Seizures are one of the main neurological reasons for admission to paediatric emergency departments (ED). The prompt and appropriate management of acute seizures is crucial to improve patients’ outcomes, with prehospital care playing a critical role in this matter.
MethodsWe conducted a retrospective cross-sectional study of patients under 18 years old admitted due to seizures to a metropolitan paediatric ED during the period of 1 year (June 2023–May 2024). Prehospital management and its association with clinical evolution were analyzed.
ResultsA total of 697 emergency episodes of seizures were identified: 47.1% (n=328) epileptic seizures; 41.6% (n=290) febrile seizures; 6.7% (n=47) convulsive status epilepticus (SE); and 4.6% (n=32) febrile SE. Patients were referred to the ED by the emergency medical services (EMS) in 73.5% (n=512) of the episodes. A first dose of an antiseizure medication (ASM) was administered in the prehospital setting in 29.4% (n=205) of the episodes, using a benzodiazepine in 99.5% (n=204). The prehospital ASM administration was more frequent in patients assisted by EMS (p<0.001). Prehospital protocol compliance was verified in 71.7% (n=114) of the episodes. Patients assisted by EMS had a higher likelihood of prehospital seizure control and hospital discharge (p<0.05).
ConclusionsThe contribution of prehospital care was demonstrated by its association with higher prehospital seizure control and lower patient's hospitalization. These findings emphasize the relevance of studying the prehospital approach, allowing to identify improvement opportunities, not only related to EMS procedures, but also to the caregivers’ knowledge about paediatric seizures.
Las crisis epilépticas son una de las principales causas neurológicas de admisión en los servicios de urgencias pediátricas. El manejo adecuado y precoz de las crisis agudas es fundamental para mejorar los resultados clínicos, siendo la atención prehospitalaria un elemento clave en este proceso.
MétodosSe realizó un estudio transversal retrospectivo de pacientes menores de 18 años atendidos por crisis epilépticas en un Servicio de Urgencias Pediátricas de ámbito metropolitano durante un año (junio de 2023 a mayo de 2024). Se analizó la atención prehospitalaria y su asociación con la evolución clínica.
ResultadosSe identificaron 697 episodios de urgencia por crisis: 47,1% (n=328) crisis epilépticas; 41,6% (n=290) crisis febriles; 6,7% (n=47) estado epiléptico convulsivo (EEC); y 4,6% (n=32) EEC febril. En el 73,5% (n=512) de los episodios, los pacientes fueron derivados al Servicio de Urgencias por los servicios médicos de emergencia (SME). En el 29,4% (n=205) de los casos se administró una primera dosis de medicación antiepiléptica (MAE) en el entorno prehospitalario, utilizándose benzodiacepinas en el 99,5% (n=204). La administración de MAE fue más frecuente en los pacientes atendidos por los SME (p <0,001). Se observó cumplimiento del protocolo prehospitalario en el 71,7% (n=114) de los episodios. Los pacientes atendidos por los SME presentaron una mayor probabilidad de control de la crisis antes del ingreso y de alta hospitalaria (p <0,05).
ConclusionesLa atención prehospitalaria mostró una asociación con un mayor control de las crisis antes del ingreso hospitalario y una menor tasa de hospitalización. Estos hallazgos destacan la importancia de analizar el abordaje prehospitalario, permitiendo identificar oportunidades de mejora, tanto en los procedimientos de los SME como en el conocimiento de los cuidadores sobre las crisis epilépticas pediátricas.
Seizures are a frequent cause of admission to paediatric emergency departments (ED) and are among the main neurological reasons for emergency care.1,2 Approximately 5% of children will experience a seizure before the age of 16, with risk being higher in children younger than three years old.3 Additionally, 1 in 150 children is diagnosed with epilepsy within the first 10 years of life.3,4
Prolonged seizures, lasting longer than five minutes, or recurrent seizures without returning to the baseline are classified as status epilepticus (SE), which is considered the most severe form of seizure.5 The overall incidence of SE is 17–23 per 100,000 children per year.6 This condition can lead to neuronal injury, affecting both functional and cognitive development and significantly impacting the quality of life. Its mortality rate may be as high as 20%.7 Although aetiology is a key factor for the long-term prognosis, observational studies have shown that delayed treatment and prolonged seizure time are independently associated with both increased morbidity and mortality.7–9
Prompt and appropriate management of acute seizures is crucial, with prehospital emergency care playing a critical role in early intervention.10–12 Worldwide, several published protocols guide the in-hospital management of these patients. However, its implementation at the prehospital level may be challenging due to resources limitations or due to the limited experience of the emergency professionals approaching paediatric patients with seizures.13–15 Current international research on paediatric acute seizures and SE management mainly focuses on in-hospital care, with reduced awareness for prehospital practices. There is a lack of data on the real-world prehospital approach to paediatric patients with seizures, with or without status epilepticus.16 A better understanding of prehospital seizure management could make it possible to gauge compliance with current recommendations and to identify strategies for improving these procedures.
