From the FDA Drug Label
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From the Research
The NSW Ambulance Clinical Practice Guidelines (CPG) for seizure management recommend a stepwise approach to treating patients experiencing seizures, prioritizing midazolam as the first-line medication for active seizures lasting more than 5 minutes, administered at 5mg IV/IO or 10mg IM/IN for adults (0.15mg/kg for pediatric patients, maximum 10mg) 1.
Key Considerations
- Ensure patient safety by protecting the head, maintaining airway patency, and administering oxygen if required.
- For active seizures lasting more than 5 minutes, midazolam is the preferred medication due to its efficacy and rapid onset of action, as supported by recent studies 2, 1.
- If seizures persist after 5 minutes, a second dose of midazolam may be given, considering the potential benefits of repeated doses in refractory status epilepticus 3.
- For refractory status epilepticus, levetiracetam (Keppra) 1000-2000mg IV over 15 minutes for adults (20-60mg/kg for pediatrics) may be considered, based on its favorable tolerability profile and effectiveness in established status epilepticus 3.
Addressing Underlying Causes
- Paramedics should also address potential underlying causes such as hypoglycemia by checking blood glucose levels and administering glucose if levels are below 4mmol/L.
- Febrile seizures in children should be managed with antipyretics like paracetamol, considering the importance of controlling fever in this population.
Recent Evidence
- A recent study published in 2024 highlights the importance of benzodiazepines in the treatment of seizure clusters, with midazolam nasal spray and diazepam nasal spray being FDA-approved options for this indication 1.
- The study also discusses the potential benefits of seizure action plans and candidates for their use, emphasizing the need for individualized treatment approaches.
Prioritizing Morbidity, Mortality, and Quality of Life
- The recommended approach prioritizes terminating seizure activity quickly to prevent neuronal damage and complications from prolonged seizures, as status epilepticus becomes increasingly resistant to treatment over time and can lead to significant morbidity and mortality if not promptly controlled 2, 1.