Is Intranasal Midazolam as effective as other routes of administration—who nose?
Seizures are among the most common conditions of childhood attended by emergency medical services (EMS), forming between 6 and 9% of emergency calls to children. Delayed administration of anticonvulsants has been shown to increase in-hospital mortality. Improving prehospital management of seizures is therefore a priority for research.
In America, the National Association of State EMS Officials protocols for EMS advocate the use of intramuscular (IM) and intranasal (IN) midazolam and other medications, rather than using intravenous (IV) or intraosseous (IO) routes. Previous studies suggest that IN midazolam led to a greater need for subsequent doses, while other studies show underdosing of midazolam by EMS when dealing with children.
This retrospective cohort study used anonymised prehospital patient care records sourced from the 2018–2022 ESO data collaborative (Austin, Texas) to evaluate the association of the route of midazolam administration with the use of additional midazolam doses for children cared for by the EMS. The sample included 2923 encounters with children who were given at least one weight-appropriate dose of midazolam by EMS for a seizure. The first administrations of midazolam within the cohort were 46.3% IM, 21.8% IN and 31.9% IV. The association in logistic regression models, adjusted for age, vital signs, pulse oximetry, level of consciousness, and time spent with the patient, were evaluated.
The results showed that the median time of the first dose was similar between IM and IN midazolam administration (7.3 minutes, IQR=4.6–12.5 minutes for IM; 7.8 minutes, IQR=4.5–13.4 for IN). However, a longer time was observed for IV midazolam (13.1 minutes, IQR=8.2–19.4). A total of 626 patients (21.4%) required at least one additional dose of benzodiazepine. In those patients, the percentages based upon the route of administration of the first dose were: 21.6% IM, 25.4% IN and 18.5% IV.
The authors concluded that IN midazolam was associated with greater need of repeated benzodiazepine dosing in relation to IM administration; however, they recognised that cofounding factors may have affected this. As usual…more research required!
Improving assessment of children in the prehospital setting—it's vital!
Measuring vital signs in children is essential to assessing the risk of deterioration and informing diagnosis and management. While a system-wide paediatric observations-tracking approach is being implemented in the UK to recognise and respond to deterioration in children who are in hospital, it has been recognised that further work is required to assess the utility of paediatric early warning systems in prehospital care.
This retrospective cross-sectional study described the association between vital signs, for children in the prehospital setting, and their receipt of potentially lifesaving interventions (LSI) by EMS. EMS encounters with children (0 to <18 years) from 2022 in the National Emergency Medical Services Information System were analysed. The primary exposures were heart rate (HR), respiratory rate (RR), systolic blood pressure (SBP) and pulse oximetry; the first recorded value of each vital sign was evaluated. LSI was the primary outcome measure.
Data from 987 515 children (median age: 10 years) were analysed: 96.8% (n= 956 045) had a documented HR; 95.8% (n= 946 130) had documented RR; 90% (n= 889 173) had documented pulse oximetry; and 81.8% (n= 807 336) had documented SBP. An LSI occurred in 4.3% (n=42 609) of encounters, including 2.1% (n=20 406) respiratory procedures; 1.2% (n=12 338) resuscitative interventions; and 2.0% (n=19 295) medication administration.
The detailed statistical analysis enabled calculation of cut-off criteria for specificity (children requiring LSI) and sensitivity (children not needing LSI). Using higher specificity criteria can identify children more likely to deteriorate; these criteria could be used in prehospital protocols aimed at identifying children requiring frequent ongoing vital signs assessments and closer monitoring.
Conversely, higher sensitivity cut-off criteria can identify children at lowest risk and, therefore, facilitate the refinement of prehospital protocols relating to non-transports, including children who could be transported to hospital by basic instead of PALS providers.