Pediatric Seizure Management in the Out-Of-Hospital Environment
Michael Lohmeier MD, Vanessa Tamas MD
If you were to ask the average person to describe a seizure, they would likely compare it to the portrayals they have seen in television and film - a person lying on the ground, eyes closed and unconscious with rhythmic shaking of the extremities while foaming at the mouth. Indeed, even some medical providers would paint a similar picture. But because they have incompletely myelinated neurons, pediatric seizures often lack this stereotypical presentation and may be exceptionally subtle as a result. They are often overlooked or misinterpreted, resulting in a delay to appropriate termination of the seizure. These nuanced presentations are further highlighted when Emergency Medical Services (EMS) Providers are tasked to quickly and accurately assess the pediatric patient with undifferentiated altered mental status. They often receive minimal collateral information and usually have a limited clinical exposure to these relatively infrequent patients.
Previous studies have estimated that pediatric patients make up approximately 13% of EMS transports (1), and that pediatric seizures comprise 5-8% of pediatric calls (2). Research into the prehospital management of seizures has primarily focused on the efficacy of various benzodiazepines and their routes of administration (intra-nasal, intramuscular, and intravenous) for the termination of seizure activity (3-7). However, these studies have not addressed the accuracy with which EMS Providers can identify a pediatric patient with active seizure activity.
Consistent with the national experience, pediatric patients in Dane County, Wisconsin make up the minority of activations for the 9-1-1 system, with very few requiring Advanced Life Support (ALS) level skill during evaluation and management. As such, EMS Providers have infrequent contact with critically ill pediatric patients, limiting their opportunity to advance their skills and knowledge base.
As the first significant endeavor into Dane County EMS Quality Improvement (QI), all pediatric seizure calls for the 2014 calendar year were reviewed with emphasis on cases treated at our institution. All 9-1-1 calls coded as pediatric seizure with patient contact by EMS were reviewed for the following: Vital Signs, physical exam findings, medication administration and EMS provider narrative. These reports were then compared with the physical exam findings, medication records, physician notes and final diagnoses from the receiving institution. After close comparison of the out-of-hospital with the in-hospital documentation, it was determined that approximately 10-15% of cases were actively seizing on arrival to the Emergency Department, and were believed to be under recognized by the EMS Providers.
Based on this data, we felt that an intervention was necessary. We first developed a Continuing Medical Education lecture for EMS Providers, with stress on the pathophysiology of seizure disorders in children as well as a review of the classic and subtle presentation patterns. This educational content was delivered to all of the ALS providers participating in the Dane County ALS Consortium, and has subsequently been made available to all EMS Providers within the Dane County.
At the same time, the Pediatric Seizure algorithm within Dane County EMS Protocols was rewritten with a special highlight on key physical exam findings to help identify subtle and atypical presentations of seizure. Emphasis was placed on early identification of seizure and escalation of care to the ALS level in order to terminate seizures in a timely manner. In cases of active seizure on EMS arrival, the new algorithm encourages the provider to prioritize seizure management with intranasal midazolam over obtaining IV access, a significant paradigm shift from previous versions of this protocol.
The response to this point has been overwhelmingly positive. The Pediatric Neurologists and the Pediatric Emergency Medicine Physicians both feel that emphasizing the early identification and appropriate management of seizures will help reduce the number of under identified seizures that arrive via EMS, and should reduce the incidence of prolonged seizure. The EMS Providers feel reassured with a more structured approach to the pediatric seizure, and that less reliance on the experience of the individual will lead to fewer variations in the level of care provided.
In order to gauge the efficacy of our improvements, we plan to reassess performance at 6-month and 1-year intervals. The Pediatric EMS Medical Director will give directed feedback to individual providers as necessary. By providing specific physical exam clues and continuous feedback, we aim to decrease the percentage of pediatric patients who arrive to the Emergency Department with under recognized and untreated seizure activity.
- Shah, MN, Cushman JT, Davis CO, et al. The epidemiology of emergency medical services use by children: an analysis of the National Hospital Ambulatory Medical Care Survey. Prehosp Emerg Care 2008;12(3):269-76
- Micheal E, O’Connor RE. The diagnosis and management of seizures and status epilepticus in the prehospital setting. Emerg Med Clin N Am 2011; 29: 29-39
- Alldredge BK, Gelb AM, Isaacs SM, et al. A comparison of lorazepam, diazepam, and placebo for the treatment of out-of-hospital status epilepticus. N Engl J Med 2001;345(9):631–7.
- Warden CR, Frederick C. Midazolam and diazepam for pediatric seizures in the prehospital setting. Prehosp Emerg Care 2006;10(4):463–7.
- Chamberlain JM, Altieri MA, Futterman C, et al. A prospective, randomized study comparing intramuscular midazolam with intravenous diazepam for the treatment of seizures in children. Pediatr Emerg Care 1997;13(2):92–4.
- Vilke GM, Sharieff GQ, Marino A, et al. Midazolam for the treatment of out-of-hospital pediatric seizures. Prehosp Emerg Care 2002;6(2):215–7.
- Holsti M, Sill BL, Firth SD, et al. Prehospital intranasal midazolam for the treatment of pediatric seizures. Pediatr Emerg Care 2007;23(3):148–53.