A recent podcast episode is drawing attention to the challenges EMS providers face in recognizing and treating status epilepticus before patients arrive at the hospital.
The episode, part of the Sharp Waves series produced by Epigraph, features Dr. Elan Guterman, a neurohospitalist and associate professor of neurology at the University of California, San Francisco. Guterman breaks down findings from a study he led, analyzing more than 1,200 EMS calls involving patients who were later diagnosed with status epilepticus in the emergency department.
Using ESO data from 2019 to 2021, the study looked at how prehospital recognition — or lack of recognition — impacted treatment timelines and medication dosing.
“Every minute really makes a difference in terms of the likelihood of seizures being controlled,” he said.
The study found that just over 10% of patients later diagnosed with status epilepticus had not been identified as such by EMS. While some of these patients still received benzodiazepines, treatment was delayed by approximately 4.5 minutes, and the administered doses were often lower, typically one milligram less of midazolam.
Among those not diagnosed with status epilepticus by EMS, the most common documented presentations were altered level of consciousness (about 40%) and suspected stroke (just under 25%). Guterman noted that seizures with subtle or non-convulsive symptoms may be harder to identify, particularly in high-stress prehospital settings.
Despite advancements in electronic medical records and data-sharing between EMS and hospitals, Guterman said diagnosing neurologic emergencies in the field remains challenging. He cited concerns such as respiratory depression risks, difficulty with pediatric dosing, and access restrictions to controlled substances as barriers to administering benzodiazepines in some cases.
“Even among patients diagnosed with status epilepticus in the field, about 20% were not treated with a benzodiazepine until they reached the hospital,” he said.
Guterman emphasized that the study was not meant to critique EMS providers. “Diagnosing these patients can be extremely difficult,” he said. “This is about identifying areas where additional tools or training could help EMS teams do what they’re already doing—even better.”
Possible solutions could include the development of a standardized seizure scale for EMS or future use of portable EEG technology in ambulances. Guterman also pointed to the need for more long-term research on how treatment delays impact cognitive outcomes and quality of life.
“Ultimately, we need better ways to equip EMS with the tools and support they need to identify and treat these patients earlier,” he said. “That’s where improved outcomes begin.”
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