EMS protocols may be delaying treatment for febrile status epilepticus

A study of infants and children with febrile status epilepticus found that convulsing children received antiepileptic drugs a full half-hour into their seizures, a lag to treatment that researchers described as "unacceptable."

Dr. Syndi A. Seinfeld of the department of neurology at Virginia Commonwealth University in Richmond and her colleagues identified a lack of standardized protocol among emergency medical services – not a failure to recognize seizure activity – as the main obstacle to prompt treatment in a review of data from the FEBSTAT (Consequences of Prolonged Febrile Seizures in Childhood) study. Delays to treatment with antiepileptic drugs (AEDs) in the 8-year, multicenter, prospective cohort study correlated with longer seizure duration. The study involved 199 children aged 1 month to 6 years with febrile status epilepticus (FSE) seen at five urban medical centers in the United States during 2003-2010 (Epilepsia 2014 Feb. 6 [doi:10.1111/epi.12526]).

FSE seldom resolves spontaneously, and for the majority of these children, multiple AEDs were needed to stop the seizures.

Emergency medical services (EMS) personnel, involved in more than three-quarters of the cases, recognized all but 12% as involving seizure activity. However, because not all EMS teams are authorized to administer antiepileptic drugs such as diazepam and lorazepam, more than half of subjects were not treated with these until arriving in the emergency department. Median time from seizure onset to first AED was 30 minutes for all subjects.

Of the 179 children who received AEDs, the first drug was given by the family in 1% of cases and by EMS in 41%. The remaining 58% of children were treated only when they reached the emergency department.

The mean seizure duration was 81 minutes among children given medication before arriving in the ED and 95 minutes for those who received their first drug after arrival, which was not a statistically significant difference (P = 0.1). The median time from the first dose of AED to the end of seizure was 38 minutes for all subjects.

Dr. Seinfeld and her colleagues also found that about 20% of the children who were treated with AEDs in any setting received a suboptimal first dose, which may have been because of "fear of respiratory concerns," Dr. Seinfeld said in response to e-mailed questions. Of those treated with AEDs, 78% required treatment with more than one AED; about half received respiratory support from EMS or in the hospital. The study showed that respiratory support was more likely to be needed in kids who had been seizing longer, which is notable because fear of causing respiratory problems "plays a big role" in why treatment is delayed, she said.

"The medicine may require the child to need respiratory support. ... and there have been studies that show that people who get multiple doses of AEDs vs. adequate initial doses are more likely to require respiratory support."

The researchers noted that prolonged seizures of any type are associated with an increased risk of complications. Longer seizure duration has been shown to increase potential risk of short-term morbidity, including intubation related injuries, and long-term morbidity, including consequences of hippocampal injury.

In FSE, the researchers argued in their analysis, "prompt and aggressive treatment" with adequate doses of medication is key. "When initial treatment is significantly delayed, the entire treatment paradigm shifts, which prolongs total seizure duration."

"I think people are aware they need to treat seizures sooner. Recognition of seizures as we reported is not the main problem, though it plays a role. And there are some squads that do try and treat seizures more aggressively. There are squads trying to change their protocols. It’s difficult because there are so many types of EMS – volunteer squads; paid [personnel]; and in remote areas, the fire department and police may be first responders. It’s difficult to coordinate care when you have that many people involved," Dr. Seinfeld said.

She and her colleagues noted as a limitation of their study the fact that recruitment took place after the FSE episode was over. They also noted that the FEBSTAT study used data collected only through 2010. However, EMS protocols have not been standardized in the interim.

"EMS still cannot administer AEDs in many jurisdictions," they wrote. And despite mounting evidence that management of FSE should begin prior to hospital arrival, "most published guidelines are limited to hospital settings."

The FEBSTAT study was funded by the National Institutes of Health. Dr. Seinfeld and her coauthors declared that they had no conflicts of interest.

A study of infants and children with febrile status epilepticus found that convulsing children received antiepileptic drugs a full half-hour into their seizures, a lag to treatment that researchers described as "unacceptable."

Dr. Syndi A. Seinfeld of the department of neurology at Virginia Commonwealth University in Richmond and her colleagues identified a lack of standardized protocol among emergency medical services – not a failure to recognize seizure activity – as the main obstacle to prompt treatment in a review of data from the FEBSTAT (Consequences of Prolonged Febrile Seizures in Childhood) study. Delays to treatment with antiepileptic drugs (AEDs) in the 8-year, multicenter, prospective cohort study correlated with longer seizure duration. The study involved 199 children aged 1 month to 6 years with febrile status epilepticus (FSE) seen at five urban medical centers in the United States during 2003-2010 (Epilepsia 2014 Feb. 6 [doi:10.1111/epi.12526]).

FSE seldom resolves spontaneously, and for the majority of these children, multiple AEDs were needed to stop the seizures.

Emergency medical services (EMS) personnel, involved in more than three-quarters of the cases, recognized all but 12% as involving seizure activity. However, because not all EMS teams are authorized to administer antiepileptic drugs such as diazepam and lorazepam, more than half of subjects were not treated with these until arriving in the emergency department. Median time from seizure onset to first AED was 30 minutes for all subjects.

Of the 179 children who received AEDs, the first drug was given by the family in 1% of cases and by EMS in 41%. The remaining 58% of children were treated only when they reached the emergency department.

The mean seizure duration was 81 minutes among children given medication before arriving in the ED and 95 minutes for those who received their first drug after arrival, which was not a statistically significant difference (P = 0.1). The median time from the first dose of AED to the end of seizure was 38 minutes for all subjects.

