SEIZURE

Inclusion Criteria:  All patients actively seizing on EMS arrival, or who have a history of seizure lasting at least 5 minutes prior to EMS arrival.  Guidelines are included for patients whose seizure stopped prior to EMS arrival.

NOTE:  Consider alternative, organic explanations for seizures.  (A-E-I-O-U-T-I-P-S; alcohol, epilepsy (or head injury), insulin (hypoglycemia), overdose, underdose/uremia, trauma, infection, psychosis, sepsis.)

Basic Level

1. Assess and support ABCs.
2. Place the patient in a position of comfort or in left lateral recumbent position facing the rescuers.  If there is evidence of shock, place the patient supine with the feet elevated and monitor airway closely.  Treat shock according to the SHOCK Guidelines.
3. Administer oxygen, as needed, to maintain a SpO2 of at least 94%.
4. Perform POC glucose analysis.

1. If an adult patient is hypoglycemic but responsive AND can protect his or her airway, administer 1 tube (15 g) of oral glucose SL. (Pediatric patient age 1 to 13 years: administer ¼ - ½ tube SL.)
2. If symptoms persist after 10 minutes AND the patient can protect his or her own airway, administer a second tube (15 g) of oral glucose SL. (Pediatric patient 1 to 13 years old: administer ¼ - ½ tube SL.)

Advanced Level

5. Consider establishing IV access at a TKO rate or use a saline lock.  If the patient is hypotensive, treat according to the SHOCK Guidelines.
6. All patients treated under this guideline must have continuous ECG and ETCO2 monitoring.
7. If the patient is hypoglycemic AND . . .

. . . the level of consciousness does not improve with oral glucose, or if oral glucose could not be given, administer:

At least 14 years of age

• Start IV/IO, and administer 50% dextrose, 50 mL (25 grams) IVP/IO;
• If symptoms and/or hypoglycemia persist after 10 minutes, administer an additional 25 grams (50 mL).

1 year to 13 years of age

• 25% dextrose 2 mL/kg IVP/IO (waste 25 mL of D50; replace with 25 mL Normal Saline).
• If symptoms and/or hypoglycemia persist after 10 minutes, administer an additional 2 mL/kg IVP/IO.

Less than 1 year of age

• 10% dextrose 5 mL/kg IVP/IO (waste 40 mL of D50; replace with 40 mL Normal Saline).
• Contact BioTel if additional dosing is required.
• Newborn under 1 month of age: administer only 2 mL/kg.

. . . IV or IO access cannot be obtained, administer:

At least 14 years of age

• Glucagon 1 mg IM/IN/SQ.
• May repeat once after 20 min.

1 year to 13 years of age

• Glucagon 1 mg IM/IN/SQ.
• May repeat once after 20 min.

Less than 1 year of age

• Glucagon 0.5 mg IM/IN/SQ.
• May repeat once after 20 min.

8. Before administration of benzodiazepines, especially in the pediatric patient, prepare for assisted BVM ventilation with 100% oxygen and appropriately-sized equipment.
9. If the patient is actively seizing upon EMS arrival or seizes again after EMS arrival, administer a benzodiazepine until the seizure stops or until the maximum dose has been administered:

   Adult

   • Diazepam: 2.5 – 5 mg slow IVP/IO/IN/IM;
     • May repeat, if needed, up to a maximum, total, cumulative dose of 5 mg IV/IO/IM or 10 mg IN.
       
       OR
   • Midazolam 2.5 – 5 mg slow IVP/IO/IN/IM;
     • May repeat, if needed, up to a maximum, total, cumulative dose of 10 mg IV/IO/IM or 10 mg IN.
   • Closely monitor for cardiorespiratory depression and prepare for assisted ventilation.

   Pediatric

   • Midazolam:
     • INTRANASAL:
       • 1-6 months old: 0.2 mg/kg to a maximum initial dose of 1 mg.
       • More than 6 months old: 0.2 – 0.3 mg/kg to a maximum initial dose of 5 mg.
         • Divide the dose between the two nostrils, if possible.
     • INTRAVENOUS :
       • 0.15 to 0.2 mg/kg to a maximum single initial dose of 5 mg.

     OR

     • Diazepam 0.5 mg/kg per rectum, single dose (Maximum 10 mg).\
     • BioTel may order additional doses beyond standing order doses.
     • Closely monitor for cardiorespiratory depression and prepare for assisted ventilation.

   NOTE: Individual agencies may carry only one of these medications. They are not required to carry both.

For additional patient care considerations not covered under standing orders, consult BioTel.