Emergency management of status epilepticus in a high-fidelity simulation

Abstract

Objectives To quantify the quality of physicians' emergency first response to status epilepticus (SE) and to identify risk factors for nonadherence to treatment guidelines in a standardized simulated scenario. Methods In this prospective trial, 58 physicians (of different background) of the University Hospital Basel, a Swiss academic medical care center, were confronted with a simulated SE. Primary outcomes were time to (1) airway protection, (2) supplementary oxygen, and (3) administration of antiseizure drugs (ASDs). Results All physicians recognized ongoing seizures. Airways were checked by 54% and protected by 16% within a median of 3.9 minutes. Supplementary oxygen was administered by 76% with a median of 2.8 minutes. First-line ASDs were administered by 98% (benzodiazepines 97% within a median of 2.9 minutes), and second-line ASDs by 57% within 8.1 minutes. Regarding secondary outcomes, the median time to monitor blood pressure and heart rate was 1.8 (interquartile range [IQR] 1.3–2.6) and 2.0 (IQR 1.4–2.7) minutes, respectively. Neurologic affiliation of physicians was associated with inadequate assessments of vital signs (odds ratio [OR] = 0.2; 95% CI 0.04–0.93) and most frequent administration of second-line ASDs (OR = 5.0; 95% CI 1.01–25.3). Knowing treatment guidelines and subjective certainty regarding SE diagnosis were associated with frequent administration of second-line ASDs (OR = 10.4; 95% CI 1.2–88.1). Conclusions Nonadherence to SE treatment guidelines is frequent. The lack of airway assessment and protection in the simulated clinical scenario of SE may increase mortality and promote treatment refractoriness related to aspiration pneumonia. Guideline-based clinical training is urgently needed to increase the quality of SE management. Registration ISRCTN registry (ID ISRCTN60369617; www.isrctn.com/ISRCTN60369617).