Related Experiment Video
Updated: Dec 17, 2025
Author Spotlight: Advancing Pediatric Epilepsy Surgery in Children Through Novel Biomarkers and Enhanced Localization
Published on: September 20, 2024
Multicenter Evaluation of Prehospital Seizure Management in Children
Insights
Implementing evidence-based guidelines for pediatric prehospital seizures increased midazolam use by emergency medical services (EMS). However, incorrect dosing remains a challenge, necessitating further research for optimal seizure cessation.
Area of Science:
- Pediatric Emergency Medicine
- Prehospital Care Research
- Clinical Protocol Implementation
Background:
- Pediatric seizures are a frequent reason for emergency medical services (EMS) transport.
- Prompt seizure termination is crucial to prevent adverse neurologic outcomes, respiratory issues, and mortality.
- Evidence-based pediatric prehospital guidelines can improve seizure management timeliness and medication dosing.
Purpose of the Study:
- To compare the management of pediatric prehospital seizures across multiple EMS systems following protocol revisions aligned with evidence-based guidelines.
- To assess the impact of protocol updates on the administration of midazolam, seizure cessation, and patient outcomes.
Main Methods:
- A retrospective, cross-sectional study evaluated actively seizing pediatric patients (0-17 years) before and after protocol modifications in three EMS agencies.
- Data on demographics, medications, seizure cessation, airway interventions, and timeliness were collected from EMS and hospital records.
- Primary outcome was appropriate midazolam administration (route and dose); secondary outcomes included seizure recurrence, respiratory failure, and care timeliness.
Main Results:
- Midazolam administration increased post-protocol update (61% vs. 71%), with greater use of preferred intranasal (IN) or intramuscular (IM) routes (49% vs. 77%).
- Despite increased administration, 36% received incorrect weight-based doses, and 72% of those received a sub-therapeutic dose.
- Twenty-nine percent of patients experienced seizure recurrence or persistence upon emergency department (ED) arrival; 17% experienced respiratory failure.
Conclusions:
- Evidence-based seizure protocols for EMS enhance midazolam administration rates.
- Frequent administration of incorrect weight-based midazolam doses is a significant issue.
- Future research should prioritize optimizing correct midazolam dosing to improve seizure cessation rates in pediatric emergencies.
Background:
Seizures are a common reason why emergency medical services (EMS) transports children by ambulance. Timely seizure cessation prevents neurologic morbidity, respiratory compromise, and mortality. Implementing recommendations from an evidence-based pediatric prehospital guideline may enhance timeliness of seizure cessation and optimize medication dosing.
Objective:
We compared management of pediatric prehospital seizures across several EMS systems after protocol revision consistent with an evidence-based guideline.
Methods:
Using a retrospective, cross-sectional approach, we evaluated actively seizing patients (0-17 years old) EMS transported to a hospital before and after modifying local protocols to include evidence-based recommendations for seizure management in three EMS agencies. We electronically queried and manually abstracted both EMS and hospital data at each site to obtain information about patient demographics, medications given, seizure cessation and recurrence, airway interventions, access obtained, and timeliness of care. The primary outcome of the study was the appropriate administration of midazolam based on route and dose. We analyzed these secondary outcomes: frequency of seizure activity upon emergency department (ED) arrival, frequency of respiratory failure, and timeliness of care.
Results:
We analyzed data for 533 actively seizing patients. Paramedics were more likely to administer at least one dose of midazolam after the protocol updates [127/208 (61%) vs. 232/325 (71%), p = 0.01, OR = 1.60 (95% CI: 1.10-2.30)]. Paramedics were also more likely to administer the first midazolam dose via the preferred intranasal (IN) or intramuscular (IM) routes after the protocol change [(63/208 (49%) vs. 179/325 (77%), p < 0.001, OR = 3.24 (2.01-5.21)]. Overall, paramedics administered midazolam approximately 14 min after their arrival, gave an incorrect weight-based dose to 130/359 (36%) patients, and gave a lower than recommended dose to 94/130 (72%) patients. Upon ED arrival, 152/533 (29%) patients had a recurrent or persistent seizure. Respiratory failure during EMS care or subsequently in the ED occurred in 90/533 (17%) patients.
Conclusions:
Implementation of an evidence-based seizure protocol for EMS increased midazolam administration. Patients frequently received an incorrect weight-based dose. Future research should focus on optimizing administration of the correct dose of midazolam to improve seizure cessation.