The aim of this study was to describe the prehospital management of patients with seizures admitted to a tertiary healthcare institution, as well as to analyze factors associated with their clinical evolution.
MethodsStudy designA retrospective cross-sectional observational study, evaluating patients admitted to the paediatric ED of a tertiary hospital over a period of one year (June 1st, 2023, and May 31st, 2024) due to an acute seizure episode. This multicentric ED, designated as Urgência Pediátrica Integrada do Porto (UPIP), admits paediatric patients from the referral areas of 3 hospitals (two tertiary and one secondary) and mainly from the North of Portugal, constituting a metropolitan ED. The study protocol was approved by the Clinical Research Ethics Committee and by the data protection officer of the Unidade Local de Saúde do São João. Data was collected and stored in a pseudo anonymized and coded database.
ParticipantsPatients between 1 month and 18 years old with at least one admission to the paediatric ED coded under the “neurologic” category and the “seizure” subgroup were included. We excluded the episodes in which (1) the final diagnosis was not a seizure, (2) presentation was a non-convulsive status epilepticus, (3) patient left the ED after admission without receiving hospital care and (4) seizures had in-hospital onset.
Since the prevalence of the condition in the target population was unknown, the required sample size was estimated using the formula for proportion estimation with an unknown prevalence:
where ZZ represents the critical value for a 95% confidence level (1.96); EE is the margin of error, set at 5% (0.05).
Applying these parameters, the minimum required sample size was calculated as 384 patients, ensuring a reliable estimation of the studied outcomes within the predefined margin of error. However, during the study period, 697 seizure-related emergency episodes were identified, exceeding the initially estimated sample size.
Data collectionData was extracted from the electronic records of emergency episodes, using JOne® V6 software, the platform used in the ED for clinical records.
For each episode, we obtained data regarding patient demographics (age, sex), clinical data (previous diagnosis of epilepsy, current antiseizure medication (ASM), neurological comorbidities), prehospital and in-hospital interventions (activated emergency services, therapeutic approach, airway management, intravenous (IV) access establishment and IV fluids administration) and seizure characteristics (type of seizure and classification in accordance with ILAE criteria). To evaluate the in-hospital evolution the researchers collected data about the in-hospital approach to the seizure, therapeutic response, and patient referral (discharge, hospitalization, or admission to an Intensive Care Unit (ICU)).
Febrile seizure was defined as a seizure occurring in a child aged between 6 months and 5 years old during a febrile episode not caused by an acute central nervous system (CNS) disease, presupposing the absence of neurologic deficits (i.e., with no pre-, peri-, or postnatal brain damage, with normal psychomotor development, and with no previous afebrile seizures).17 Convulsive SE was defined as prolonged seizure, lasting longer than 5min for tonic–clonic SE or longer than 10min for focal SE, or a series of seizures without full recovery of consciousness between them.5 Febrile SE was defined as prolonged febrile seizure, lasting longer than 30min, or a series of seizures without full recovery of consciousness between them.17 Epileptic seizures were classified into focal seizures, focal to bilateral seizures or generalized seizures.18
The protocol established by the Portuguese Society of Neuropediatrics was regarded as the standard reference.14 To evaluate prehospital protocol compliance and assess dose appropriateness, weight-for-age was estimated using the Best Guess Method for the episodes where weight was unavailable.19
OutcomesThe key outcomes of this study were the prehospital ASM administration to seizure management, focusing on the compliance with the established protocol. Secondary outcomes included the seizure control (the need for additional ASMs at the in-hospital setting) and the patient referral after the episode (home discharge, paediatric ward admission or ICU admission).
Statistical analysisStatistical analysis was performed using the IBM SPSS Statistics software, version 29.0.0.0 (IBM Corp., Armonk, New York, USA).
