Dr. Peter Antevy reviews Harvard/UCLA data on 770 pediatric seizure patients and proposes a simpler EMS algorithm: give benzodiazepine first (midazolam 0.2 mg/kg IM/IN), then check blood glucose only if the child stays altered. Only 0.5% of actively seizing kids were hypoglycemic, so routine glucose testing wastes time.
Questions this video answers
770
84 (about 14%)
4 (about 0.5% of total)
0.2 mg/kg IM or IN
≥60 mg/dL
Chapters
Hello everyone, this is Dr. Peter Entebbe. Another edition of the Entebbe Minute. This is something really exciting I want to talk about, which is a case of a five year old seizure. Some recent data has been published to suggest that we may have a different algorithm for treating a child with a seizure. So here's my question. You arrive on scene, five year old is having a seizure, sats are 85%. What do you do first? Well, of course it's open up the airway with your two hands, throw in some oxygen. What would you do next? Would you A, check a blood sugar or B, give a dose of benzodiazepine? Let's discuss that.
And so while you're thinking of your answer, let's talk about this data that just came out. This is from Kate Remick and Marianne Gaiche Hill at Harvard ucla. They essentially look at all the pediatric seizure patients over a one year period that were brought in by EMS. And so there were 770 pediatric seizure patients in total. And it turns out that of those 770, 84 of those, about 14% were actively seizing upon arrival of EMS. And so of those patients, how many were actually hypoglycemic? It may surprise you that the answer was only 4. So this is only 0.5% of the total number of patients who were seizing actually had a low blood sugar. Now that's a very small number, right? In 2005, another study looked at about 6,000 patients, also found a very similar number of about 0.8%. So we're looking at the total number of patients who are actively seizing. And you may run on the total number of children who actually made hypoglycemic due to those as a cause of those seizures may be very low.
And that's a very important part of what we're about to discuss.
And so I'm really excited to talk about Katie Remick's and Marianne Garcia Hill's paper because it's a very nice algorithm to consider. So if you walk up to a child actively seizing, first thing you do, open airway, use your two hands, nothing else. Jaw thrust, chin lift, child's actively seizing, the first thing you do is a dose of benzodiazepine. Most people nowadays using midazolam, which is versed IM or in. In these two routes, you can go at a dose of 0.2 milligrams per kilogram.
And so first thing you do after the seasoning is not check a blood sugar, it's actually give a dose of benzo and if the child's not seizing, here's the interesting part. If the GCS is 15, they're saying no blood sugar at all, which is very interesting. Okay, now, if you've given the midazolam already, now, the next step after midazolam, now you check a blood sugar. If the GCS was not 15 and they're a little altered, then you check a blood sugar. Now, once you check a blood sugar, if it's normal, and in this study, they're looking at over 60 is normal, then you repeat midazolam. If they're still seizing, if the blood sugar is less than 60, here's where you give dextrose. And of course, you can use D10 cradle to grave. You can also use, per your protocol, D10, D25 or D50. Again, that's important here, that you check a blood sugar after the benzo and you can repeat the midazolam if the blood sugar is normal or you actually give dextrose if the blood sugar is low. Again, this is going to be very few patients that are going to come along this route right here. Most patients are going to require midazolam and stop or they'll need a repeat dose of midazolam. So great information from the folks at Harvard ucla. Remember, use your hands first, give a benzosecond, check a blood sugar. Depending on what the blood sugar is, you'll either repeat or you'll give dextrose. And interestingly, if the patient looks perfectly fine and back to baseline, they're recommending not to do a blood sugar. And I agree with that. Again, Dr. Peter Entevi for another edition of the Entebi Minute. Thank you.
