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Pfeiffer CK, Smith K, Bernard S, Dalziel SR, Hearps S, Geis T, Kabesch M, Babl FE. Prehospital benzodiazepine use and need for respiratory support in paediatric seizures. Emerg Med J 2022; 39:608-615. [PMID: 35078857 DOI: 10.1136/emermed-2021-211735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 01/08/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Paramedics are frequently called to attend seizures in children. High-quality evidence on second-line treatment of benzodiazepine (BZD)-refractory convulsions with parenteral long-acting antiepileptic drugs in children has become available from the ED. In order to address the potential need for an alternative agent, we set out to determine the association of BZD use prehospital and the need for respiratory support. METHODS We conducted a retrospective observational study of state-wide ambulance service data (Ambulance Victoria in Victoria, Australia, population: 6.5 million). Children aged 0-17 years assessed for seizures by paramedics were analysed for demographics, process factors, treatment and airway management. We calculated adjusted ORs (AOR) of the requirement for respiratory support in relation to the number of BZD doses administered. RESULTS Paramedics attended 5112 children with suspected seizures over 1 year (1 July 2018 to 30 June 2019). Overall, need for respiratory support was low (n=166; 3.2%). Before ambulance arrival, 509 (10.0%) had already received a BZD and 420 (8.2%) were treated with midazolam by paramedics. Of the 846 (16.5%) patients treated with BZD, 597 (70.6%) received 1 BZD dose, 156 (18.4%) 2 doses and 93 (11.0%) >2 doses of BZD. Patients who were administered 1, 2 and >2 doses of BZD received respiratory support in 8.9%, 32.1% (AOR 4.6 vs 1 dose, 95% CI 2.9 to 7.4) and 49.5% (AOR 10.3 vs 1 dose, 95% CI 6.0 to 17.9), respectively. CONCLUSIONS Increasing administration of BZD doses was associated with higher use of respiratory support. Alternative prehospital antiepileptic drugs to minimise respiratory depression should be investigated in future research.
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Affiliation(s)
- Christina K Pfeiffer
- Clinical Sciences, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Wissenschafts- und Entwicklungscampus Regensburg, University Children's Hospital Regensburg (KUNO-Clinics) at St Hedwig Hospital of the order of St John, Regensburg, Germany
| | - Karen Smith
- Research and Evaluation, Ambulance Victoria, Melbourne, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Clayton, Victoria, Australia
| | - Stephen Bernard
- Department of Epidemiology and Preventive Medicine, Monash University, Clayton, Victoria, Australia
- Ambulance Victoria, Doncaster, Victoria, Australia
| | - Stuart R Dalziel
- Paediatric Research in Emergency Departments International Collaborative (PREDICT), Melbourne, Victoria, Australia
- Departments of Surgery and Paediatrics, The University of Auckland, Auckland, New Zealand
| | - Stephen Hearps
- Clinical Sciences, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Tobias Geis
- Wissenschafts- und Entwicklungscampus Regensburg, University Children's Hospital Regensburg (KUNO-Clinics) at St Hedwig Hospital of the order of St John, Regensburg, Germany
| | - Michael Kabesch
- Wissenschafts- und Entwicklungscampus Regensburg, University Children's Hospital Regensburg (KUNO-Clinics) at St Hedwig Hospital of the order of St John, Regensburg, Germany
| | - Franz E Babl
- Clinical Sciences, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Paediatric Research in Emergency Departments International Collaborative (PREDICT), Melbourne, Victoria, Australia
- Emergency Department, Royal Children's Hospital, Parkville, Victoria, Australia
- Departments of Paediatrics and Critical Care, University of Melbourne, Melbourne, Victoria, Australia
