protection and desaturation as 
the case progresses. IV access can be obtained after an initial intranasal dose of midazolam is given.   
 
Case Intro/Clinical Vignette (Read out loud to participants): 
The paramedics are about to arrive with Rahul an 8-year-old male who is unresponsive and has been having tonic-clonic movements of his limbs for the 
past 10 minutes.  
 
Additional Hx (if asked): 
HPI: previous well 
PMH: Nil 
Meds: Nil 
Algs: Nil 
 
 
 
 
 
 
 
 

 
 
 
 
 
 
 
 
 
 
 
 
 
Protocol number: 1 
Version date: 16-Aug-23 
 
Page 20 of 27  
 
 
 
Stage 1: 
Patient Condition 
Simulator 
Parameters 
Effective Management 
Consequences of 
ineffective management 
Notes: 
General: Unresponsive, no work of 
breathing, normal colour 
Airway: No stridor, neck flexed, 
Breathing: No WOB, normal chest 
rise 
Circulation: Normal pulses, cap refill 
<3, warm extremities 
Disability: Unresponsive, Pupils 
dilated, reactive 
 
P/E: 
Cardio: Unremarkable 
Resp: Unremarkable 
Abdo: unremarkable 
Neuro: Pupils dilated, no reflexes, 
stiff tone, repeated flexion of arms, 
head deviation to one side 
 
 
HR: 122 
RR: 10 
SaO2: 90% 
BP: 110/75 
Temp: 37.7C 
 
A: 
• Attempt better 
positioning 
• Jaw thrust 
• Suction 
• Oral Airway 
 
B: 
• O2 by non-
rebreather or 
facemask 
 
C: 
• Attempt IV access 
• Cycle BP’s 
 
Monitors: 
• Chest leads, sat 
monitor, BP Cuff 
 
Investigations: 
• POC Glucose (4.0) 
• Blood work 
 
• IV access is 
unsuccessful 

 
 
 
 
 
 
 
 
 
 
 
 
 
Protocol number: 1 
Version date: 16-Aug-23 
 
Page 21 of 27  
 
 
Medications: 
• Intranasal Midaz 
or Diazepam PR 
 
Stage 2: 
Patient Condition 
Simulator Parameters 
Effective Management 
Consequences of 
ineffective management 
Notes: 
General: 5 minutes have 
passed, and patient is 
continuing to seize 
Airway:  
No intervention: Mild 
stridor, poor position 
Intervention: supported 
effectively 
Breathing:  
If no jaw thrust mild work 
of breathing, 
otherwise unremarkable 
Circulation: Normal 
pulses, normal cap refill  
Disability: Unresponsive 
 
P/E: Unchanged 
HR: 126 
RR: 12 
SaO2:  
84% if no intervention 
95 if O2 and airway 
management 
BP: 112/80 
Temp: 37.8 
 
A: 
• Airway 
management 
above if not 
completed 
B: 
• Nil 
C: 
• Obtain IV access 
 
Medication: 
• Lorazepam IV 
• Keppra IV or other 
second line agent 
 
Need to get to second 
line agent to abort 
seizure 
 
 
Expected / Critical Actions 
Unacceptable Actions: 
• Attempted IV access and repeat attempt later 
• No airway management when patient is stridulous  

 
 
 
 
 
 
 
 
 
 
 
 
 
Protocol number: 1 
Version date: 16-Aug-23 
 
Page 22 of 27  
 
• Transition to Non-IV medication when access unavailable 
• Call for support (Neuro) if seizure continues 
 
Medical Expert Points to bring up for discussion: 
• Intranasal midazolam vs IV Lorazepam and effectiveness 
• Importance of airway management 
• Work-up for unknown seizure (Glucose, lytes) 
 
Lab 
Result 
Normal Range 
CBC 
 
 
WBC 
7 x 109 
4-12x109 
Hgb 
130 
130 – 160 
Plt 
320 
150 – 450 
 
 
 
Glucose 
5.7 
 
 
 