Dr. Seinfeld and her colleagues also found that about 20% of the children who were treated with AEDs in any setting received a suboptimal first dose, which may have been because of "fear of respiratory concerns," Dr. Seinfeld said in response to e-mailed questions. Of those treated with AEDs, 78% required treatment with more than one AED; about half received respiratory support from EMS or in the hospital. The study showed that respiratory support was more likely to be needed in kids who had been seizing longer, which is notable because fear of causing respiratory problems "plays a big role" in why treatment is delayed, she said.

"The medicine may require the child to need respiratory support. ... and there have been studies that show that people who get multiple doses of AEDs vs. adequate initial doses are more likely to require respiratory support."

The researchers noted that prolonged seizures of any type are associated with an increased risk of complications. Longer seizure duration has been shown to increase potential risk of short-term morbidity, including intubation related injuries, and long-term morbidity, including consequences of hippocampal injury.

In FSE, the researchers argued in their analysis, "prompt and aggressive treatment" with adequate doses of medication is key. "When initial treatment is significantly delayed, the entire treatment paradigm shifts, which prolongs total seizure duration."

"I think people are aware they need to treat seizures sooner. Recognition of seizures as we reported is not the main problem, though it plays a role. And there are some squads that do try and treat seizures more aggressively. There are squads trying to change their protocols. It’s difficult because there are so many types of EMS – volunteer squads; paid [personnel]; and in remote areas, the fire department and police may be first responders. It’s difficult to coordinate care when you have that many people involved," Dr. Seinfeld said.

She and her colleagues noted as a limitation of their study the fact that recruitment took place after the FSE episode was over. They also noted that the FEBSTAT study used data collected only through 2010. However, EMS protocols have not been standardized in the interim.

"EMS still cannot administer AEDs in many jurisdictions," they wrote. And despite mounting evidence that management of FSE should begin prior to hospital arrival, "most published guidelines are limited to hospital settings."

The FEBSTAT study was funded by the National Institutes of Health. Dr. Seinfeld and her coauthors declared that they had no conflicts of interest.

A study of infants and children with febrile status epilepticus found that convulsing children received antiepileptic drugs a full half-hour into their seizures, a lag to treatment that researchers described as "unacceptable."

Dr. Syndi A. Seinfeld of the department of neurology at Virginia Commonwealth University in Richmond and her colleagues identified a lack of standardized protocol among emergency medical services – not a failure to recognize seizure activity – as the main obstacle to prompt treatment in a review of data from the FEBSTAT (Consequences of Prolonged Febrile Seizures in Childhood) study. Delays to treatment with antiepileptic drugs (AEDs) in the 8-year, multicenter, prospective cohort study correlated with longer seizure duration. The study involved 199 children aged 1 month to 6 years with febrile status epilepticus (FSE) seen at five urban medical centers in the United States during 2003-2010 (Epilepsia 2014 Feb. 6 [doi:10.1111/epi.12526]).

FSE seldom resolves spontaneously, and for the majority of these children, multiple AEDs were needed to stop the seizures.

Emergency medical services (EMS) personnel, involved in more than three-quarters of the cases, recognized all but 12% as involving seizure activity. However, because not all EMS teams are authorized to administer antiepileptic drugs such as diazepam and lorazepam, more than half of subjects were not treated with these until arriving in the emergency department. Median time from seizure onset to first AED was 30 minutes for all subjects.

Of the 179 children who received AEDs, the first drug was given by the family in 1% of cases and by EMS in 41%. The remaining 58% of children were treated only when they reached the emergency department.

The mean seizure duration was 81 minutes among children given medication before arriving in the ED and 95 minutes for those who received their first drug after arrival, which was not a statistically significant difference (P = 0.1). The median time from the first dose of AED to the end of seizure was 38 minutes for all subjects.

Dr. Seinfeld and her colleagues also found that about 20% of the children who were treated with AEDs in any setting received a suboptimal first dose, which may have been because of "fear of respiratory concerns," Dr. Seinfeld said in response to e-mailed questions. Of those treated with AEDs, 78% required treatment with more than one AED; about half received respiratory support from EMS or in the hospital. The study showed that respiratory support was more likely to be needed in kids who had been seizing longer, which is notable because fear of causing respiratory problems "plays a big role" in why treatment is delayed, she said.

"The medicine may require the child to need respiratory support. ... and there have been studies that show that people who get multiple doses of AEDs vs. adequate initial doses are more likely to require respiratory support."

The researchers noted that prolonged seizures of any type are associated with an increased risk of complications. Longer seizure duration has been shown to increase potential risk of short-term morbidity, including intubation related injuries, and long-term morbidity, including consequences of hippocampal injury.

In FSE, the researchers argued in their analysis, "prompt and aggressive treatment" with adequate doses of medication is key. "When initial treatment is significantly delayed, the entire treatment paradigm shifts, which prolongs total seizure duration."

"I think people are aware they need to treat seizures sooner. Recognition of seizures as we reported is not the main problem, though it plays a role. And there are some squads that do try and treat seizures more aggressively. There are squads trying to change their protocols. It’s difficult because there are so many types of EMS – volunteer squads; paid [personnel]; and in remote areas, the fire department and police may be first responders. It’s difficult to coordinate care when you have that many people involved," Dr. Seinfeld said.

She and her colleagues noted as a limitation of their study the fact that recruitment took place after the FSE episode was over. They also noted that the FEBSTAT study used data collected only through 2010. However, EMS protocols have not been standardized in the interim.

"EMS still cannot administer AEDs in many jurisdictions," they wrote. And despite mounting evidence that management of FSE should begin prior to hospital arrival, "most published guidelines are limited to hospital settings."

The FEBSTAT study was funded by the National Institutes of Health. Dr. Seinfeld and her coauthors declared that they had no conflicts of interest.