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Ramgopal S, McCans K, Martin-Gill C, Owusu-Ansah S. Variation in Prehospital Protocols for Pediatric Seizure Within the United States. Pediatr Emerg Care 2021; 37:e1331-e1338. [PMID: 32011553 DOI: 10.1097/pec.0000000000002029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The objective of this study was to compare statewide prehospital protocols for the management of pediatric seizures. METHODS We performed a descriptive analysis comparing statewide protocols for emergency medical services management of pediatric seizures within the United States, excluding states for which no statewide protocol/model was available. We compared antiepileptic drugs (AEDs), routes and doses of administration, and differences in febrile seizure management. RESULTS Of 50 states, 34 had either statewide protocols or models and were included. All had a protocol for the management of seizures and provided specific recommendations for the management of pediatric seizures. Twelve states (35%) preferentially recommended midazolam over other benzodiazepines. Thirty-two (94%) of 34 allowed for use of midazolam, with variable use of other AEDs. All allowed for use of intramuscular AED. Twenty-six (77%) allowed for intranasal AED. Nine (27%) allowed emergency medical services to administer a patient's own abortive AED, and 6 (18%) allowed for use of a patient's vagal nerve stimulator, when present. There was a wide variability with respect to dosing ranges for medications. Thirty-two (94%) of 34 included blood glucose measurement within the protocol. Twenty-one protocols (62%) provided recommendations for febrile seizures, including recommending active/passive cooling (8/34, 24%) and antipyretic administration (9/34, 26%). CONCLUSIONS All statewide protocols carried specific guidelines for the prehospital management of pediatric seizures; however, there was wide variability with respect to specific AEDs, routes of administration, and drug dosages. In addition to broader availability of statewide guidance, areas of potential protocol improvement and research include AED dose optimization, reprioritization of blood glucose, and greater emphasis on intranasal or intramuscular medication dosing.
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Affiliation(s)
- Sriram Ramgopal
- From the Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Feinberg School of Medicine, Chicago, IL
| | - Kerry McCans
- UPMC Center for Emergency Medicine, School of Health and Rehabilitation Sciences
| | | | - Sylvia Owusu-Ansah
- Division of Pediatric Emergency Medicine, Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA
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Salmi H, Oulasvirta J, Rahiala E, Kuisma M, Lääperi M, Harve H. Out-of-Hospital Seizures in Children: A Population-Based Study. Pediatr Emerg Care 2021; 37:e1274-e1277. [PMID: 31977765 DOI: 10.1097/pec.0000000000002001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Seizures seem to represent a frequent cause for pediatric emergency medical (EM) and emergency room (ER) contacts, but few population-based data are available. Our aim was to study the incidence, prehospital and ER treatment, and outcomes of pediatric seizures necessitating out-of-hospital care. METHODS We studied the out-of-hospital evaluation procedures, ER treatment, diagnostics and 2-year prognosis of all cases of pediatric (0-16 years) seizures encountered by the emergency medical services (EMS) in Helsinki, Finland, in 2012 (population 603,968, pediatric population 92,742); 251 patients were encountered by the EMS, of which 220 seen at the ER. RESULTS The yearly incidence of pediatric seizures necessitating EMS activation was 2.8/1000 in the pediatric population. Febrile seizures were responsible for 97 (44.1%) of the cases transported to the ER. Only a minority of patients required advanced life support measures out-of-hospital or complex diagnostics in the ER. Still, of the 220 patients seen at ER, 68 (30.9%) were hospitalized, and 106 (48.2%) had follow-up contacts scheduled. CONCLUSIONS Pediatric seizures were a common cause for EM and ER contacts. Advanced life support measures were seldom needed, and the prognosis was good, but seizures still required considerable resources. They often resulted in urgent EM dispatch and transport, hospitalization, follow-up visits, new medication, and complementary studies. This emphasizes the role the EMS plays in recognizing and terminating pediatric seizures and in referring these children to appropriate care.