For the descriptive analysis, continuous variables with a normal distribution were reported as mean and standard deviation and continuous variables with a non-normal distribution were presented as median and range. Normality was assessed using the Kolmogorov–Smirnov test. Categorical variables were reported as absolute values (n) and relative frequencies (%).
For comparative analysis, the association between categorical variables was assessed using the chi-square test. The association between continuous variables was analyzed using parametric tests (for normally distributed variables) and non-parametric tests (for non-normally distributed variables). Multivariate analysis was performed using a multinominal logistic regression. A p value<0.05 was considered statistically significant.
ResultsSample characteristicsOver a period of 366 days, 697 emergency episodes due to seizures were identified. These episodes corresponded to 480 different patients. The number of episodes per patient ranged from one to fourteen, with 374 patients (77.9%) having only one admission and 3 patients having more than 5 admissions. Among the 480 patients, 54.8% (n=263) were boys, and the median age was 3.8 years (range: 1 month to 17 years and 11 months). Regarding patients presenting with epileptic seizures or convulsive SE, a previous diagnosis of epilepsy was identified in 50.2% (n=120) of patients. Before the event, 46.9% (n=112) were on at least one ASM, with the most frequently used drugs being levetiracetam (68.7%, n=77) and valproic acid (36.6%, n=41). 7.9% (n=19) were on three or more ASM. 187 neurologic comorbidities were reported in patients with afebrile seizures (Table 1).
Demographic and clinical characteristics of the 480 patients admitted for seizure to the emergency department.
| Patients, n | 480 |
| Male sex, n (%) | 263 (54.8) |
| Age, median (range, years) | 3.8 (0.1–18.0) |
| Epilepsy history, n (%) | 120 (25.0) |
| Patients on ASM, n (%) | 112 (23.3) |
| Number of ASM per medicated patient, median (range) | 1 (1–5) |
| ASM, n (%) | |
| Levetiracetam | 77 (16.0) |
| Valproic acid | 41 (8.5) |
| Clobazam | 21 (4.4) |
| Oxcarbazepine | 8 (1.7) |
| Lamotrigine | 7 (1.5) |
| Topiramate | 7 (1.5) |
| Others | 35 (7.3) |
| Comorbidities, n (%) | |
| Metabolic/genetic disorders | 30 (6.3) |
| Hypoxic–ischaemic encephalopathy | 14 (2.9) |
| CNS tumours | 14 (2.9) |
| CNS vascular diseases | 13 (2.7) |
| CNS malformations | 9 (1.9) |
| CNS infections | 8 (1.7) |
| Others (ASD, ADHD, ID, DD) | 99 (20.6) |
| Emergency episodes per patient, median (range, n) | 1 (1–14) |
ADHD: attention deficit and hyperactivity disorder; ASD: autism spectrum disorder; ASM: antiseizure medication; CNS: central nervous system; DD: developmental delay; ID: intellectual disability.
Among the 697 emergency episodes identified, 47.1% (n=328) were classified as epileptic seizures, 41.6% (n=290) as febrile seizures and 11.3% (n=79) as SE, being 6.7% (n=47) convulsive SE and 4.6% (n=32) febrile SE. The data displayed in Table 2 describes the sample regarding the seizure type classification.
Demographic and clinical characteristics of the 697 emergency episodes according to the seizure classification. Comparative group analysis.
| Febrile seizures | Epileptic seizures | Status epilepticus | p-Value | ||
|---|---|---|---|---|---|
| Febrile | Convulsive (non-febrile) | ||||
| Emergency episodes, n (%) | 290 (41.6) | 328 (47.1) | 32 (4.6) | 47 (6.7) | |
| Male sex, n (%) | 163 (56.2) | 186 (56.7) | 13 (40.6) | 32 (68.1) | 0.118 |
| Age, median (range, years) | 2.2 (0.4–13.0) | 10.2 (0.1–18.0) | 1.9 (0.7–5.9) | 9.3 (1.6–17.1) | <0.001* |
| Previous diagnosis of epilepsy, n (%) | - | 212 (64.6) | - | 29 (61.7) | 0.695 |
| Seizure type, n (%) | |||||
| Focal | 31 (10.7) | 77 (23.5) | 1 (3.1) | 10 (21.3) | <0.001* |
| Focal to bilateral | 12 (4.1) | 34 (10.4) | 1 (3.1) | 5 (10.6) | |
| Generalized | 247 (85.2) | 217 (66.2) | 30 (93.8) | 32 (68.1) | |
| Prehospital referral, n (%) | |||||
| Direct ED admission | 76 (26.2) | 97 (29.6) | 7 (21.9) | 5 (10.6) | <0.001* |
| EMS | 178 (61.4) | 208 (63.4) | 19 (59.4) | 24 (51.1) | |
| EMS with medical assistance | 36 (12.4) | 23 (7.0) | 6 (18.8) | 18 (38.3) | |
| Seizure control, n (%) | |||||
| Prehospital | 274 (94.5) | 288 (87.8) | 19 (59.4) | 33 (70.2) | <0.001* |
| In-hospital | 16 (5.5) | 40 (12.2) | 13 (40.6) | 14 (29.8) | |
In 73.5% (n=512) of the episodes, patients were assisted to the ED by the national emergency medical services (EMS). Within this group, 16.2% (n=83) received prehospital medical assistance with subsequent transportation supervised by the medical emergency vehicles. The remaining 83.8% (n=429) were assisted by nurses, emergency medical technicians or firefighters. In 26.5% (n=185) of the episodes, patients were directly admitted to the ED, without prehospital referral (Fig. 1).
