Pre-Hospital Management of Seizure

Ability to support the airway and administer medications is of critical importance. Therefore, most seizure transport is provided by an advanced life support unit. Pre-hospital personnel have protocols that allow for use of these first-line agents en route to the ED.⁸ Early use of appropriate medication, such as a benzodiazepine, results in the most favorable outcomes.⁹ If quick intravenous access is not possible, a typical dose of benzodiazepine may be given via intramuscular (IM) or intranasal (IN) routes.⁹ A dose of midazolam (Versed) 0.1–0.2 mg/kg IM (maximum dose 4 mg) or IN 0.2 mg/kg (maximum dose 4 mg) can be given prior to ED arrival.^{9, 10} The higher intranasal dose is to account for incomplete absorption of the dose through nasal mucosa. Lorazepam (Ativan) and diazepam (Valium) may not be as effective if given IM due to slow onset of action and delay in seizure termination.¹¹ 

Airway adjunct consideration depends on assessment of the patient airway and may include supplemental oxygen and placement of oral or nasal airways. 

ED Management of Status Epilepticus in Children 

First-line agents: A child who continues to seize upon ED arrival, will be given additional doses of benzodiazepine to stop the seizure. The choice of benzodiazepine agent depends on whether an intravenous access is present. Both in pre-hospital and in hospital settings, midazolam is the first choice if IM or IN route is chosen. If an intravenous line is present, lorazepam 0.1 mg/kg is an appropriate alternative and may be slightly preferred to midazolam for its longer duration of action. However, due to depot effect and slower onset of action, lorazepam is less desirable than midazolam when administrated as IM or IN.¹² It is important to note that benzodiazepine doses can be repeated every two to four minutes as needed, but when multiple doses of a benzodiazepine are used, respiratory depression should be anticipated, and it is important to have proper pediatric airway equipment available to use. For this reason, after two doses of benzodiazepine administered in the ED (in addition to dose administered by the pre-hospital personnel or paramedics), if seizure has not stopped, a second-line agent should be used.¹²

Second-line agents: The goal of seizure management with first line agent is to stop seizure within 10 minutes. If seizure still persists beyond this time, a second line agent should be used. In children, the following second line agents have similar efficacy and can be used interchangeably:¹³