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Affiliation(s)
| | - Jelena Oulasvirta
- Division of Anaesthesiology, Department of Anaesthesiology, Intensive Care and Pain Medicine
| | | | - Markku Kuisma
- Emergency Medical Services, Department of Emergency Care, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Mitja Lääperi
- Emergency Medical Services, Department of Emergency Care, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Heini Harve
- Emergency Medical Services, Department of Emergency Care, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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Fouche PF, Stein C, Jennings PA, Boyle M, Bernard S, Smith K. Review article: Emergency endotracheal intubation in non-traumatic brain pathologies: A systematic review and meta-analysis. Emerg Med Australas 2019; 31:533-541. [PMID: 31041848 DOI: 10.1111/1742-6723.13304] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Revised: 04/03/2019] [Accepted: 04/05/2019] [Indexed: 12/30/2022]
Abstract
Endotracheal intubation is an advanced airway procedure performed in the ED and the out-of-hospital setting for acquired brain injuries that include non-traumatic brain pathologies such as stroke, encephalopathies, seizures and toxidromes. Controlled trial evidence supports intubation in traumatic brain injuries, but it is not clear that this evidence can be applied to non-traumatic brain pathologies. We sought to analyse the impact of emergency intubation on survival in non-traumatic brain pathologies and also to quantify the prevalence of intubation in these pathologies. We conducted a systematic literature search of Medline, Embase and the Cochrane Library. Eligibility, data extraction and assessment of risk of bias were assessed independently by two reviewers. A bias-adjusted meta-analysis using a quality-effects model pooled prevalence of intubation in non-traumatic brain pathologies. Forty-six studies were included in this systematic review. No studies were suitable for meta-analysis the primary outcome of survival. Thirty-nine studies reported the prevalence of intubation in non-traumatic brain pathologies and a meta-analysis showed that emergency intubation was used in 12% (95% CI 0-33) of pathologies. Endotracheal intubation was used commonly in haemorrhagic stroke 79% (95% CI 47-100) and to a lesser extent for seizures 18% (95% CI 10-27) and toxidromes 25% (95% CI 6-48). This systematic review shows that there is no high-quality clinical evidence to support or refute emergency intubation in non-traumatic brain pathologies. Our analysis shows that intubation is commonly used in non-traumatic brain pathologies, and the need for rigorous evidence is apparent.
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Affiliation(s)
- Pieter F Fouche
- Department of Community Emergency Health and Paramedic Practice, Monash University, Melbourne, Victoria, Australia
| | - Christopher Stein
- Department of Emergency Medical Care, University of Johannesburg, Johannesburg, South Africa
| | | | - Malcolm Boyle
- School of Medicine, Griffith University, Griffith, Queensland, Australia
| | - Stephen Bernard
- Research and Evaluation, Ambulance Victoria, Melbourne, Victoria, Australia
| | - Karen Smith
- Research and Evaluation, Ambulance Victoria, Melbourne, Victoria, Australia
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Silverman EC, Sporer KA, Lemieux JM, Brown JF, Koenig KL, Gausche-Hill M, Rudnick EM, Salvucci AA, Gilbert GH. Prehospital Care for the Adult and Pediatric Seizure Patient: Current Evidence-based Recommendations. West J Emerg Med 2017; 18:419-436. [PMID: 28435493 PMCID: PMC5391892 DOI: 10.5811/westjem.2016.12.32066] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Revised: 12/14/2016] [Accepted: 12/30/2016] [Indexed: 12/26/2022] Open
Abstract
INTRODUCTION We sought to develop evidence-based recommendations for the prehospital evaluation and treatment of adult and pediatric patients with a seizure and to compare these recommendations against the current protocol used by the 33 emergency medical services (EMS) agencies in California. METHODS We performed a review of the evidence in the prehospital treatment of patients with a seizure, and then compared the seizure protocols of each of the 33 EMS agencies for consistency with these recommendations. We analyzed the type and route of medication administered, number of additional rescue doses permitted, and requirements for glucose testing prior to medication. The treatment for eclampsia and seizures in pediatric patients were analyzed separately. RESULTS Protocols across EMS Agencies in California varied widely. We identified multiple drugs, dosages, routes of administration, re-dosing instructions, and requirement for blood glucose testing prior to medication delivery. Blood glucose testing prior to benzodiazepine administration is required by 61% (20/33) of agencies for adult patients and 76% (25/33) for pediatric patients. All agencies have protocols for giving intramuscular benzodiazepines and 76% (25/33) have protocols for intranasal benzodiazepines. Intramuscular midazolam dosages ranged from 2 to 10 mg per single adult dose, 2 to 8 mg per single pediatric dose, and 0.1 to 0.2 mg/kg as a weight-based dose. Intranasal midazolam dosages ranged from 2 to 10 mg per single adult or pediatric dose, and 0.1 to 0.2 mg/kg as a weight-based dose. Intravenous/intrasosseous midazolam dosages ranged from 1 to 6 mg per single adult dose, 1 to 5 mg per single pediatric dose, and 0.05 to 0.1 mg/kg as a weight-based dose. Eclampsia is specifically addressed by 85% (28/33) of agencies. Forty-two percent (14/33) have a protocol for administering magnesium sulfate, with intravenous dosages ranging from 2 to 6 mg, and 58% (19/33) allow benzodiazepines to be administered. CONCLUSION Protocols for a patient with a seizure, including eclampsia and febrile seizures, vary widely across California. These recommendations for the prehospital diagnosis and treatment of seizures may be useful for EMS medical directors tasked with creating and revising these protocols.
