Abstracts

Rationale: Status Epilepticus (SE) is defined as prolonged or recurrent seizures that are unlikely to be controlled by intervention. Seizures lasting for more than 5 minutes are likely to be prolonged and may lead to permanent neuronal injury if lasts more than 30 minutes. Therefore, emergently controlling seizures is very crucial. Benzodiazepines (BZD) in lorazepam equivalent (LE) dose of 4 mg (pre-hospital) or 0.1 mg/kg (in-hospital dose) is considered first line medication. We evaluated practice patterns of BZD dosing at presentation in SE, and the effect of dose on outcome. Methods: This is a retrospective analysis of prospectively collected data of 100 patients presenting with SE admitted to Neurointensive unit over 2 years. We collected demographics and initial presentation of SE,categorized as generalized convulsive SE (GCSE), complex partial SE (CPSE), nonconvulsive SE (NCSE) or myoclonic SE. The progression of SE to refractory SE (RSE-defined as ongoing seizures after treatment with BZD and one antiepileptic medication) and NCSE was evaluated. The LE dosage of BZD was calculated, and we analyzed variations in progression of SE if more than 4 mg of LE (adequate BZD) was administered. Continuous data was analyzed with Mann U-Whitney and categorical data with chi-square. Results: Among 100 patients, median age was 58 (IQR 45-65), 53% men and 84% African American. The median weight was 72 kg (IQR 65-88). Most patients (70%) had prior history of epilepsy and only 54.7% of these patients were compliant with their medications. Patients presenting with SE were given either IV/IM midazolam, IV lorazepam or IM diazepam in pre or in hospital settings. The median dose LE dose was 3mg (IQR 2-5). BZD were not administered as first line treatment in 7 patients. Only 31% of patients received adequate BZD dose. Age, gender and race did not play a role in dosing BZD. Only 18.9% of patients with CPSE received adequate BZD vs 39% of patients who had other presentations (p=0.04). Among patients who progressed to RSE, 75.4% did not receive adequate BZD dose. Cumulative incidence of NCSE inversely correlated with BZD dosage (r=-0.2, p=0.03), with a cumulative risk of developing NCSE of 19.4% for those who received adequate BZD, vs. 37.3% for those who did not. Conclusions: Fewer patients presenting with CPSE received adequate BZD suggesting a delay in diagnosis or a less aggressive treatment approach. Higher doses of BZD prevented occurrence of NCSE and there was a trend towards development of NCSE in patients who were not adequately dosed. The median dose of BZD given in our population was suboptimal and this may have been due to the fear of compromising the airway. Our data suggest that inadequate BZD dose results in RSE which in turn may compromise the airway as suggested by the RAMPART study. Based on the in-hospital dosing guidelines of 0.1 mg/kg of lorazepam, our adequate BZD dose should have been atleast 7 mg. Even with our conservative approach of more than ?-4 mg LE, our findings indicate that BZD dosing remains to be a problem in the first-responders approach to treatment of status epilepticus. Funding: None