Abstracts

Rationale: Acute generalized convulsive Status Epilepticus (SE) is a neurologic emergency. Data from large prospective randomized controlled trials have provided evidence to guide first line treatment with benzodiazepines. There are no large prospective trials to guide subsequent decisions regarding second or third line treatment. Absent high quality data, treatment decisions are often guided by past experience, side effect profiles of medications, consensus opinions, or institutional or organizational treatment protocols. We performed the first observational study to determine current prescribing practice and responsiveness to acute treatment of generalized convulsive status epilepticus.Methods: We retrospectively reviewed the ICD9 coding database for visits to the University of Virginia Hospital, Charlottesville, Virginia from 1/1/2006-12/31/2010 for the primary SE code of 345.3 grand mal status and reviewed the medical records of each case to determine if patients coded as SE met criteria of acute generalized convulsive SE presenting to the University of Virginia Emergency Department or one of our referral hospitals. SE was defined as seizing on EMS/ED arrival or greater than 3 seizures without return to baseline. Treatment response was a cessation of SE after treatment as assessed by clinical evaluation and electrographic data, if available. Results: We identified 177 episodes of acute convulsive status epilepticus presenting to the University of Virginia emergency department occurring in 170 patients. All except one received benzodiapepine for first line treatment. Of these patients, 130 received second line treatment. Phenytoin or fosphenytoin were used most commonly (41%) with others receiving levetiracetam, midazolam, phenobarbital, propofol, or valproic acid. Of the 78 patients who did not respond to benzodiazepines and required second line treatment for seizure cessation, 49 (63%) had seizure cessation following second line treatment administration. 6/28 (22%) responded to phenytoin/fosphenytoin compared with 17/19 (89%) to phenobarbital, 13/14(83%) to propofol, 7/9 (78%) to levetiracetam, 5/6 (83%) to midazolam, and 1/2 (50%) to valproic acid. Phenytoin/fosphenytoin was statistically significantly less effective than other treatments when analyzed compared to each drug singly or when combined. This relationship is not explained by differences in age, dosing, or location of treatment. Conclusions: This study is the first observational review of the current practice of acute treatment of generalized convulsive status epilepticus. In our observational study, 63% of patients with status epilepticus who failed first line treatment with benzodiazepines responded to second line treatment. Phenytoin/fosphenytoin was used most commonly for second line treatment but was the least effective. This relationship is not explained by differences in age, dosing, or location of treatment. Prospective, randomized controlled data will provide further insight into this finding.