Direct admissions to the ED due to a seizure were more frequent in younger patients (p<0.001). Patients with SE were more often assisted by the EMS (p<0.05). Furthermore, patients assisted by EMS were more likely to cease seizures in the prehospital setting (p<0.05). No other differences were identified, particularly with regard to the history of epilepsy, other neurological comorbidities or the type of seizure (Table 3).
Characterization of the seizure admissions according to the prehospital referral. Comparative group analysis.
| Prehospital referral | |||
|---|---|---|---|
| Direct ED admission | EMS | p-Values | |
| Episodes, n (%) | 185 (26.5) | 512 (73.5) | |
| Male sex, n (%) | 99 (53.5) | 295 (57.6) | 0.335 |
| Age, median (range, years) | 2.9 (0.2–17.5) | 5.2 (0.1–18.0) | <0.001* |
| Previous diagnosis of epilepsy, n (%) | 63 (35.0) | 178 (34.8) | 0.862 |
| Patients on ASM, n (%) | 60 (32.4) | 167 (32.6) | 0.963 |
| Neurologic comorbidities, n (%) | 62 (33.5) | 146 (28.5) | 0.203 |
| Prehospital seizure control, n (%) | 154 (83.2) | 460 (89.8) | <0.05* |
| Evolution to SE, n (%) | 12 (6.5) | 67 (13.1) | <0.05* |
In the group of the 185 patients without prehospital referral, 13.5% (n=25) were admitted to the ED without seizure control and did not receive any prehospital ASM. These were mainly patients with a first episode of seizure (n=16, 64.0%). At least one dose of an ASM was administered in the prehospital setting in 19.5% (n=36) of episodes, most commonly rectal diazepam (88.9%, n=32). A correct first-line therapy was used in all these 36 episodes. We were able to analyze the ASM dose on 55.6% (n=20) of the episodes, of which 90.0% (n=18) were in a correct dose and only 2 patients received subtherapeutic doses (Fig. 1).
In the group of patients who received EMS assistance, prehospital seizure resolution occurred in 89.8% (n=460). 5.6% (n=29) were admitted to the ED without seizure control and did not receive any prehospital ASM. A first dose of an ASM was given in 33.0% (n=169), predominantly diazepam, used in 96.4% (n=163) as first line therapy (88.7% rectal, 4.7% IV). The dose of the first benzodiazepine (BZD) was appropriate in 82.0% (n=109), subtherapeutic in 12.0% (n=16), and supratherapeutic in 6.0% (n=8). We could not ascertain the ASM dose in 30 episodes. It was observed that in 22 episodes a second drug was administered to control the seizure, mostly diazepam (77.3%), however 31.8% received diazepam rectally while 40.9% received it intravenously. Fig. 1 provides information on the use of three or four drugs.
The use of an ASM in the prehospital setting was more frequent in patients with male sex (p<0.05), younger age (p<0.05), previous diagnosis of epilepsy (p<0.001), prior use of ASM at home (p<0.001); and previous neurologic comorbidities (p<0.001). Additionally, it was more frequent among patients assisted by the EMS (p<0.001) and in those presenting with SE comparing to non-SE episodes (p<0.001). In the multivariate analysis, the prehospital ASM administration remained independently associated with male sex (p<0.05), younger age (p<0.001), referral trough the EMS (p<0.001) and occurrence of SE (p<0.001). Patients with generalized onset seizures were more probable to receive an ASM at the prehospital setting (p<0.05).
