EMT Standing Order:

• Routine Patient Care.
• Check finger stick glucose by glucometer. If the blood glucose reading is < 60 mg/dl, (3.3 mmol\dl (treat patient for seizures and see Diabetic Emergencies (Hypoglycemia) Protocol - Adult (3 medical)))
• If diazepam rectal gel or intranasal midazolam (Versed) has been prescribed by the patient’s physician, assist the patient or caregiver with administration in accordance with the physician’s instructions.
• Call for AEMT/Paramedic intercept. & Assisst AEMT/Paramedic in patient care.

AEMT/Paramedic Standing Order

• Do not delay administration of medications to start IV.
• For seizure lasting > 5 minutes (status epilepticus), administer:
• Midazolam 10 mg IM (preferred) or intranasal, may repeat 10 mg IM or intranasal every 10 minutes (maximum dose 20 mg) (Note: a 5 mg/mL concentration is recommended for IM/intranasal administration.); OR
• Midazolam 5 mg IV repeated every 5 minutes until seizure activity is resolved (maximum dose 20 mg) OR
• Diazepam 5 - 10 mg IV, then 2.5 mg every 5 minutes (maximum dose 20 mg).
• Consider magnesium sulfate, 4 grams in 10 mL D5W or 0.9% NaCl slow IV push over 5 minutes, in the presence of seizures in the third trimester of pregnancy or post-partum.
• Contact Medical Direction for additional dosing.

PEARLS:

• Do not attempt to restrain the patient; protect the patient from injury.
• History preceding a seizure is very important. Find out what precipitated the seizure (e.g., medication non-compliance, infection, seizure history, trauma, hypoglycemia, alcohol/substance abuse, third-trimester pregnancy or post-partum).
• Post-partum patients may experience eclamptic seizures up to several weeks after giving birth.
• Status epilepticus is defined as any generalized seizure lasting more than 5 minutes. This is a true emergency requiring rapid airway control, treatment (including benzodiazepines), and transport.
• Any seizure still present upon EMS arrival and/or lasting more than 5 minutes should be treated with benzodiazepines.
• Diazepam and lorazepam are not effective when administered IM and should be given IV.
• The preferred initial dose of benzodiazepine is midazolam IM/intranasal. After initial dose, establish an IV in case additional medication doses are needed. If an IV is already established, administer benzodiazepine IV.