 
Electrolytes & Extended electrolytes: 
 
 
Sodium (Na+) 
140 
135 – 145  
Potassium (K+) 
4.2 
3.5 – 5.5 
Chloride (Cl-) 
103 
102 – 112  
Ionized Calcium (iCa) 
1.18 
1.15 – 1.3 
Phosphate (PO4-2) 
1.5 
1.16 – 1.81 
Magnesium (Mg2+) 
0.8 
0.66 – 0.91 
 

 
 
 
 
 
 
 
 
 
 
 
 
 
Protocol number: 1 
Version date: 16-Aug-23 
 
Page 23 of 27  
 
Scenario 2 
Case Title: Status epilepticus in a 1-year-old child 
 
 
 
Author: John Ramsay  
Date Last Updated: 2022-11-30 
Reason for Development: Simulation research scenario  
Target Population: 2nd year medical students 
Target Duration: 10 minute simulation 
Learning Objectives: 
1. ABC approach in a sick child 
2. Initiation of seizure management and review of Trekk Algorithm  
3. Initiation of basic seizure investigations 
 
Core Competencies Checklist: 
Medical Expert: ☒   Professional: ☒   Communicator: ☒   Collaborator: ☐   Leader: ☒   Health Advocate: ☐   Scholar: ☐ 
 
 
Crisis Resource Management Skills: 
Know Environment: ☒   Anticipate & Plan: ☒   Call for help early: ☒   Distribute workload: ☐   Exercise leadership & Followership: ☐    
Mobilize all available resources: ☐   Use all information: 
 ☒   Re-evaluate case: ☒   Prevent & Manage Fixation errors: ☐    Use good teamwork: ☒  
Communicate effectively: ☒   Allocate attention: ☒   Set priorities dynamically ☒ 
Scenario Setup: 
Clinical Setting: 
 
ED Resus Room: ☐ 
 
Sim Lab: ☒ 
 
Other: ☐ Ward 
System:  
 
Low fi infant: ☐ 
 
Low-fi Child: ☐ 
 
High-Fi Infant: ☒ 
High-fi Child: ☐ 
Equipment Needs:
☒ Bed  
☒Medication Cart 
☐ IV Pump + Pole 
☐ Defibrillator/Pacer/ECG Leads 
☒ O2 delivery (NP, NRB mask, BVM) 
☐ Airway cart (Laryngoscope, ETT, etc) 
☒ IV Catheters 
☒ Vitals: chest leads, pulse ox, Bp cuff 
☐ PPE 
☐ IO Setup 
☐ Chest tube set up 
☐ Three-way stopcock 
☐ Foley Catheter
Adjuncts Needed:
ECG: ☐  
Imaging: ☐  
Bloodwork: ☒ Appendix A 
Videos/Photos: ☐  
Guidelines: ☒ Appendix B 
Flowsheets: ☐ 
 
 
 

 
 
 
 
 
 
 
 
 
 
 
 
 
Protocol number: 1 
Version date: 16-Aug-23 
 
Page 24 of 27  
 
Age: 1 yr 
 
 
 
 
 
 
 
Sex: Female  
 
 
 
 
 
 
Wt: 10kg 
Case Summary (For Facilitator): 
1-year-old girl presenting on the ward who has been having seizure for the past 5 minutes. Her seizures will resolve following the administration of a 
second line anti-epileptic. The scenario is complicated by inability to obtain IV access for the first dose and worsening airway protection and desaturation as 
the case progresses. IV access can be obtained after an initial intranasal dose of midazolam is given.   
 
Case Intro/Clinical Vignette (Read out loud to participants): 
The nurse calls you about with Zoe a 1-year-old girl who is unresponsive and has been having tonic-clonic movements of her limbs for the past 5 minutes. 
She was admitted for gastroenteritis and pulled her IV out earlier today. 
 