In the prehospital setting, airway support was required in a small percentage of cases. Non-invasive ventilation was used in only 1 patient, while invasive mechanical ventilation was necessary in 3 episodes (with sedation). Intravenous access was established in 5.7% (n=29) and IV fluids were administrated in 4.6% (n=24). Regarding the 322 febrile episodes, in at least 55.3% (n=178) of admissions an antipyretic drug was administered at the prehospital setting.
In-hospital managementAt least one ASM was administered in the in-hospital setting in 11.5% (n=80), with the number of drugs per patient ranging from one to six. Between the 151 drug doses administered, 61.5% (n=93) corresponded to a first line drug, with the most used ASM being diazepam (58.9%, n=89). 38.4% (n=58) were second line drugs, including levetiracetam, valproic acid, phenytoin, phenobarbital and lacosamide.
Sedation in the hospital setting was performed in 3 episodes. The used drugs for this propose included midazolam, fentanyl and propofol. For airway support, non-invasive ventilation was used in 3 episodes and invasive ventilation in 2.
Protocol complianceProtocol compliance with the national guidelines regarding prehospital setting approach for seizures, was completely applied in 71.7% of the episodes (n=114). Failures of the protocol are illustrated in Fig. 1. A higher adherence to treatment guidelines was more frequent in younger patients (p<0.05), patients with no previous diagnose of epilepsy (p<0.05), without usual ASM (p<0.05), without neurologic comorbidities (p<0.05) and who did not progress to SE (p<0.05). However, after the multivariate analysis, only the absence of epilepsy history, the patients without usual ASM and the episodes without progression to SE remained significantly associated with higher protocol compliance (p<0.001, p<0.001 and p<0.05, respectively) (Table 4).
Multivariate analysis of factors related to prehospital ASM administration, prehospital protocol compliance, prehospital seizure control, in-hospital administration of two or more ASM and patient hospitalization.
| Prehospital ASM(n=205) | Coefficient | p-Value | Prehospital protocol compliance(n=114) | Coefficient | p-Value | Prehospital seizure control(n=614) | Coefficient | p-Value | Two or more in-hospital ASM(n=38) | Coefficient | p-Value | Patient hospitalization(n=66) | Coefficient | p-Value | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Male sex, n (%) | 131 (63.9) | 0.387 | <0.05* | 71 (62.3) | 0.414 | 0.310 | 348 (56.7) | 0.125 | 0.625 | 22 (57.9) | 0.031 | 0.934 | 31 (47.0) | −0.477 | 0.096 |
| Age, median (range) | 5.5 (0.4–17.7) | −0.070 | <0.001* | 5.0 (1.2–17.7) | −0.056 | 0.255 | 4.9 (0.1–18.0) | 0.160 | <0.001* | 2.4 (0.3–17.1) | −0.128 | <0.05* | 2.0 (0.1–17.3) | −0.097 | <0.05* |
| Previous diagnosis of epilepsy, n (%) | 95 (46.3) | 0.457 | 0.338 | 47 (41.2) | −18.699 | <0.001* | 208 (33.9) | −0.007 | 0.992 | 19 (50.0) | 0.750 | 0.443 | 21 (31.8) | −0.608 | 0.405 |
| Patients on ASM, n (%) | 91 (44.4) | 0.699 | 0.151 | 44 (38.6) | −18.955 | <0.001* | 195 (31.8) | −0.399 | 0.581 | 18 (47.4) | 0.840 | 0.423 | 21 (31.8) | 0.392 | 0.611 |
| Neurologic comorbidities, n (%) | 79 (38.5) | 0.265 | 0.291 | 36 (31.6) | −0.503 | 0.360 | 175 (28.5) | −0.839 | <0.05* | 14 (36.8) | −0.475 | 0.385 | 24 (36.4) | 0.913 | <0.05* |
| Prehospital referral by EMS, n (%) | 169 (82.4) | 0.767 | <0.001* | 96 (84.2) | −1.079 | 0.180 | 460 (74.9) | 0.312 | 0.274 | 21 (55.3) | −0.801 | <0.05* | 40 (60.6) | −0.338 | 0.249 |
| Prehospital ASM administration, n (%) | – | – | – | – | – | – | 176 (28.7) | 0.087 | 0.767 | 12 (31.6) | −0.564 | 0.204 | 15 (22.7) | −0.472 | 0.162 |
| Evolution to SE, n (%) | 45 (22.0) | 1.272 | <0.001* | 21 (18.4) | −0.892 | <0.05* | 52 (8.5) | −1.813 | <0.001* | 17 (44.7) | 2.503 | <0.001* | 12 (18.2) | 0.832 | <0.05* |
| Generalized seizure onset, n (%) | 161 (78.5) | 0.444 | <0.05* | 91(79.8) | 0.164 | 0.724 | 475 (77.4) | 0.662 | <0.05* | 21 (55.3) | −0.808 | <0.05* | 42 (63.6) | −0.506 | 0.091 |
Control of seizures at the prehospital setting was associated with older age (p<0.001), absence of neurological comorbidities (p<0.05), generalized seizure onset (p<0.05), non-SE presentation (p<0.001), assisted by the EMS (p<0.05). In the multivariate analysis, the association with the EMS assistance lost statistical significance (Table 4).
