Prehospital management of pediatric status epilepticus in the United States: areas for improvement and intervention

[eng] Introduction: Status epilepticus (SE) represents a common time-sensitive life-threatening emergency characterized either by a prolonged seizure or recurrent seizures without recovery of consciousness between them. Patient age, SE etiology, and SE duration may affect clinical outcomes, but SE duration is the most modifiable factor in the short term by providing timely treatment. This thesis has focused on potential areas for improvement and intervention in the prehospital management of pediatric status epilepticus in the United States of America (US), and is presented in the form of compendium of publications. Content: The objectives were: 1) to estimate the hospital readmission rate for SE and to study potentially related risk factors using the largest all-payer provider database in the US; 2) to describe the prehospital management pathway and Emergency Medical Services (EMS) timeliness in children who developed refractory convulsive SE (RCSE) with multicenter observational data prospectively collected across the US; 3) to describe the escalation from benzodiazepines (BZDs) to non-BZD anti-seizure medications (ASMs) in children who developed RCSE and to analyze potential risk factors related to deviations from treatment guideline recommendations with multicenter observational data prospectively collected across the US; and 4) to explore EMS protocols as one of the potential barriers to provide optimized pediatric prehospital treatment in the US. Conclusion: In summary, results and conclusions are as follows: 1) Hospital readmissions for SE are frequent in the US, which may highlight a need for intervention. Resources focused on patients with risk factors, such as refractory epilepsy and pediatric age, and mainly within the first 3 months after a hospital admission may help decrease readmissions for SE; 2) In this multicenter study on pediatric RCSE in the US, no patient received two different medication types in the prehospital setting. Prehospital management of SE through EMS in the US faces systematic barriers that may impede the optimal implementation of current recommended SE guidelines. Based on observational data, we suggest steps for systematic improvements and implementation to enhance SE treatment; 3) In this multicenter study on pediatric RCSE in North America, about one-third of patients received more than two BZD doses before transitioning to non-BZD ASMs, and more than half received BZD doses after 30 minutes from seizure onset (beyond the most efficacious timeframe). Out-of-hospital seizure onset and intermittent SE were associated with the failure to escalate from BZDs to non-BZD ASMs. Specifically, patient handoffs between prehospital and in-hospital settings may hinder the escalation of ASM due to restarts of treatment algorithms and may offer an opportunity for future intervention and care improvement; and 4) First responders involved in seizure management in the out-of-hospital setting are hindered by limitations imposed by EMS protocols in the US. The development of a nationwide effort including different professionals may help improve prehospital clinical care through further exploration of other potential obstacles and creating standardized SE outpatient guidelines anticipating challenges in the field.