Additional Hx (if asked): 
HPI: previous well 
PMH: Nil 
Meds: Nil 
Algs: Nil 
 
 
 
 
 
 
 
 

 
 
 
 
 
Stage 1: 
 
 
Patient Condition 
Simulator 
Parameters 
Effective Management 
Consequences of 
ineffective management 
Notes: 
General: Unresponsive, no work of 
breathing, normal colour 
Airway: No stridor, neck flexed, 
Breathing: No WOB, normal chest rise 
Circulation: Normal pulses, cap refill 
<3, warm extremities 
Disability: Unresponsive, Pupils 
dilated, reactive 
 
P/E: 
Cardio: Unremarkable 
Resp: Unremarkable 
Abdo: unremarkable 
Neuro: Pupils dilated but reactive,, no 
reflexes, stiff tone, repeated flexion of 
arms, head deviation to one side 
 
 
HR: 170 
RR: 14 
SaO2: 90% 
BP: 95/55 
Temp: 37.6C 
 
A: 
• Attempt better 
positioning 
• Jaw thrust 
• Suction 
• Oral Airway 
B: 
• O2 by non-
rebreather or 
facemask 
C: 
• Attempt IV access 
• Cycle BP’s 
 
Monitors: 
• Chest leads, sat 
monitor, BP Cuff 
 
Investigations: 
• POC Glucose (2.0) 
• Blood work 
 
Medications: 
• Intranasal Midaz 
or Diazepam PR 
Call for help 
 
 
• IV access is 
unsuccessful 

 
 
 
 
 
 
 
 
 
 
 
 
 
Protocol number: 1 
Version date: 16-Aug-23 
 
Page 2 of 27  
 
Stage 2: 
Patient Condition 
Simulator Parameters 
Effective Management 
Consequences of 
ineffective management 
Notes: 
General: 5 minutes have 
passed, and patient is 
continuing to seize 
Airway:  
No intervention: Mild 
stridor, poor position 
Intervention: supported 
effectively 
Breathing:  
If no jaw thrust mild work 
of breathing, 
otherwise unremarkable 
Circulation: Normal 
pulses, normal cap refill  
Disability: Unresponsive 
 
P/E: Unchanged 
HR: 126 
RR: 12 
SaO2:  
84% if no intervention 
95 if O2 and airway 
management 
BP: 112/80 
Temp: 37.8 
 
A: 
• Airway 
management 
above if not 
completed 
B: 
• Nil 
C: 
• Obtain IV access 
 
D: 
• IV D10W  
 
Medication: 
• Lorazepam IV 
• Keppra IV or other 
second line agent 
 
- 
Need to get to 
second line agent 
to abort seizure 
- 
Should correct 
glucose to stop 
seizure.  
 
 
Expected / Critical Actions 
Unacceptable Actions: 
• Attempted IV access and repeat attempt later 
• Transition to Non-IV medication when access 
unavailable 
• Call for support (Neuro/Staff) if seizure continues 
• No airway management when patient is stridulous  
Medical Expert Points to bring up for discussion: 
• Intranasal midazolam vs IV Lorazepam and effectiveness 
• Importance of airway management 
• Work-up for unknown seizure (Glucose, lytes) 

 
 
 
 
 
 
 
 
 
 
 
 
 
Protocol number: 1 
Version date: 16-Aug-23 
 
Page 3 of 27  
 
 
Lab 
Result 
Normal Range 
CBC 
 
 
WBC 
8 x 109 
4-12x109 
Hgb 
145 
130 – 160 
Plt 
270 
150 – 450 
 
 
 
Glucose 
4.2 
 
 
 
 
Electrolytes & Extended 
electrolytes: 
 
 
Sodium (Na+) 
144 
135 – 145  
Potassium (K+) 
4.5 
3.5 – 5.5 
Chloride (Cl-) 
103 
102 – 112  
Ionized Calcium (iCa) 
1.2 
1.15 – 1.3 
Phosphate (PO4-2) 
1.4 
1.16 – 1.81 
Magnesium (Mg2+) 
0.8 
0.66 – 0.91