Abstracts

Rationale: Studies have demonstrated the need for early and aggressive management of convulsive status epilepticus (CSE) with antiseizure medications (ASMs). However, time to treatment is often significantly delayed. While the majority of CSE episodes start out-of-hospital, a minority of patients receive pre-hospital treatment, even in patients with known epilepsy or prior episodes of CSE. We aim to evaluate the pre-hospital management, specifically highlighting the adherence to status epilepticus medication algorithms and use of seizure rescue medications (RMs) by caregivers, in a cohort of pediatric patients presenting to a tertiary care center.  Methods: Children aged 1 month to 21 years with CSE (defined as a single seizure lasting 5 minutes or longer) or a seizure cluster (defined as 2 or more seizures in 6 hours) admitted to a tertiary pediatric hospital requiring an ASM(s) were included. We excluded patients with infantile spasms, episodes of non-convulsive status epilepticus, and seizures resolving without ASM use.  Results: 84 patients (median age (p25-p75) of 4.1 (1.3-8.5) years; 46% females, n=39) were enrolled over a 13-month period from February 2016-March 2017. Considering only the first episode in the enrollment period meeting inclusion criteria, 44% (n=37) of cases presented with CSE, and 56% (n=47) had seizure clusters. 79% (n=66) had a prior history of epilepsy, and 54% (n=45) had at least one prior episode of SE. 51% (n=43) had seizure onset out-of-hospital.In patients with out-of-hospital CSE onset, median time (p25-p75) to first, second, and third ASMs was 14 (5-20), 28 (20-53), and 38 (35-73) minutes, respectively; comparatively, median time (p25-p75) to first, second, and third ASMs with in-hospital onset was 5.5 (5-7), 9 (8-29), and 21 (10-33) minutes, respectively (p < 0.05). In patients with known epilepsy and pre-hospital CSE onset (n=11), 91% (n=10) had been prescribed a RM. The RM was used as the first ASM in only 50% of cases (n=5). When given by the caregiver, the median time (p25-p75) to first ASM was 5 (5-5) minutes. This was prolonged to 10.5 (8-13) minutes if given by emergency medical personnel or 35 (21.5-47.5) minutes if given after arrival to the hospital (p=0.004) (Table 1).22% (n=8) of cases followed the hospital-approved standardized CSE medication algorithm, with ASMs given at nonstandard doses, sequence, or administration times in all other cases. When a personalized CSE medication algorithm was present (n=25), this was followed in 48% (n=12) of cases. In these patients, the median seizure duration (p25-p75) was 9 (6-18) minutes compared to 22 (9-62) minutes with algorithm compliance versus noncompliance, respectively (p=0.0493). Median time (p25-p75) from seizure onset to the first, second and third ASMs when the algorithm was followed versus when not followed was 4.5 (3-5) versus 15.5 (6.5-29) (p < 0.001), 8 (6.5-16.5) versus 30 (13-44) (p=0.0263), and 18 (9-29) versus 49 (21-73) (p=0.0665) minutes (Figure 1). Conclusions: Time from seizure onset to ASM administration in CSE and seizure clusters is delayed, particularly with out-of-hospital onset. The majority of patients in this cohort were prescribed a RM, but it was used in only 50% of cases as the first ASM. When the RM was not given by the caregiver, time to treatment was further delayed. While there is low adherence to a hospital-approved standardized CSE medication algorithm, we found better adherence to a personalized algorithm in nearly half of cases. When the personalized algorithm was followed, time to treatment was accelerated and seizure duration was shortened.  Funding: Fred Lovejoy Grant and Epilepsy Research Fund