A retrospective observational study of current treatment for generalized convulsive status epilepticus

This study aimed at determining the current state of practice of treatment for acute generalized convulsive status epilepticus (GCSE) and responsiveness to therapy.

This observational study was performed by retrospectively identifying patients with GCSE presenting to an emergency room setting. The primary outcome was seizure cessation following medication administration. Secondary outcomes were rates of intubation and mortality.

One hundred seventy-seven episodes of GCSE were identified. All patients, except 1, received a benzodiazepine for first-line treatment. Only 11% of these patients, all children, were treated with at least 0.1mg/kg of lorazepam or an equivalent dose of an alternative benzodiazepine. A first-line treatment was effective in 56% of the patients, a second-line treatment in an additional 28%, and a third-line treatment in 12%. Phenytoin was the most prescribed second-line treatment (41%) but statistically significantly least effective (22% versus 86% seizure cessation, p<0.0001) compared with all other second-line agents together. Propofol was the most prescribed third-line treatment.

Results emphasize that, in clinical practice, approximately half of GCSE patients respond to first-line therapy and, among nonresponders, approximately two-thirds respond to second-line and approximately three-quarters respond to third-line therapies. The variations in treatment selection reflect that there are no randomized controlled trials to guide treatment beyond use of benzodiazepines for first-line treatment. The observation that phenytoin is statistically substantially worse than other second-line treatments raises the possibility that the most commonly selected second-line treatment is the least effective and provides equipoise for a large randomized controlled trial of second-line therapies.