During the emergency episode, 38 patients needed two or more ASM to control the seizure, this was associated with younger age (p<0.05), epilepsy history (p<0.05), use of ASM at home (p<0.05), direct admission to the ED (p<0.05), focal onset seizures (p<0.05) and the SE presentation (p<0.001). After multivariate analysis, the need for two or more ASM to control the seizure at the in-hospital setting was associated with younger age, non-assistance by EMS, evolution to SE and focal seizures.
Patients’ hospitalizationHospitalization of the patient occurred in 8.9% (n=62) of the patients, with 631 being discharged to home. Admission to the paediatric ICU occurred in 4 episodes: two epileptic seizures, one febrile SE and one convulsive SE.
Patient hospitalization was more probable in the case of younger patients (p<0.001), admitted without prehospital EMS assistance (p<0.05) and presenting with focal onset seizures (p<0.05). However, after multivariate analysis, the only statistically significant associations were with younger patients (p<0.05), SE presentation (p<0.05) and neurologic comorbidities (p<0.05) (Table 4).
DiscussionPrehospital managementIn this retrospective study conducted in a multicentric paediatric ED of a tertiary hospital, we were able to characterize the prehospital approach of seizures and to explore possible factors associated with better outcomes.
One of the aims of this study was to analyze how paediatric patients with seizures arrive at the ED and whether those who are assisted by the EMS behave differently from patients brought by their caregivers. We observed that most of the patients received prehospital assistance by the EMS, with this proportion being slightly lower than that found in previous similar studies.20,21 The few remaining published studies selected patients who are assisted by their EMS.8,21 It was perceived that the patients brought directly by the caregivers were younger, which is understandable considering that many of them were first-time febrile seizures and the caregivers might not be so aware of how to proceed. This finding reinforces the need to educate parents and schools’ professionals on how to proceed in the event of a seizure, with or without fever, namely safety precautions and contact with the EMS. Furthermore, it should be noted that patients with SE were more often assisted by EMS, which is in line with findings from previous research.22
In this study most of the seizures ceased in the prehospital setting, without the need of an ASM in accordance with the literature.8 From the one-third that received at least one ASM dose, a BZD represented the vast majority of drugs firstly chosen, complying with the first line therapy recommended by the national management protocol.14 In almost 80% of the administered ASM, this corresponded to rectal diazepam, while midazolam was chosen in a small proportion of cases. In fact, at the time of this study, rectal diazepam was the prescribed drug for the approach of acute seizure episodes in patients with seizures in our country. Recently buccal midazolam is also available for home prescription.
In a limited number of episodes, BZD were repeatedly administered without IV access, although representing an insignificant number of episodes. This prehospital management pattern is similar to the one reported in other studies.23,24 Amengual-Gual, M. et al. in a retrospective study on the paediatric SE approach by EMS, reported the use of more than two BZD in one-fifth of the participants without escalating to non-BZD (second line) drugs, with this being a widespread issue.16
Prehospital protocol compliance, which included the appropriate therapeutic regimen at the optimal dose, was met in more than half of the cases. However, from the 240 administered ASM, more than 10% were in subtherapeutic doses and 4% were at supratherapeutic doses. Among the episodes where more than two ASMs were administered, the proportion of non-optimal doses was higher, suggesting that this factor may impact seizure control. Ramgopal and Martin-Gill et al., in a retrospective study on prehospital seizure management, reported that insufficient doses of BZD were administered in 43% of children with seizures, which was associated with an increased need for additional ASM doses and a higher risk of airway interventions.21 Inappropriate seizure management results in prolonged seizure episodes, leading to a progressive tolerance to BZD and worse outcomes.12 As the seizure persists, the postsynaptic membrane availability for chemical receptors changes, resulting in the internalization of GABA receptors and gradual resistance to this pharmacological class.6,14 Therefore, repeated doses of BZD offer limited effectiveness and the pharmacological approach to acute seizure episodes should follow the current recommendations.10 Despite the high compliance rate verified, the significant number of non-optimally dosed ASM administered and incorrect drug sequence enhances an opportunity to review and potentially improve dosing practices or protocols.
