Prehospital Care for the Adult and Pediatric Seizure Patient: Current Evidence-based Recommendations

Abstract

IntroductionWe sought to develop evidence-based recommendations for the prehospital evaluation and treatment of adult and pediatric patients with a seizure and to compare these recommendations against the current protocol used by the 33 emergency medical services (EMS) agencies in California.MethodsWe performed a review of the evidence in the prehospital treatment of patients with a seizure, and then compared the seizure protocols of each of the 33 EMS agencies for consistency with these recommendations. We analyzed the type and route of medication administered, number of additional rescue doses permitted, and requirements for glucose testing prior to medication. The treatment for eclampsia and seizures in pediatric patients were analyzed separately.ResultsProtocols across EMS Agencies in California varied widely. We identified multiple drugs, dosages, routes of administration, re-dosing instructions, and requirement for blood glucose testing prior to medication delivery. Blood glucose testing prior to benzodiazepine administration is required by 61% (20/33) of agencies for adult patients and 76% (25/33) for pediatric patients. All agencies have protocols for giving intramuscular benzodiazepines and 76% (25/33) have protocols for intranasal benzodiazepines. Intramuscular midazolam dosages ranged from 2 to 10 mg per single adult dose, 2 to 8 mg per single pediatric dose, and 0.1 to 0.2 mg/kg as a weight-based dose. Intranasal midazolam dosages ranged from 2 to 10 mg per single adult or pediatric dose, and 0.1 to 0.2 mg/kg as a weight-based dose. Intravenous/intrasosseous midazolam dosages ranged from 1 to 6 mg per single adult dose, 1 to 5 mg per single pediatric dose, and 0.05 to 0.1 mg/kg as a weight-based dose. Eclampsia is specifically addressed by 85% (28/33) of agencies. Forty-two percent (14/33) have a protocol for administering magnesium sulfate, with intravenous dosages ranging from 2 to 6 mg, and 58% (19/33) allow benzodiazepines to be administered.ConclusionProtocols for a patient with a seizure, including eclampsia and febrile seizures, vary widely across California. These recommendations for the prehospital diagnosis and treatment of seizures may be useful for EMS medical directors tasked with creating and revising these protocols.

Statewide Emergency Medical Services Protocols for Status Epilepticus Management

“…IV medications included midazolam (31 states), lorazepam (23 states), and diazepam (23 states); IM medications included midazolam (29 states), lorazepam (4 states), and diazepam (4 states); and IN medications included midazolam (27 states) and lorazepam (4 states). Recommended weight‐based pediatric dosing for IM and IN midazolam matches expert recommendations 11,12 in 64% and 79% of states, respectively (see Fig 2C, D).…”

“…Furthermore, while real‐world adherence to state guidelines may vary among EMS systems, variation may be even more profound in states without any statewide protocols, as local EMS agencies are left to rely on regional, county, or health care system–based guidelines. A substantial degree of variability was demonstrated in previous reviews of regional EMS protocols in California, 12,18 whereas opportunities to analyze regional EMS systems in other states are limited, as protocols in those states are publicly available in only a small minority of regions. Finally, we did not survey individual EMS agencies or health care systems to determine provider adherence to published protocols.…”

Status epilepticus 2020

“…fluid-attenuated inversion recovery; GABA = (gamma-aminobutyric acid) gamma-aminovajsav; IgG = immunglobulin-G; ILAE = (International League Against Epilepsy) Nemzetközi Epilepsziaellenes Liga; MgSO 4 = magnézium-szulfát; MRI = (magnetic resonance imaging) mágnesesrezonancia-képalkotás; NCSE = non-convulsiv status epilepticus; NMDA = N-metil-D-aszpartát; NORSE = (new-onset refractory status epilepticus) de novo rezidens status epilepticus; OGP = oligoclonalis gammopathia; PNER = pszichogén nem epilepsziás roham A status epilepticus az akut stroke után a második leggyakoribb, sürgősségi kezelést igénylő neurológiai állapot; évente átlagosan 20-40/100 000 lakost érint, hazánkban tehát évi 2-3 ezer esettel kell számolnunk [1,2]. Az Orvosi Hetilapban utoljára 2002-ben Tóth és Futó tollából jelent meg összefoglaló a status epilepticus kezeléséről [3].…”

“…Vércukorméréssel azért sem érdemes húzni az időt, mert a rohamok max. 2%-át okozza hypoglykaemia: sokkal fontosabb, hogy minél gyorsabban beadjuk a benzodiazepint, és csak utána mérjünk cukrot [1].…”

“…A korai status epilepticus komplikációja lehet a légzésdepresszió (10-15%), a hypotensio (25-30%), a cardialis arrhythmia (2-7%) [1].…”