The diagnosis and management of seizures and status epilepticus in the prehospital setting

Evaluation of the Use of Ketamine in Prehospital Seizure Management: A Retrospective Review of the ESO Database

OBJECTIVES

Benzodiazepines are the primary antiseizure medication used by Emergency Medical Services (EMS) for seizures. Available literature in the United States and internationally shows 30% to 40% of seizures do not terminate with benzodiazepines called benzodiazepine refractory status epilepticus (BRSE). Ketamine is a potential treatment for BRSE due to its unique pharmacology. However, its application in the prehospital setting is mostly documented in case reports. Little is known about its use by EMS professionals for seizure management, whether as initial treatment or for BRSE, creating an opportunity to describe its current use and inform future research.

METHODS

We performed a retrospective review of 9-1-1 EMS encounters with a primary or secondary impression of seizure using the ESO Data Collaborative from 2018 to 2021. We isolated encounters during which ketamine was administered. We excluded medication administrations prior to EMS arrival and encounters without medication administration. Subgroup analysis was performed to control for airway procedure as an indication for ketamine administration. We also evaluated for co-administration with other antiseizure medications, dose and route of administration, and response to treatment.

RESULTS

We identified 99,576 encounters that met inclusion. There were 2,531/99,576 (2.54%) encounters with ketamine administration and 50.7% (1,283/2,531) received ketamine without an airway procedure. There were 616 cases (48%, 616/1,283) where ketamine was given without another antiseizure medication (ASM) and without any airway procedure. The remaining 667 (52%) cases received ketamine with at least one other ASM, most commonly midazolam (89%, 593/667). Adjusted for the growth in the ESO dataset, ketamine use by EMS professionals during encounters for seizures without an airway procedure increased from 0.90% (139/15,375) to 1.45% (416/28,651) an increase of 62% over the study period.

CONCLUSIONS

In this retrospective review of the ESO Data Collaborative, ketamine administration for seizure encounters without an airway procedure increased over the study period, both as a single agent and with another ASM. Most ketamine administrations were for adult patients in the south and in urban areas. The frequency of BRSE, the need for effective treatment, and the growth in ketamine use warrant prospective prehospital research to evaluate the value of ketamine in prehospital seizure management.

The Effectiveness of Intranasal Midazolam for the Treatment of Prehospital Pediatric Seizures: A Non-inferiority Study

Background: Intranasal (IN) midazolam allows for rapid, painless treatment of pediatric seizures in the prehospital setting and may be a preferred administration route if determined to be non-inferior to intravenous (IV) or intramuscular (IM) routes. We sought to evaluate the effectiveness of IN midazolam for terminating prehospital pediatric seizures compared to midazolam administered by alternate routes. Methods: We performed a retrospective, non-inferiority analysis using data from a regional Emergency Medical Services (EMS) database. We included pediatric patients ≤ 14 years treated with midazolam (0.1 mg/kg) by EMS for non-traumatic seizures. The primary outcome was the proportion of patients requiring redosing of midazolam after initial treatment with IN midazolam compared to those that received IV or IM midazolam. We established a priori a risk difference of 6.5% as the non-inferiority margin. Results: We evaluated outcomes from 2,034 patients (median age 6 years [interquartile range 3 - 10 years], 55% male). Initial administration routes were 461 (23%) IN, 547 (27%) IM, 1024 (50%) IV, and 2 (0.1%) intraosseous (IO). Midazolam redosing occurred in 116 patients (25%) who received IN midazolam versus 222 patients (14%) treated initially with midazolam via alternate routes (risk difference 11% [95%CI 7 - 15%]). The age-adjusted odds ratio for redosing midazolam after intranasal administration compared to alternate route administration was 2.0 (95% CI 1.6 - 2.6). Conclusion: Prehospital treatment of pediatric seizure with intranasal midazolam was associated with increased frequency of redosing compared to midazolam administered by other routes, suggesting that 0.1 mg/kg is a subtherapeutic dose for intranasal midazolam administration.

Statewide Emergency Medical Services Protocols for Status Epilepticus Management

Although seizures are common in prehospital settings, standardized emergency medical services (EMS) treatment algorithms do not exist nationally. We examined nationwide variability in status epilepticus treatment by analyzing 33 publicly available statewide EMS protocols. All adult protocols recommend intravenous benzodiazepines (midazolam, n = 33; lorazepam, n = 23; diazepam, n = 24), 30 recommend intramuscular benzodiazepines (midazolam, n = 30; lorazepam, n = 8; diazepam, n = 3), and 27 recommend intranasal benzodiazepines (midazolam, n = 27; lorazepam, n = 3); pediatric protocols also frequently recommend rectal diazepam (n = 14). Recommended dosages vary widely, and first- and second-line agents are designated in only 18 and 2 states, respectively. Given this degree of variability, standardized national EMS guidelines are needed. ANN NEUROL 2021;89:604-609.