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Affiliation(s)
- Eric C. Silverman
- University of California, San Francisco, School of Medicine, Department of Emergency Medicine, San Francisco, California
| | - Karl A. Sporer
- University of California, San Francisco, Department of Emergency Medicine, San Francisco, California
| | - Justin M. Lemieux
- Stanford School of Medicine, Department of Emergency Medicine, Stanford, California
| | - John F. Brown
- University of California, San Francisco, School of Medicine, Department of Emergency Medicine, San Francisco, California
| | - Kristi L. Koenig
- University of California, Irvine, School of Medicine, Department of Emergency Medicine, Irvine, California
| | - Marianne Gausche-Hill
- University of California, Los Angeles, David Geffen School of Medicine, Department of Emergency Medicine, Los Angeles, California
- Harbor-UCLA Medical Center, Department of Emergency Medicine, Torrance, California
| | | | | | - Greg H. Gilbert
- Stanford School of Medicine, Department of Emergency Medicine, Stanford, California
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Osborne A, Taylor L, Reuber M, Grünewald RA, Parkinson M, Dickson JM. Pre-hospital care after a seizure: Evidence base and United Kingdom management guidelines. Seizure 2014; 24:82-7. [PMID: 25264355 DOI: 10.1016/j.seizure.2014.09.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Revised: 08/08/2014] [Accepted: 09/01/2014] [Indexed: 11/25/2022] Open
Abstract
PURPOSE Seizures are a common presentation to pre-hospital emergency services and they generate significant healthcare costs. This article summarises the United Kingdom (UK) Ambulance Service guidelines for the management of seizures and explores the extent to which these guidelines are evidence-based. METHODS Summary of the Clinical Practice Guidelines of the UK Joint Royal Colleges Ambulance Liaison Committee relating to the management of seizures. Review of the literature relating to pre-hospital management of seizure emergencies. RESULTS Much standard practice relating to the emergency out of hospital management of patients with seizures is drawn from generic Advanced Life Support (ALS) guidelines although many patients do not need ALS during or after a seizure and the benefit of many ALS interventions in seizure patients remains to be established. The majority of studies identified pertain to medical treatment of status epilepticus. These papers show that benzodiazepines are safe and effective but it is not possible to draw definitive conclusions about the best medication or the optimal route of administration. CONCLUSION The evidence base for current pre-hospital guidelines for seizure emergencies is incomplete. A large proportion of patients are transported to hospital after a seizure but many of these may be suitable for home management. However, there is very little research into alternative care pathways or criteria that could be used to help paramedics avoid transport to hospital. More research is needed to improve care for people after a seizure and to improve the cost-effectiveness of the healthcare systems within which they are treated.
