Chronological Sequence of Convulsive Status Epilepticus Treatment Steps in a Real-Life Scenario for Patients Enrolled...

Status epilepticus (SE) is a medical emergency requiring rapid intervention. Despite treatment guidelines, delays in real-world SE management persist, potentially worsening outcomes. The Established Status Epilepticus Treatment Trial (ESETT), while comparing second-line antiseizure medications, also enabled analysis of treatment timelines in emergency settings.

This study evaluates the timing of SE treatment steps in ESETT to assess adherence to guideline-recommended timeframes and identify factors contributing to delays.

This secondary analysis of ESETT included patients aged ≥ 2 years with generalized convulsive SE unresponsive to benzodiazepines, randomized to receive fosphenytoin, levetiracetam, or valproic acid. Key intervals analyzed included time from emergency department (ED) arrival to first benzodiazepine, initiation of second-line therapy, and other interventions (e.g., intubation, rescue meds). We used descriptive statistics and the Van Elteren test to compare timelines between those who achieved treatment success, defined as seizure cessation and improved mental status at 60 min, and those who did not.

Among 487 patients (53% adults, 47% children; 57% male), 46% achieved treatment success. Nearly half did not receive any prehospital benzodiazepines. Median time from ED arrival to first benzodiazepine was 11 min (IQR 5-41), and to second-line antiseizure medications was 26 min (IQR 18-43), both generally aligning with guidelines. Earlier administration of second-line therapy was significantly associated with treatment success (p = 0.03).

Although many treatment steps occurred within recommended windows, considerable variability exists. Prehospital benzodiazepine use was often absent, and in-hospital treatment timing was inconsistent. Earlier delivery of second-line therapy correlated with improved outcomes. These real-world data provide a lens through which to better understand the causes and impact of practice variability in time to treatment and assess the extent to which current guidelines on timing may be important, but also how they may be ambiguous or unrealistic.