SCCM Resource Library-08-Prehospital and Emergency Department Management of Pediatric Status Epilepticus

Video Transcription

Thank you for inviting me to the 50th Critical Care Congress. My name is Nicholas Regas. I'm a third year pediatric resident at UNLV School of Medicine.  My presentation is titled Pre-Hospital and Emergency Department Management of Pediatric Status Epilepticus.  We have no actual or potential conflicts of interest in relation to this presentation.  Status epilepticus is the most common medical neurologic emergency in childhood and is associated with a significant risk of neurologic morbidity and mortality.  Multiple studies indicate that there is untimely administration of benzodiazepines in the treatment of status epilepticus.  This study aims to describe the adequacy of first-line anti-epileptic drugs in the treatment of status epilepticus in a pre-hospital and emergency department setting.  We hypothesized that greater than 15% of status epilepticus patients received inadequate weight-based dosing of first-line benzodiazepines at our tertiary medical center.  This is a single-center retrospective study including pediatric patients who presented to the ED between January 1st, 2018 and May 1st, 2020.  Patients under the age of 18 years who presented in status were included, and patients missing dosing information were excluded from the study.  Definitions in dosing were based on the recommendations put forth by the Neurocritical Care Society guidelines for evaluation and management of status epilepticus.  Sample dosing percentages were compared to the hypothesized cutoff using Z-tests, and Chi-squared T-tests were used to determine the association between inadequate weight-based  dosing and clinical outcome variables. A total of 111 patients were included in the study. The majority, 56.8%, were male, and the median age was two years.  Thirty-eight patients were given a total of 47 doses of benzodiazepines by emergency medical services, with 87% of first doses and 50% of second doses below the NCS-recommended  dose. In the EMS setting, first- and second-dose proportions were greater than the 15% hypothesized  cutoff, both statistically significant, with Z-scores of 11.2 and 2.8, respectively. Fifty patients received a total of 65 doses of benzodiazepines in the emergency department  setting, with 54% of first doses and 79% of second doses below the Neurocritical Care Society-recommended dose.  The emergency department first- and second-dose proportions were also greater than the 15%  hypothesized cutoff, both statistically significant, with Z-scores of 7.7 and 6.7, respectively.  IV lorazepam was the most frequently administered benzodiazepine in the emergency department, with a median dose of 0.08 mg per kg, with the Neurocritical Care Society-recommended  dose being 0.1 mg per kg. Intramuscular midazolam was the most frequently administered benzodiazepine by EMS, with a  median dose of 0.1 mg per kg, and the Neurocritical Care Society guidelines recommending intramuscular midazolam be dosed at 0.2 mg per kg.  There was no significant relationship between inappropriate benzodiazepine dosing by EMS  or the emergency department and need for mechanical intubation, admission to the hospital or pediatric intensive care unit, or duration of status epilepticus.  This was likely due to our small sample size in each of these categories and the fact that most patients received inappropriate weight-based dosing.  A significant percentage of pediatric status epilepticus patients received inadequate first- and second-doses of benzodiazepines in the pre-hospital and ED settings.  This is concerning given the established relationship between inadequate and or delayed treatment and increased mortality.  A driving factor may be inadequate benzodiazepine dosing due to fear of airway compromise, although this is not validated in larger studies.  Our study results indicate the critical importance of establishing and adhering to treatment protocols for the management of pediatric status epilepticus.  I would like to give special recognition to my research director, Dr. Yacoub, and research team, Evans Clouther, Daniel Jones, Crystal Oden, and Gail Allenbeck.  We appreciate the opportunity to present our research at the Critical Care Conference. Thank you.

Video Summary

In this presentation, Nicholas Regas discusses the management of pediatric status epilepticus in the pre-hospital and emergency department setting. The study aims to assess the adequacy of first-line anti-epileptic drugs in treating status epilepticus. The results show that a significant number of patients received inadequate doses of benzodiazepines both in the emergency medical services (EMS) and emergency department. This is concerning because inadequate or delayed treatment is associated with increased mortality. The study highlights the need for treatment protocols and emphasizes the importance of proper dosing in managing pediatric status epilepticus.

Asset Subtitle

Pediatrics, Neuroscience, 2021

Asset Caption

The Society of Critical Care Medicine's Critical Care Congress features internationally renowned faculty and content sessions highlighting the most up-to-date, evidence-based developments in critical care medicine. This is a presentation from the 2021 Critical Care Congress held virtually from January 31-February 12, 2021.

Nicholas J. Regas

Introduction/Hypothesis: Status epilepticus (SE) is the most common medical neurological emergency in childhood and is associated with a significant risk of neurologic morbidity and mortality. The study aims to describe pre-hospital and emergency department (ED) management of pediatric SE. We hypothesized that greater than 15% of patients received inadequate dosing of first-line anti-seizure medication (benzodiazepines).

Methods: This single-center, retrospective study included 43 pediatric patients who presented between January 1, 2018 and May 1, 2020 to the ED of a tertiary medical center. Patients, ranging in age from 1 month to 18 years, with SE were included. We used the definition and dosing recommendations put forth by the Neurocritical Care Society 'Guidelines for Evaluation and Management of Status Epilepticus'. Sample percentages were compared to the hypothesized cutoff using z-tests for the one proportion.

Results: A total of 43 patients were included, among whom 22 (51%) were male. The median age was 1 (1 - 2) year. Eleven patients received a total of 13 doses of benzodiazepines by EMS, all of which (100%) were below the recommended dose. This was significantly greater than the 15% hypothesized cutoff (z = 7.90, p <.001, 95% CI = 71.5% - 100.0%). Thirteen patients received a total of 18 doses of benzodiazepines in the ED, of which 61% were inadequate. This was also significantly greater than the 15% cutoff (z = 5.48, p <.001, 95% CI = 35.7% - 82.7%). Intramuscular midazolam was the most frequently administered benzodiazepine (58%), with a median dose of 0.1 (0.09 - 0.12) mg/kg. We did not identify a relationship between inadequate benzodiazepine dose and hospital/ICU admission or the need for mechanical intubation likely due to our small sample size.

Conclusions: A significant percentage of pediatric SE patients received inadequate benzodiazepine dosing in the pre-hospital and ED setting (100% and 61%, respectively). This is concerning given the established relationship between inadequate and/or delayed treatment and increased mortality. The study results indicate the critical importance of establishing and adhering to treatment protocols for the management of pediatric SE. Further study is required to determine the short and long term outcomes associated with inadequate treatment of pediatric SE.

Meta Tag

Content Type Presentation

Knowledge Area Pediatrics

Knowledge Area Neuroscience

Knowledge Level Intermediate

Knowledge Level Advanced

Learning Pathway Emergency Medicine and EMS Care

Membership Level Select

Tag Seizure

Year 2021

Keywords

Nicholas Regas

pediatric status epilepticus

pre-hospital

emergency department

anti-epileptic drugs

Emergency Medicine and EMS Care

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