Abstracts

Rationale: Guideline-based treatment for out-of-hospital status epilepticus involves rapid benzodiazepine administration by emergency medical services (EMS) providers. However, preliminary studies demonstrate benzodiazepines are underused and underdosed in this setting. Methods: We used data from a single EMS agency from 2013 to 2018 to examine rates of benzodiazepine use among adult patients with status epilepticus and the association between benzodiazepine dose and the need for rescue therapy and respiratory support. Midazolam was the only benzodiazepine available to providers. Our primary exposure was receiving a midazolam dose > 5mg versus < 5mg. We examined the association between patient (demographic, medical history, and exam data) and provider characteristics (seizure cases per provider) and our primary exposure. We then built unadjusted logistic regression and multilevel mixed effects models adjusting for variables associated with our primary exposure at a p-value < 0.1 and incorporating EMS provider as a random effect. Results: There were 1,726 patients identified with status epilepticus (EMS diagnostic impression of 'active seizures,' defined as > 3 seizures in <= 5 minutes or any seizure lasting > 5 minutes by agency protocol). Patients had a mean age of 52.9 years and 793 (45.9%) were female. Among these patients, 1,052 (61%) received midazolam at any dose, 617 (36%) received 5mg or higher, and none received a guideline-concordant dose of 10mg. Patients who received midazolam > 5mg had significantly more epilepsy (OR 1.7, 95% CI 1.3-2.1), less comorbid alcohol or drug use (OR 0.7, 95% CI 0.5-0.9), higher pulse (OR 1.0, 95% CI 1.0-1.0), higher blood pressure (OR 1.0, 95% CI 1.0-1.0, and lower GCS score (GCS 8-12 OR 0.6, 95% CI 0.5-0.8; GCS 13-15 OR 0.4, 95% CI 0.3-0.5). Providers with higher seizure case number were more likely to give any midazolam but less likely to give > 5mg, however, this did not meet statistical significance in the multivariable model (Table 1). Among those who received any midazolam, 172 patients (16.3%) required rescue therapy and 445 patients (41%) required respiratory support. Those who received midazolam > 5mg had lower odds of requiring rescue therapy in an unadjusted (OR 0.7, 95% CI 0.5-0.9) and adjusted multilevel analysis (OR 0.6, 95% CI 0.4-0.9). There was no association between high midazolam dose and the need for respiratory support (OR 1.0, 95% CI 0.8-1.3) (Table 2). Conclusions: Among adult patients evaluated for status epilepticus in the prehospital setting, all received either no benzodiazepine or a dose lower than recommended. Lower doses were associated with increased need for rescue therapy and higher dosing was not associated with respiratory complications. This finding identifies a gap in status epilepticus care that carries important clinical implications if EMS agencies nationally parallel this single site experience. Funding: No funding