Clinical courseAlmost 90% of episodes had prehospital seizure control. In two-thirds of the episodes where patients arrived at the hospital in active seizure, no prehospital ASM was administrated, which was primarily observed in the group without prehospital referral.
When comparing febrile and epileptic seizures, prehospital resolution was more common in the former, as expected due to their benign nature. Febrile seizures are typically self-limited and often end before the patient arrives at the hospital.25 However, in episodes of SE, this trend is reversed, with prehospital resolution being more frequent in convulsive SE. Data on the time until seizure control was not available, limiting the interpretation of the results regarding seizure resolution. Further research should include this key factor.
Prehospital seizure control, the need for two or more in-hospital ASM, and patient hospitalization were more likely in younger patients, those without prehospital referral, and in focal onset seizures. This aligns with the previous literature. Seizures with focal onset are more difficult to recognize, delaying the treatment initiation and worsening patients’ outcomes.26 Moreover, previous literature indicates that patients age is a major determinant of the long-term prognosis, with the youngest, mainly less than one, having poorer outcomes and higher mortality rates.7 The better outcomes in patients with prehospital assistance emphasises the significant role of the EMS in patient management. Moreover, the higher likelihood of 2 or more in-hospital ASM in patients with a previous diagnose of epilepsy or those previously on ASM may be attributed to the higher complexity of these patients.
Limitations and strengthsThis is a retrospective study based on data collected from electronic records, with inherent limitations of this method. Missing information in many patients prehospitally assisted by the EMS, including the exact seizure duration and a detailed account of the administered supportive care (such as airway support and intravenous access), hindered a further analysis on prehospital determinants for patient's outcomes. Data on treatment timings, a well-known key factor for the successful seizure management, was not analyzed. This may constitute a confounding factor in the identified associations. Data on response timings and seizure aetiology was also unavailable. Additionally, only patients admitted to the ED were enrolled, while convulsive SE episodes with in-hospital onset or patients transferred from other units and directly admitted to the ICU were not included. Furthermore, patients managed exclusively in the prehospital setting without subsequent ED admission were also not part of our study population. Therefore, the study population may not be fully representative of all children with seizures.
Nevertheless, a high number of episodes were included, with a large dataset, enhancing estimates precision and allowing for more detailed subgroup analysis, with greater generalizability of the results. The study was conducted in a multicentric ED of a tertiary hospital, admitting paediatric patients from the referral areas of 3 hospitals, being highly representative of the national scene. This is a unique study, being one of the few in the paediatric field to focus on prehospital management, including patients without prehospital assistance, which allows the caregivers approach management analysis. There are several studies centred on the SE approach, whereas this one includes non-SE episodes. The current study provides valuable insights on the current state of the prehospital seizure management.
This preliminary study enhances the necessity of further research, which should be conducted through prospective studies in cooperation with the EMS. The impact of additional variables on prehospital care should be investigated, including the timings of prehospital intervention and treatment, the correlation of prehospital management with the exact seizure duration and the influence of aetiology on patients’ outcomes. The underlying factors promoting this associations deserve deeper investigation in additional studies.
ConclusionClinical outcomes on the prehospital management may be improved with a joint effort from caregivers, EMS professionals and clinicians. Health education for acute seizure management among families and emergency professionals, self-management plans, inclusion and training for second line therapies administration by first responders and awareness improvement for the complications of inappropriate management are simple measures that can modify the disease prognosis.
The prehospital seizure management in paediatric patients remains a significant determinant in patients’ prognosis and should be subject to continuous optimization. First responders’ awareness improvement for the prompt and appropriate management constitutes an essential strategy in this process. Further investigation is needed to identify possible barriers in prehospital care.
FundingThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Conflict of interestNone.