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Affiliation(s)
- Andrew Osborne
- Academic Unit of Primary Medical Care, The Medical School, The University of Sheffield, Samuel Fox House, Northern General Hospital, Herries Road, Sheffield S5 7AU, South Yorkshire, United Kingdom.
| | - Louise Taylor
- Academic Unit of Primary Medical Care, The Medical School, The University of Sheffield, Samuel Fox House, Northern General Hospital, Herries Road, Sheffield S5 7AU, South Yorkshire, United Kingdom.
| | - Markus Reuber
- Academic Neurology Unit, The University of Sheffield, Royal Hallamshire Hospital, Glossop Road, Sheffield S10 2JF, South Yorkshire, United Kingdom.
| | - Richard A Grünewald
- Academic Neurology Unit, The University of Sheffield, Royal Hallamshire Hospital, Glossop Road, Sheffield S10 2JF, South Yorkshire, United Kingdom.
| | - Martin Parkinson
- Yorkshire Ambulance Service NHS Trust, Springhill 2, Brindley Way, Wakefield 41 Business Park, Wakefield WF2 0XQ, West Yorkshire, United Kingdom.
| | - Jon M Dickson
- Academic Unit of Primary Medical Care, The Medical School, The University of Sheffield, Samuel Fox House, Northern General Hospital, Herries Road, Sheffield S5 7AU, South Yorkshire, United Kingdom.
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Abstract
OBJECTIVE This study aimed to quantify risk factors for apnea in children 0 to 5 years of age with out-of-hospital seizure. METHODS This is a retrospective study of pediatric patients with seizure transported by paramedics to the pediatric emergency department (PED) of a tertiary center from July 2008 to June 2009. Patients with traumatic injury and those with another diagnosis after PED evaluation were excluded. We evaluated the effect of field diazepam and other potential risk factors on the occurrence of apnea, defined as the need for airway management, that is, bag-mask ventilation by paramedics or bag-mask ventilation or intubation by PED staff within 30 minutes of arrival. RESULTS There were 336 pediatric patients meeting inclusion criteria. The median age was 1.9 years (interquartile range,1.3-3.0 years); 193 patients (57%) were male. Fifty-four patients (16%) were treated with diazepam before PED arrival. There were 28 apneic events (8.3%). The adjusted relative risk for apnea given diazepam in the field by any route was 10.2 (95% confidence interval, 3.9-21.8; P < 0.0001), adjusted for age and seizure on arrival. Persistent seizure on PED arrival was also highly associated with apnea, with an adjusted relative risk of 15.8 (95% confidence interval, 6.5-28.9; P < 0.0001). CONCLUSIONS Field treatment with diazepam and seizing at the time of PED arrival are associated with the occurrence of apnea in children 0 to 5 years of age with out-of-hospital seizure. Larger studies are needed to determine what other factors may contribute to this risk.
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Beskind DL, Rhodes SM, Stolz U, Birrer B, Mayfield TR, Bourn S, Denninghoff K. When should you test for and treat hypoglycemia in prehospital seizure patients? PREHOSP EMERG CARE 2014; 18:433-41. [PMID: 24459993 DOI: 10.3109/10903127.2013.864358] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
OBJECTIVES Seizure is a frequent reason for activating the Emergency Medical System (EMS). Little is known about the frequency of seizure caused by hypoglycemia, yet many EMS protocols require glucose testing prior to treatment. We hypothesized that hypoglycemia is rare among EMS seizure patients and glucose testing results in delayed administration of benzodiazepines. METHODS This was a retrospective study of a national ambulance service database encompassing 140 ALS capable EMS systems spanning 40 states and Washington DC. All prehospital calls from August 1, 2010 through December 31, 2012 with a primary or secondary impression of seizure that resulted in patient treatment or transport were included. Median regression with robust and cluster (EMS agency) adjusted standard errors was used to determine if time to benzodiazepine administration was significantly related to blood glucose testing. RESULTS Of 2,052,534 total calls, 76,584 (3.7%) were for seizure with 53,505 (69.9%) of these having a glucose measurement recorded. Hypoglycemia (blood glucose <60 mg/dL) was present in 638 (1.2%; CI: 1.1, 1.3) patients and 478 (0.9%; CI: 0.8, 1.0) were treated with a glucose product. A benzodiazepine was administered to 73 (11.4%; CI: 9.0, 13.9) of the 638 hypoglycemic patients. Treatment of seizure patients with a benzodiazepine occurred in 6,389 (8.3%; CI: 8.1, 8.5) cases and treatment with a glucose product occurred in 975 (1.3%; CI: 1.2, 1.4) cases. Multivariable median regression showed that obtaining a blood glucose measurement prior to benzodiazepine administration compared to no glucose measurement or glucose measurement after benzodiazepine administration was independently associated with a 2.1 minute (CI: 1.5, 2.8) and 5.9 minute (CI: 5.3, 6.6) delay to benzodiazepine administration by EMS, respectively. CONCLUSIONS Rates of hypoglycemia were very low in patients treated by EMS for seizure. Glucose testing prior to benzodiazepine administration significantly increased the median time to benzodiazepine administration. Given the importance of rapid treatment of seizure in actively seizing patients, measurement of blood glucose prior to treating a seizure with a benzodiazepine is not supported by our study. EMS seizure protocols should be revisited.
