Chloe Knudsen-Robbins, University of Cincinnati College of Medicine, Cincinnati, OH, United States; Jacqueline Raetz-Vigon, CHOC Children's Hospital of Orange County, Irvine, CA, United States; Madison Palarca-Wong, University of California, Irvine, School of Medicine, Irvine, CA, United States; Tiffany Lao, CHOC Children's Hospital of Orange County, Orange, CA, United States; Anahita Darabpour, CHOC Children's Hospital of Orange County, 273 Richland rd, CA, United States; Raymond Nguyen, CHOC Children's Hospital of Orange County, Anaheim, CA, United States; Catherine Roman-Estrada, CHOC Children's Hospital of Orange County, Carson, CA, United States; Mingfei Dong, CHOC Children's Hospital of Orange County, Los Angeles, CA, United States; Shelby K. Shelton, Children's Hospital of Orange County, Orange, CA, United States; Theodore Heyming, CHOC Children's Hospital of Orange County, Orange, CA, United States
Manager Clinical Research Programs (ED) Children's Hospital of Orange County Orange, California, United States
Background: Seizures are among the most frequent medical calls for pediatric EMS transport. Seizures carry significant risk including direct neuronal damage and respiratory compromise, and prehospital treatment has been shown to positively affect outcomes. However, prehospital seizure protocols vary from locale to locale, and studies have demonstrated that adherence to these protocols in the field remains scattered. Objective: The objective of this study was to examine patient outcomes following the prehospital administration of 0.1 versus 0.2 mg/kg of intramuscular (IM) midazolam. Design/Methods: This was a retrospective cohort study of pediatric patients ( < 15 years) transported by EMS to the ED of a quaternary care pediatric hospital between 1/2020-9/2022 (T1) and 10/2022-8/2024 (T2). The county EMS standing order for IM midazolam increased from 0.1 to 0.2 mg/kg in October 2022. Data were abstracted from the EMS and ED charts. Data were analyzed using descriptive statistics, Pearson's Chi-squared test, Fisher's exact test, Pearson's Chi-squared test, and Wilcoxon rank sum test. Results: 459 patients were included in this study. The mean age was 4.8 years, 51% of patients were male. EMS administered midazolam to 459 patients; 457 patients had an EMS-witnessed seizure. Overall, 48% of patients were discharged home, 27% were admitted to floor status, and 21% were admitted to the Intensive Care Unit (ICU). 23% of patients had a seizure in the ED, 16% were intubated in the ED. In T1 30% of patients received 0.00-0.05mg/kg, 35% received 0.05-0.15mg/kg, 30% received 0.15-0.25mg/kg, and 5.5% received 0.25-0.5mg/kg. In T2 40% received 0.00-0.05mg/kg, 17% received 0.05-0.15 mg/kg, 39% received 0.15-0.25mg/kg, and 3.5% received 0.25-0.5mg/kg. Administration of 0.16-0.24 mg/kg was associated with a lower proportion of lorazepam administration in the ED (p=0.031). More patients in T2 were discharged home or admitted to the ICU compared to T1 (p=0.05); T2 was also associated with an increased proportion of patients requiring intubation or a midazolam drip (p=0.034, p=0.009).
Conclusion(s): These results suggest that prehospital Midazolam dosing in the pediatric population is inexact, likely secondary to a range of factors. In T2 we noted an increase in patients who were able to be discharged home, and decreased ED lorazepam use, though we also found an increase in patients requiring ICU admission, intubation in the ED, and benzodiazepine drips. Further detailed investigation may demonstrate if increased prehospital midazolam dosing is associated with improved efficacy or increased risk of negative outcomes.
