EMS Benzodiazepines for Status Epilepticus – Go Big

Written by Vivian Lei

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In this single EMS agency study, most patients with status epilepticus did not receive evidence-based treatment with appropriate midazolam administration. A higher initial dose of midazolam was associated with decreased need for rescue therapy as well as decreased need for respiratory support.

Why does this matter?
Out-of-hospital status epilepticus requires immediate benzodiazepine administration by EMS providers. However, under-treatment is common in prehospital settings, potentially increasing morbidity and healthcare utilization consequences.

Go big or the patient may not go home
Researchers analyzed EMS medical records for adult patients with out-of-hospital status epilepticus over a 5 year period. This particular EMS agency protocol recommended administration of a single dose of 0.1 mg/kg (up to a maximum of 6 mg) of midazolam IM/IV/IO or 5 mg intranasal. Of the 38,995 encounters for out-of-hospital seizure, 8.7% were identified with status epilepticus. Of these patients, only 61.6% of patients were given midazolam at any dose, but none received the national guideline-based dose of 10 mg IM. Intranasal (47%) and intravenous (38.3%) routes were more common than intramuscular (13.7%) and intraosseous (1%) routes. Rescue therapy with a second dose of midazolam was required in 18.3% of patients who received any dose of midazolam. Those patients who received a higher initial dose of midazolam were less likely to require rescue medication (OR 0.8, CI 0.7-0.9). Receiving a higher dose of midazolam was not associated with increased need for respiratory support. While this study is limited by issues inherent to retrospective review of EMS records, it does reveal an important gap in treatment of status epilepticus, which requires early and appropriately dosed benzodiazepine administration. In this study, the EMS agency’s protocol did not meet national guidelines. Perhaps a first step in guiding appropriate treatment would be to reevaluate local EMS protocols on benzodiazepine administration for status epilepticus.

Source
Prehospital midazolam use and outcomes among patients with out-of-hospital status epilepticus. Neurology. 2020 Sep 17:10.1212/WNL.0000000000010913. doi: 10.1212/WNL.0000000000010913. Online ahead of print.

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