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Shah MI, Macias CG, Dayan PS, Weik TS, Brown KM, Fuchs SM, Fallat ME, Wright JL, Lang ES. An Evidence-based Guideline for Pediatric Prehospital Seizure Management Using GRADE Methodology. PREHOSP EMERG CARE 2013; 18 Suppl 1:15-24. [DOI: 10.3109/10903127.2013.844874] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Bosson N, Santillanes G, Kaji AH, Fang A, Fernando T, Huang M, Lee J, Gausche-Hill M. Risk factors for apnea in pediatric patients transported by paramedics for out-of-hospital seizure. Ann Emerg Med 2013; 63:302-8.e1. [PMID: 24120630 DOI: 10.1016/j.annemergmed.2013.09.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2013] [Revised: 08/22/2013] [Accepted: 09/12/2013] [Indexed: 11/25/2022]
Abstract
STUDY OBJECTIVE Apnea is a known complication of pediatric seizures, but patient factors that predispose children are unclear. We seek to quantify the risk of apnea attributable to midazolam and identify additional risk factors for apnea in children transported by paramedics for out-of-hospital seizure. METHODS This is a 2-year retrospective study of pediatric patients transported by paramedics to 2 tertiary care centers. Patients were younger than 15 years and transported by paramedics to the pediatric emergency department (ED) for seizure. Patients with trauma and those with another pediatric ED diagnosis were excluded. Investigators abstracted charts for patient characteristics and predefined risk factors: developmental delay, treatment with antiepileptic medications, and seizure on pediatric ED arrival. Primary outcome was apnea defined as bag-mask ventilation or intubation for apnea by paramedics or by pediatric ED staff within 30 minutes of arrival. RESULTS There were 1,584 patients who met inclusion criteria, with a median age of 2.3 years (Interquartile range 1.4 to 5.2 years). Paramedics treated 214 patients (13%) with midazolam. Seventy-one patients had apnea (4.5%): 44 patients were treated with midazolam and 27 patients were not treated with midazolam. After simultaneous evaluation of midazolam administration, age, fever, developmental delay, antiepileptic medication use, and seizure on pediatric ED arrival, 2 independent risk factors for apnea were identified: persistent seizure on arrival (odds ratio [OR]=15; 95% confidence interval [CI] 8 to 27) and administration of field midazolam (OR=4; 95% CI 2 to 7). CONCLUSION We identified 2 risk factors for apnea in children transported for seizure: seizure on arrival to the pediatric ED and out-of-hospital administration of midazolam.
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Affiliation(s)
- Nichole Bosson
- Department of Emergency Medicine, Harbor-UCLA Medical Center, and the Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, CA; David Geffen School of Medicine at UCLA, Los Angeles, CA.
