Case summary:

An ALS crew responded to a 1-year-old who was seizing.  When the crew arrived, the patient was being carried by his mother outside to meet the crew.  She reported that he had a high fever earlier that day and had seized for ~20m before the crew arrived but the seizure had stopped.  The crew noted that the patient was only responding to painful stimuli and had a patent airway.  They placed him on oxygen and were attempting to obtain initial vitals when he seized again.  The crew used a Broselow tape to estimate his weight and administered the appropriate weight-based dose per protocol of intramuscular (IM) midazolam.  The seizure stopped after a couple of minutes.  The crew obtained the following vitals while attempting to place an IV:

Vitals: BP 106/65,  HR 165  RR 60,  Sat 100% on O2, glucose: 211, ETCO2 35 mmHg

The IV attempt was not successful so the crew placed a tibial interosseous (IO) line.  The patient seized again so the crew gave the weight-based dose of midazolam IO as well as gave a bolus of normal saline.  The seizure broke again, and the crew began transport.  During transport, the patient seized again and was given another dose of IO midazolam.  The airway remained patent the entire time, but the patient remained post-ictal and did not return to his baseline while under EMS care.

Highlights of the case:

Early use of benzodiazepines is key for the treatment of status epilepticus.

This patient meets the definition for status epilepticus.  Any patient who is seizing for more than 15 minutes without stopping or who has multiple seizures without ever returning completely to his/her neurologic baseline would be considered to have status epilepticus.  Status epilepticus has high morbidity and mortality since seizures can irreversibly damage the brain and the longer someone seizes, the harder it is to break the seizure.  For this reason, any patient who is seizing should be given a benzodiazepine as soon as possible by whatever route is available at that time.  If you have an IV, then by all means use it!  However, if you do not have one yet, the patient should be given an IM dose since we do not want to delay administration for IV placement.  In addition, placing an IV on an actively seizing patient is very difficult.  In addition to getting the medication on board right away, we also need to make sure we give the correct dose since underdosing can be the reason that the seizure failed to terminate.  It is easy to underdose children so we want to quickly and accurately calculate the proper dose based in either the families report of the patients weight or a validated tool (such as Broselow tape).  The doses we give children might seem high and I have heard providers mention concerns that the patient could lose their airway from getting too much of a benzodiazepine.  While we do worry about sedation with the use of benzodiazepines, the seizure itself is more likely to compromise an airway than the benzodiazepine so we should actually be more concerned about underdosing than overdosing.  This crew provided fantastic treatment to a critically ill patient in status epilepticus.  They gave benzodiazepines early and often to give this patient his best possible chance at a good outcome.

Always check a glucose level on all altered patients and all seizure patients.

While this patient was not hypoglycemic, this crew absolutely did the correct thing checking a glucose level.  All patients who are altered or seizing should be considered hypoglycemic until proven otherwise.  The reason for this is that hypoglycemia is life-threatening when not immediately address and is both easy to diagnose and easy to treat in the field.  In patients who are seizing, it is important to consider checking glucose levels multiple times.  The reason is that when patients seize, the seizure itself uses loads of energy which chews through glucose stores.  While the seizure might not initially have been due to hypoglycemia, if it persists for long enough, it can cause hypoglycemia.  The new hypoglycemia might be leading to ongoing seizures.