For this EMS protocol review, I wanted to focus on prehospital seizure treatment. Both the adult and pediatric algorithms are the same and utilize the same medications and weight based dosing. Paramedics are authorized to utilize 3 different benzodiazepines to treat active seizures:
Midazolam (Versed) 0.2mg/kg IV/IN/IM. If effect is not achieved, may be repeated after 5 minutes. Max single dose is 5mg and max cumulative dose is 10mg.
Lorazepam (Ativan) 0.1mg/kg IV/IN/IM. If effect is not achieved, may be repeated after 5 minutes. Max single dose is 2mg and max cumulative dose is 4mg.
Diazepam (Valium) 0.2mg/kg IV, infused over 1 minute. If effect is not achieved, may be repeated after 5 minutes. Max single dose is 5mg and max cumulative dose is 10mg.
The Medical Control Option for refractory seizures is to administer additional doses of any of these standing order medications. Some considerations for medication choice include availability, as Lorazepam requires refrigeration is not always carried, nor is IV Diazepam due to supply issues. Of these 3 medications, Midazolam is the fastest acting. With mounting doses of benzodiazepines, loss of spontaneous breathing should be a consideration, but typically can be outweighed by ceasing the seizure activity.
Finally, some patients with known seizure disorders, usually pediatrics, will have home prescriptions for PR diazepam, also known as Diastat. Occasionally, you will receive calls from EMS asking if they can administer this home medication. This formulation is not in the algorithm and has a much more erratic absorption than other routes of benzodiazepine administration. Because EMS is already present and has access to faster acting and more reliable medications like Midazolam, this should be administered instead.
Check out the RAMPART trial for a more in depth study on IM vs IV benzodiazepines and their efficacy!