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 & O 2 consumption  Increased CO 2 & 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 5

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

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 8

9. PREHOSPITAL TREATMENT: EVIDENCE-BASED GUIDELINE 9

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 1 st 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 17

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 ??????????????????????????????????