Pediatric Prehospital Seizure Management: Evidence Based Guidelines and State of Care in CO

1. Pediatric Prehospital Seizure Management:Evidence Based Guidelines and State of Care in CO Kathleen Adelgais, MD MPH Pediatric Emergency Medicine Children’s Hospital Colorado

2. 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

3. 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

4. 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

5. Seizures in CO Prehospital Care Make up approximately 10% of top 75% of prehospital calls Total number of children: approximately 2300/yr

6. N=405 Proportion of benzodiazepines given 405 patients treated with benzodiazepines in prehospital setting Majority treated with Midazolam: 64%

7. 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

8. Goals of Seizure Management • Prehospital: • Oxygen • Glucose check and treatment • Benzodiazepines • Transport

9. Prehospital Treatment:Evidence-BASEd Guideline

10. 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)

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. Quality Benchmarks for Prehospital Seizure Management • ??????????????????????????????????