pediatric prehospital seizure management: evidence based guidelines and state of care in co kathleen...

Pediatric Prehospital Seizure Management:

Evidence Based Guidelines and State of Care in CO

Kathleen Adelgais, MD MPHPediatric Emergency

MedicineChildren’s Hospital Colorado

Introduction

• Seizures are most common neurologic disorder in children

• About 5% of all children will have at least 1 seizure within first 16 years

• Up to 10% of ambulance calls for children are for seizure activity

• Approximately 1.5% of total ED visits by children are for seizure-related complaints

Pathophysiology

• Excess neuronal discharge activity within the brain: Increased glucose & O2 consumption

Increased CO2 & lactic acid production

• Initial autoregulatory mechanisms compensate with increased cerebral blood flow

• Brief seizures rarely produce any lasting effects

Pathophysiology

• Prolonged seizure activity can result: Lactic acidosis Rhabdomyolysis Hyperkalemia Hyperthermia Hypoglycemia Shock Pulmonary failure Permanent neuronal injury

• Permanent neuronal injury probably does not occur until status lasts for longer than 1 hr

Seizures in CO Prehospital Care

Make up approximately 10% of top 75% of prehospital callsTotal number of children: approximately 2300/yr

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Proportion of benzodiazepines given

405 patients treated with benzodiazepines in prehospital settingMajority treated with Midazolam: 64%

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N=405

Goals of Seizure Management

• Rapid stabilization of cardio-respiratory function

• Termination of clinical and electrical seizure activity

• Treatment of life-threatening precipitants

• Recognition & minimization of adverse physiologic consequences

Goals of Seizure Management

• Prehospital: Oxygen Glucose check and treatment Benzodiazepines Transport

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PREHOSPITAL TREATMENT:EVIDENCE-BASED GUIDELINE

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Lorazepam

• Historically used in ED setting

• Known respiratory depression and hypotension Less respiratory depression & fewer ICU

admissions in comparison to diazepam

• Duration of action: 12-24 hrs

• Dose: 0.1mg/kg IV/IO (max 4 mg)

Diazepam

• Historically used in prehospital setting Now seen in home treatment of seizures

• Respiratory depression, somnolence, hypotension, ataxia, bradycardia

• Duration of action: up to 4 hrs (redistributes from CNS quickly)

• Can be used both IV and rectally• IV/IO dose is 0.05 mg/kg to max of 5 mg• PR dose is 0.3 mg/kg to max of 10 mg

Midazolam

• Benzodiazepine with good efficacy to stop seizures

• Duration of action: 2-6 hrs• Can be given intravenously, intranasal,

and intramuscularly IV/IO/IM dose is 0.1 mg/kg to max of 5 mg IN dose is 0.2 mg/kg to max of 10 mg

• Note: For IN administration use the MAD Nasal™ for better drug delivery

Mucosal Atomization Device (MAD Nasal™)

• Great for use in prehospital setting

• Allows for non-parenteral drug delivery

• Great in pediatrics where IV access can be challenging

• Medications Fentanyl Naloxone Midazolam Cardiac medications Glucagon

Source: http://www.lmana.com

Prehospital: IN Midazolam vs PR Diazepam

• Study performed to compare IN Midazolam to PR Diazepam for prehospital treatment of pediatric seizures

• Groups were similar in: age, gender, seizure type

• PR Diazepam more likely to: Have continued seizure activity upon

arrival to ED Require BVM en route Require ICU admission after reaching

hospital

Prehospital: Midazolam IM vs. Diazepam PR

• Study comparing Diazepam PR to Midazolam IM

• Retrospectively reviewed 93 patient charts• Groups similar with regard to age, gender,

seizure type• No difference in:

Rates of termination of seizure activity Recurrence of seizure activity Need for additional treatment Need for hospitalization

• One difference: Trend toward need for intubation in IM midazolam group

Evidence Based Guideline for Prehospital Pediatric Seizure Management:Key Features

• Rapid check of glucose• Management of

hypoglycemia with Dextrose, Glucagon

• In setting glucose >60, goal is immediate cessation of seizure with NON-parenteral meds

• IN, Buccal, IM midazolam as 1st line treatment

• If long transport time, consider IV/IO access

• Reassessment for seizure activity after 5 minutes

• IV lorazepam• IV midazolam• IV diazepam• If no IV: dosing of

midazolam as mentioned above

Case Examples

• 6 year old with known seizures estimated weight of 20 kg given 2 mg IV midazolam

• 3 year old with seizure, estimated weight of 19 (Broselow) given 4 mg of IV midazolam

• 16 mo old with seizure, estimated weight of 10 kg, given 1 mg of IM midazolam, followed by additional 1 mg when seizure recurred

• 2 year old with seizure, estimated weight of 15 kg, given 1.5 mg IV midazolam

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Additional Examples

• 8 yo with brain tumor, estimated weight of 42 lbs, given 2 mg IV midazolam

• 9 year old with seizures, no estimated weight, given 4 mg IV midazolam

• 3 year old with seizures x 10 min, estimated weight 20 kg (blue on Broselow), given 3.6 mg IM midazolam

• 3 year old with seizures, given 1 mg IN followed by 1 mg IM. No estimated weight documented

Quality Benchmarks for Prehospital Seizure Management

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