Written by Clay Smith
EMS systems in California often did not define convulsive status epilepticus according to published guidelines. Though most recommended IM midazolam first line, 94% of EMS system protocols underdosed.
Why does this matter?
Guidelines from 2016 state: “In adults with convulsive status epilepticus, intramuscular midazolam, intravenous lorazepam, intravenous diazepam and intravenous phenobarbital are established as efficacious as initial therapy (Level A).” The NETT investigators in 2012 found IM midazolam was as effective as IV lorazepam for convulsive status in the prehospital setting. Do local EMS protocols reflect these best evidence practices?
Stop the seizure
This was a cross section of California EMS systems to determine if the 33 regional EMS protocols were up to date with the latest evidence for treating convulsive status epilepticus in the prehospital arena. About 82% had been updated since 2012 (NETT RCT) and about half since guidelines were published in 2016. Only 21% defined status epilepticus per guidelines. Of the 33, 97% recommended IM midazolam, although the dose matched guideline recommendations just 6% of the time (guidelines recommend 10mg IM in patients >40kg; most were lower). Just 6% of EMS systems recommended lorazepam IV; 15% recommended diazepam IV first line, and both drugs did not match guideline recommendations over 90% of the time.
Emergency Medical Services Protocols for Generalized Convulsive Status Epilepticus. JAMA. 2019 Mar 26;321(12):1216-1217. doi: 10.1001/jama.2019.0441.
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Reviewed by Thomas Davis