EMS A to Z: Journal Club – Intranasal Midazolam for Pediatric Seizures

Show Notes:

From your hosts, Dr. Josh Gaither, Dr. Amber Rice, and Dr. Rachel Munn

 

Pediatric Seizures:

• According to the American Academy of Pediatrics, epilepsy affects up to 1% of children.


• It’s location dependent, but pediatric EMS calls can make up about 13% of our calls, with 5 – 8 % of those being for seizures. 
  
  • https://www.acep.org/how-we-serve/sections/quality-improvement--patient-safety/newsletters/february-2016/pediatric-seizure-management-in-the-out-of-hospital-environment/
  
  
  
  


• Recognizing and rapidly treating pediatric seizures or status epilepticus can decrease the morbidity associated with this disease process.

What are the best medication and route to treat pediatric seizure?  

• In our system and administrative guidelines, we are currently using IM midazolam as our first line medication.


• This decision was informed largely by the RAMPART

What are the other therapeutic options out there? 

• IV, IM, IN, buccal midazolam


• IV or PR diazepam


• IV lorazepam

What is the new study we’re discussing today? 

• Whitfield D, Bosson N, Kaji AH, Gausche-Hill M. The Effectiveness of Intranasal Midazolam for the Treatment of Prehospital Pediatric Seizures: A Non-inferiority Study. Prehosp Emerg Care. 2021 Mar 29:1-9. doi: 10.1080/10903127.2021.1897197. Epub ahead of print. PMID: 33656973.


• Study details:
  
  • This was a retrospective study looking at IN vs IM/IV midazolam and whether or not redosing of benzodiazepine was required in the prehospital setting.
  
  
  • >2,000 patients with a median age of 6 years were evaluated in the study.
  
  
  • 25% vs 14% of patients receiving IN vs IV/IM/IO midazolam required re-dosing.
  
  
  
  


• While it is tempting to say that IN midazolam just isn’t as effective for seizure control as the other routes, we must consider that the dose used was only 0.1mg/kg for all routes, whereas in other studies evaluating IN midazolam, a 0.2mg/kg dose was used. Perhaps the dose was just too small. Additionally, the outcome measured wasn’t a true patient centered outcome and we do not have follow up data on the patients' hospital courses, etc.