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 (BZD), particularly lorazepam 0.1 mg/kg. There are no large prospective trials to guide subsequent decisions regarding second or third line treatment and it is unclear how patients are treated in a contemporary setting. Thus, we performed a retrospective study to determine what medications are being chosen for SE and quantify treatment responsiveness for first, second, and third line treatment.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 for acute generalized convulsive SE presenting to an Emergency Department. SE was defined as seizing on EMS/ED arrival or greater than 2 seizures without return to baseline. First line treatment was defined as BZD administration; second line as the treatment received immediately after a BZD; and third line as the drug given after second line. Treatment response was defined as cessation of SE after treatment as assessed by clinical evaluation and electrographic data, if available. Results: There were a total of 177 episodes of SE among 160 patients. All but one episode of SE was treated with BZD either in the hospital or pre-hospital setting. BZD dosing varied by type of BZD received and route of dosing, although the majority of patients received intravenous diazepam (59%) for prehospital treatment or intravenous lorazepam (75%) in the emergency room. Only 17 patients received a single 0.1mg/kg equivalent dose of BZD in the emergency room and all of these patients were children. 58% received multiple small doses of BZD. 63% of benzodiazepine refractory episodes of SE responded to second line treatment with 40% receiving phenytoin/fosphenytoin, 22% phenobarbital, 16% propofol, 13% levetiracetam, 7% midazolam and 1% valproic acid. Of those episodes requiring third line treatment, 67% responded with 26% receiving propofol, 18% levetiracetam, 16% phenobarbital, 16% midazolam, 12% phenytoin, 8% valproic acid and 4% lorazepam. Only 9 patients did not respond to third line treatment. Conclusions: In a relatively large consecutive series of SE episodes, 55% responded to first line, 28% to second line, and 11% to third line treatment, leaving only 5% refractory to all treatments. Recommendations for lorazepam dosing were rarely followed, suggesting standard practice by ER physicians is to use smaller doses. These data suggests a typical academic ER is likely to have 10-15 SE patients per year that are eligible for participation in a randomized trial of second line therapy. Phenytoin/fosphenytoin and propofol were most frequently used second and third line treatments, respectively. Valproate was very rarely used.