| | - Genevieve Santillanes
- Keck School of Medicine of the University of Southern California, Department of Emergency Medicine, Los Angeles, CA
| | - Amy H Kaji
- Department of Emergency Medicine, Harbor-UCLA Medical Center, and the Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, CA; David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Andrea Fang
- Department of Emergency Medicine, Harbor-UCLA Medical Center, and the Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, CA
| | - Tasha Fernando
- David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Margaret Huang
- Keck School of Medicine of the University of Southern California, Department of Emergency Medicine, Los Angeles, CA
| | - Jumie Lee
- Department of Emergency Medicine, Harbor-UCLA Medical Center, and the Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, CA; School of Nursing, University of California, Los Angeles, CA
| | - Marianne Gausche-Hill
- Department of Emergency Medicine, Harbor-UCLA Medical Center, and the Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, CA; David Geffen School of Medicine at UCLA, Los Angeles, CA
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Michael GE, O'Connor RE. The diagnosis and management of seizures and status epilepticus in the prehospital setting. Emerg Med Clin North Am 2010; 29:29-39. [PMID: 21109100 DOI: 10.1016/j.emc.2010.08.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Seizure is one of the most common complaints encountered in the prehospital setting. In this review the authors discuss the prehospital management of seizures and review the evidence for specific treatment approaches. Specific attention is devoted to prehospital care of the pediatric seizure patient. Topics of interest to Emergency Medical Services directors such as patient refusal, resource allocation, and dispatch priority are also addressed.
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Affiliation(s)
- Glen E Michael
- Department of Emergency Medicine, University of Virginia School of Medicine, PO Box 800699, Charlottesville, VA 22908, USA
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Warden CR, Frederick C. Midazolam and diazepam for pediatric seizures in the prehospital setting. PREHOSP EMERG CARE 2007; 10:463-7. [PMID: 16997775 DOI: 10.1080/10903120600885126] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVE The objective of this study was to compare the efficacy and adverse events associated with the use of diazepam and midazolam for the treatment of pediatric seizures in the prehospital setting. METHODS This was a retrospective cohort study of all patients younger than 18 years treated for a seizure with a benzodiazepine by emergency medical services in Multnomah County, Oregon, from 1998 to 2001. The emergency medical services system consists of a single private advanced life support transporting ambulance service with fire department first responders that are all advanced life support capable. The benzodiazepine used changed from diazepam to midazolam at the midpoint of this period. The primary outcomes were termination of the seizure by arrival to the emergency department (ED), recurrence of seizure while in the ED, or the requirement for active airway interventions including intubation. The two cohorts were also compared for demographics, past history of seizures, long-term use of seizure medications, response times, route of administration, use of second doses of benzodiazepines, and final disposition. RESULTS Forty-five patients were treated with diazepam, and 48 were treated with midazolam. The two cohorts were comparable except the diazepam cohort had a significantly increased proportion of patients with previous afebrile seizures (53% vs. 25%; p = 0.005). The midazolam cohort had an increased use of nonintravenous route for initial dosing (65% vs. 42%; p = 0.02). The two cohorts were equivalent in rates of termination of seizures before to ED arrival, recurrence of seizures in the ED, requiring airway support or a second dose of benzodiazepine, and admission to the hospital. CONCLUSIONS Diazepam and midazolam appear to be equivalent in treating seizures and causing adverse events. Paramedics appear to be administering midazolam intramuscularly more often than they use diazepam rectally.
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Affiliation(s)
- Craig R Warden
- Department of Emergency Medicine, Oregon Health & Science University, Portland, OR 97239, USA.
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Sayre MR, White LJ, Brown LH, McHenry SD. The National EMS Research strategic plan. PREHOSP EMERG CARE 2005; 9:255-66. [PMID: 16147473 DOI: 10.1080/10903120590962238] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
One of the eight major recommendations put forth by the National EMS Research Agenda Implementation Project in 2002 was the development of an emergency medical services (EMS) research strategic plan. Using a modified Delphi technique along with a consensus conference approach, a strategic plan for EMS research was created. The plan includes recommendations for concentrating efforts by EMS researchers, policy makers, and funding resources with the ultimate goal of improving clinical outcomes. Clinical issues targeted for additional research efforts include evaluation and treatment of patients with asthma, acute cardiac ischemia, circulatory shock, major injury, pain, acute stroke, and traumatic brain injury. The plan calls for developing, evaluating, and validating improved measurement tools and techniques. Additional research to improve the education of EMS personnel as well as system design and operation is also suggested. Implementation of the EMS research strategic plan will improve both the delivery of services and the care of individuals who access the emergency medical system.
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Affiliation(s)
- Michael R Sayre
- Department of Emergency Medicine, The Ohio State University, Columbus Ohio 43220, USA.
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