Short-Term Outcome of Transported Versus Not-Transported Seizure Patients by Tehran Emergency Medical Services; a Retrospective Cohort Study

Background: One of the most frequent complaints that emergency medical services (EMS) deal with is seizure. The missions of EMS on these cases may lead to transferring the patient to the emergency department (ED). Objectives: Therefore, the present study was conducted to compare the short-term outcome of transported versus not-transported cases. Methods: Our population sample was selected retrospectively from medical records in Tehran EMS center for 6 months in which the plan was transferring to a specific hospital. The cases were divided into transported or not-transported. W extracted and compared the cases’ demographic data, vital signs, conducted prehospital management, patient disposition, and their short-term outcome. Results: We evaluated 486 cases, 173 of whom were males (35.6%) and the mean age of patients was 34.8 ± 32.0 years old. 329 (67.7%) and 157 (32.3%) were in the not-transported and the transported group, respectively. Among all not-transported cases, we could follow 172 patients, 52 of whom had gone to hospital during the next 72 hours. 22 out of the 52 cases were discharged from ED the same day. Overall, the ED discharge rate was significantly more in the transported group (P < 0.001). Short-term mortality had no significant difference in the two study groups (P = 1.00). Conclusions: Most of the not-transported patients did not go to the hospital during further 72 hours, and some were hospitalized. Most of the patients transported to the hospital were discharged from the ED. The short-term mortality rate was not different.

Active Seizures in Children Are Often Subtle and Unrecognized by Prehospital Providers

Early recognition and treatment of seizures is essential for optimal patient outcomes. Seizure activity, particularly in young children, can be subtle and often go unrecognized by providers. This case series retrospectively identified 7 cases of pediatric patients (14 years and younger) who presented to the emergency department with active seizure activity that was unrecognized by the prehospital care providers. The presentation of these patients, their clinical signs of seizure, and emergency department disposition are highlighted in this series.

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

INTRODUCTION

We 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.

METHODS

We 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.

RESULTS

Protocols 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.

CONCLUSION

Protocols 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.

Adult Status Epilepticus: A Review of the Prehospital and Emergency Department Management

Seizures are a common presentation in the prehospital and emergency department setting and status epilepticus represents an emergency neurologic condition. The classification and various types of seizures are numerous. The objectives of this narrative literature review focuses on adult patients with a presentation of status epilepticus in the prehospital and emergency department setting. In summary, benzodiazepines remain the primary first line therapeutic agent in the management of status epilepticus, however, there are new agents that may be appropriate for the management of status epilepticus as second- and third-line pharmacological agents.

Pediatric critical care

Care of the ill and injured child requires knowledge of unique pediatric anatomic and physiologic differences. Subtleties in presentation and pathophysiologic differences impact management. This article discusses pediatric resuscitation, the presentation and management of common childhood illness, pediatric trauma, and common procedures required in the critically ill child.

When should you test for and treat hypoglycemia in prehospital seizure patients?

OBJECTIVES

Seizure is a frequent reason for activating the Emergency Medical System (EMS). Little is known about the frequency of seizure caused by hypoglycemia, yet many EMS protocols require glucose testing prior to treatment. We hypothesized that hypoglycemia is rare among EMS seizure patients and glucose testing results in delayed administration of benzodiazepines.

METHODS

This was a retrospective study of a national ambulance service database encompassing 140 ALS capable EMS systems spanning 40 states and Washington DC. All prehospital calls from August 1, 2010 through December 31, 2012 with a primary or secondary impression of seizure that resulted in patient treatment or transport were included. Median regression with robust and cluster (EMS agency) adjusted standard errors was used to determine if time to benzodiazepine administration was significantly related to blood glucose testing.

RESULTS

Of 2,052,534 total calls, 76,584 (3.7%) were for seizure with 53,505 (69.9%) of these having a glucose measurement recorded. Hypoglycemia (blood glucose <60 mg/dL) was present in 638 (1.2%; CI: 1.1, 1.3) patients and 478 (0.9%; CI: 0.8, 1.0) were treated with a glucose product. A benzodiazepine was administered to 73 (11.4%; CI: 9.0, 13.9) of the 638 hypoglycemic patients. Treatment of seizure patients with a benzodiazepine occurred in 6,389 (8.3%; CI: 8.1, 8.5) cases and treatment with a glucose product occurred in 975 (1.3%; CI: 1.2, 1.4) cases. Multivariable median regression showed that obtaining a blood glucose measurement prior to benzodiazepine administration compared to no glucose measurement or glucose measurement after benzodiazepine administration was independently associated with a 2.1 minute (CI: 1.5, 2.8) and 5.9 minute (CI: 5.3, 6.6) delay to benzodiazepine administration by EMS, respectively.

CONCLUSIONS

Rates of hypoglycemia were very low in patients treated by EMS for seizure. Glucose testing prior to benzodiazepine administration significantly increased the median time to benzodiazepine administration. Given the importance of rapid treatment of seizure in actively seizing patients, measurement of blood glucose prior to treating a seizure with a benzodiazepine is not supported by our study. EMS seizure protocols should be revisited.

Pediatric seizures

Seizures are a commonly encountered condition within the emergency department and, because of this, can engender complacency on the part of the physicians and staff. Unfortunately, there is significant associated morbidity and mortality with seizures, and they should never be regarded as routine. This point is particularly important with respect to seizures in pediatric patients. The aim of this review is to provide a current view of the various issues that make pediatric seizures unique and to help elucidate emergent evaluation and management strategies.