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Study Seeks Risk Factors for Apnea in Pediatric Seizure Patients

WORTH THE RISK?
Bosson N, Santillanes G, Kaji A, et al. Risk factors for apnea in pediatric patients transported by paramedics for out-of-hospital seizure. Ann Emerg Med. 2014;63(3):302–308.

Prior research has shown that seizure is among the most common reasons for EMS transports of pediatric patients. Midazolam (Versed) has grown to prominence in the prehospital setting for treatment of seizures, and all EMS providers should be familiar with the possible side effects of parenteral benzodiazepines, such as apnea and hypotension. Apnea specifically poses a large danger to the pediatric patient, as hypoxia and respiratory failure rank as the leading cause of pediatric cardiac arrest. The Los Angeles-based authors of this study were curious to see if other factors were predictive of apnea in pediatric seizure patients.

Retrospective chart review was conducted on pediatric patients under 15 years of age who were transported by EMS to two pediatric EDs in the Los Angeles area from January 2010 to December 2011. During the study period, paramedics had access to Broselow tapes to estimate patient weight as well as wiring-based doses per kg of midazolam for treatment of seizures.

Patients treated in the ED with a diagnosis of seizure without an associated traumatic injury were included in chart review. Patients brought by private vehicle, brought via interfacility transfer, or who were treated for trauma, were excluded. During the study period, 2,403 patients were seen in the ED and of those, 1,584 (66%) met the criteria for research.

Results: Of the 1,584 seizure patients transported, 214 (14%) were given midazolam during transport with IV administration being the most common route. The median dose administered was 0.09 mg/kg, which is consistent with protocol-based dosing. There’s no information listed on how many patients required multiple doses of prehospital midazolam. Half of the patients were diagnosed in the ED with simple febrile seizures.

Apnea developed in 71 (4.5%) patients during care. Of those, 44 (62%) patients were given midazolam by paramedics, while the other 27 (38%) were not. Analysis of variables shows that apnea was most likely due to ongoing seizure activity at ED arrival and prehospital administration of midazolam. No other variables, including fever, developmental delay or home administration of rectal diazepam, were a contributing factor for apnea during treatment of seizure.

Discussion: Despite this article being available online earlier in the year, it’s worth a second look. It should be no surprise that administration of midazolam contributes to apnea; however, the need to terminate seizure activity certainly outweighs the risk of apnea, which is easily identified and treated. Although not directly addressed, we also feel this article makes a great case for the use of non-invasive end-tidal capnography on the seizure patient to recognize apnea early and begin treatment as soon as possible. Despite being a retrospective review, this article offers good information on a frequently addressed call by EMS providers. We’d like to thank the authors for publishing great research.

BOTTOM LINE
What we know: Seizures rank among the most common reasons for transports in pediatric patients. Although benzodiazepines are effective at terminating seizure activity, they have side effects that must be closely monitored. Prolonged seizure activity may also cause apnea.

What this study adds: Specific risk factors, including the administration of benzodiazepines, may be predictive of apnea.

WATCH BOX
Taylor J, McLaughlin K, McRae A, et al. Use of prehospital ultrasound in North America: A survey of emergency medical services medical directors. BMC Emerg Med. 2014;14:6. [Epub Mar. 1, 2014.]

Ultrasound has proven its worth as a rapid, non-invasive method of identifying life threats, such as abdominal bleeding and pneumothorax, in the ED. Recently, portable ultrasound devices have sporadically made their way to the prehospital setting. Researchers from Calgary, Alberta, and Vancouver, British Columbia, sent surveys to EMS medical directors in the United States and Canada to determine the characteristics of services using ultrasound and, for those who don’t use it, the reasons why those services aren’t using it.

Of the 766 surveys sent, 255 (30%) were completed. Of the agencies completing the survey, 9 (4%) reported using ultrasound actively and 46 (18%) agencies were considering future implementation. Due to the number of agencies using ultrasound, there isn’t much further information available; however, all the medical directors of agencies using prehospital ultrasound feel it improves patient care. Cost of equipment and cost of training were the most frequently cited reasons by medical directors in services where ultrasound was not actively in use. Interestingly, 97 (38%) agencies felt there wasn’t enough research to support the use of prehospital ultrasound.

In the future, we hope to see more research to support the use of prehospital ultrasound. Research like this suggests a gap in knowledge of how this device could be beneficial in the prehospital setting.

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