Prehospital treatment of people with status epilepticus rarely was consistent with expert guidelines, an analysis of emergency medical service (EMS) agency records showed.
Initial treatment was concordant with guidelines in only 3.9% of 9,176 EMS encounters for status epilepticus, reported Elan Guterman, MD, of the University of California San Francisco, and co-authors in a JAMA research letter.
Status epilepticus, a medical emergency characterized by either continued seizures or lack of full recovery between seizures, can lead to brain damage, long-term disability, or death. The American Epilepsy Society guidelines recommend that paramedics use midazolam (10 mg intramuscularly), lorazepam (4 mg intravenously), or diazepam (6-10 mg intravenously) as first-line treatment.
“Status epilepticus is a common neurologic emergency. We rely on our EMS system to provide first-line treatment, but have not tracked whether patients are being appropriately treated in the prehospital system,” Guterman told MedPage Today.
“To our knowledge, this is the first study examining EMS treatment on a national level,” she said. “Are patients treated appropriately? The answer is no. Most patients do not receive appropriate treatment and there is a lot of variation in care between EMS agencies.”
“This has huge implications for patients with status epilepticus as it likely results in more seizures and more disability,” she continued. “If we hope to improve care for patients with epilepsy, we need to start thinking about how to improve our EMS system.”
Smaller studies have suggested that patients with status epilepticus frequently are undertreated. The analysis by Guterman and colleagues used data from ESO, an electronic health record used by about 5% of EMS agencies in the country, to identify adult patients with a paramedic impression of status epilepticus who were treated with midazolam, lorazepam, or diazepam from January 2019 to January 2020. Agencies using ESO spanned all nine U.S. Census divisions in urban and rural settings.
The researchers assessed the dose and route of the first benzodiazepine administered. Of 9,176 prehospital encounters for status epilepticus across 743 EMS agencies, 83.6% were treated with midazolam, 13.8% with lorazepam, and 2.7% with diazepam.
Each EMS agency had a median of 38 encounters. Patients had a mean age of 46, and nearly half (49.3%) were women. Many patients (29.8%) received a subsequent dose of benzodiazepine.
A total of 357 encounters (3.9%, 95% CI 3.5%-4.3%) followed expert guidelines in recommended dose and route. For midazolam, treatment was guideline concordant in 4.0% of encounters. For lorazepam, it was concordant in 1.4% of encounters, and for diazepam it was concordant in 11.8%.
The mean dose of midazolam was 4 mg across all EMS agencies. Between-agency variability accounted for 47% of variance in dosing.
“For midazolam, the most common treatment, guidelines recommend intramuscular administration, bypassing the need for intravenous access,” the researchers pointed out. “However, only 34.5% were treated intramuscularly, potentially resulting in treatment delays and less effective seizure cessation.”
“The high proportion of variance attributed to the treating agency suggests that benzodiazepine dose is not arbitrarily determined by paramedics responding to particular clinical situations; rather, factors such as agency policy or treatment algorithms, which are rarely guideline concordant, influence treatment decisions,” Guterman and co-authors noted.
“This study suggests that reasons for the variation in care between emergency medical service agencies should be examined to improve the real-world prehospital care of patients with status epilepticus,” the researchers wrote.
Disclosures
The study was funded by the National Institute of Neurological Disorders and Stroke.
Guterman reported grant support from NIH and the American Academy of Neurology, and personal fees from Marinus Pharmaceuticals and Remo Health. She is an editor at JAMA Neurology. A co-author also reported grant support from NIH.