Table 1.
Adult Seizure protocols.
| Midazolam | |||||
|---|---|---|---|---|---|
|
|
|||||
| LEMSA | Blood glucosre prior To BZD | IN | IM | IV/IO | Eclampsia |
| Alameda County | No | 5 mg | 0.1 mg/kg to max 6mg, give full dose IM | 0.1 mg/kg in 1–2mg increments (no specified frequency, max single dose 6mg) | Midazolam (follow seizure protocol) |
| Central California EMS | No | 0.1 mg/kg IN to max of 4mg | 0.1 mg/kg to max 4mg × 1 only | 0.05 mg/kg to max 2mg, repeat × 1 at 10min | Midazolam, then Mag 5g IV over 20 min |
| Coastal Valleys EMS | Yes | 5mg MR ×1 at 10min | 5 mg MR ×1 at 10min | 2mg Q5min PRN, net max 10mg by all routes | Midazolam 2mg, if transport > 1hr, optional Magnesium 2g followed by drip |
| Contra Costa County | Yes | N/A | 0.1 mg/kg to max 5mg | 1mg, titrate in 1–2mg increments to max 5mg | ---- |
| El Dorado County | Yes | 5mg MR at 5min | 5mg | 2.5mg MR at 5min | Mag 6g IV over 1–2min |
| Imperial County | Yes | 0.2 mg/kg to max 10mg, repeat × 1 per BH | 0.2 mg/kg to max 10mg, repeat × 1 at 10min | 0.1 mg/kg to max 5mg, repeat × 1 at 10min | Midazolam per SZ Protocol w/all repeat doses per BH |
| Inland Counties EMA | Yes | 2.5mg MR at 5min (max 3 doses all routes) | 5mg MR at 10min (max 3 doses all routes) | 2.5mg MR at 5min (max 3 doses all routes) | Mag 4g over 3–4min, gtt at 0.6 g/hr to 2g |
| Kern County | Yes | 1st line: lorazepam 2mg IV/IO/IM Q10min to max 4mg | 2nd line: midazolam 1mg IV/IN Q2min PRN to max 5mg w/BHO | 3rd line: diazepam 5mg IV Q10min PRN to max 30mg w/BHO | 1st line: Mag 2–4g IV |
| 2nd line: diazepam 5mg IV Q10min PRN to max 30mg | |||||
| Los Angeles County | Yes | 5mg MR ×1 at 5min | 5mg MR ×1 at 5min | 2–5mg MR ×1 at 5min, net max 10mg by all routes | DO NOT delay transport for treatment |
| Marin County | Yes | 5mg | 0.1 mg/kg MR × 1 at 10min | 1mg Q3min PRN to max 0.05 mg/kg | Midazolam, NTG for HTN |
| Merced County | No | N/A | 0.2 mg/kg to max 8mg, may NOT repeat | 0.1 mg/kg to max 4mg, MR (no specified frequency or net max) | Mag 2g IV over 2 min |
| Monterey County | No | 2mg MR ×1 | 2mg MR ×1 | 1–2mg Q5min PRN to max 4mg | ---- |
| Mountain Valley EMS | Yes | N/A | 5mg MR ×1 at 10min | 2mg then titrate 1mg increments to max 6mg (no specified frequency) | ---- |
| Napa County | Yes | 5mg × 1 only (MR ×1 at 5min for eclampsia) | 0.1 mg/kg to max 6mg (max 5mg fpr eclampsia) | 1mg then titrate 1mg increments to max 6mg (no specified frequency) | Midazolam, NTG for HTN (need base contact) |
| Nor-Cal EMS | Yes | 0.2 mg/kg to max 10mg, MR ×1 to 20mg w/BHPO | N/A | 2mg Q2min PRN to max 10mg, max 20mg w/BHPO | Mag 4g IV over 20min followed by gtt at 2 g/hr |
| EMT-II | Diazepam 2.5–10mg IVP over 2min, if no access 10mg IM. MR ×1 to max 20mg IV/IM/IO w/BHPO | ||||
| North Coast EMS | Yes | 5mg w/10mg max | 5mg (0.07 mg/kg) | 1–2.5mg repeat PRN to max 0.1 mg/kg not to exceed 10mg | Mag 4g IV over 20min followed by gtt at 1–2 g/hr |
| EMT-II | Diazepam 2.5–20mg IVP titrated in 2.5mg increments to max 40mg. 5–10mg IM | ||||
| Orange County | No | 5mg MR ×1 at 3 min | 5mg MR ×1 at 3 min | N/A | Midazolam |
| Riverside County | Yes | 2.5mg MR ×1 (all dosages per chart) | 5mg MR × 1 | 2.5mg MR × 1 | Mag 5g IV over 10min or 2.5g IM × 2 divided doses |
| May substitute lorazepam 5mg IM, 2.5mg IN/IV/IO OR diazepam 5mg IM, 2.5mg IV/IO. MR ×1 | |||||
| Sacramento County | Yes | 0.1 mg/kg to max 6mg | 0.1 mg/kg to max 6mg | 0.1 mg/kg to max 6mg in 2mg increments | ---- |
| May substitute diazepam (in context of midazolam shortage) 5–10mg IV/IO, 10mg IM, MR IM ×1 | |||||
| San Benito County | Yes | 0.1 mg/kg to max 5mg, additional per BH | 0.2 mg/kg to max 10mg, additional per BH | 0.1 mg/kg to max 5mg, additional per BH | Midazolam (follow seizure protocol) |
| San Diego County | No | Midazolam IN/IM/IV/IO to max 5mg, MR × 1 at 10min to max 10mg (no specified increment or interval) | Midazolam IN/IM/IV/IO to max 5mg, MR ×1 at 10min to max 10mg | ||
| San Francisco County | No | 5mg ×1 | 5mg ×1 | 2.5mg MR at 5min, max dose 5mg | Magnesium sulfate |
| San Joaquin County | No | 4mg MR Q5min to max 10 | 2 or 4mg(?) MR Q5min to max 10mg | 2mg MR Q5min to max 10mg | Mag 2g IV over 3–5min after base hospital contact |
| San Luis Obispo County | No | 5mg MR ×1 at 10min | 0.1 mg/kg to max 5mg MR ×1 at 10min | 1–2mg MR ×1 at 10min | Midazolam (follow seizure protocol) |
| San Mateo County | No | N/A | 1–2mg Q5min PRN to max 10mg | 1–2mg Q5min PRN to max 10mg | Midazolam IV/IM 1–2mg Q5min PRN to max 10mg |
| Santa Barbara County | Yes if known h/o DM | N/A | 0.1 mg/kg to max 5mg | 1mg Q2min PRN to max 5mg | Mag 2g IV over 5 min, MUST repeat ×1, midazolam if persistent seizures > 2 min |
| Santa Clara County | Yes | 5mg | 0.1 mg/kg to max 5mg | 2mg Q2min PRN to max 5mg | midazolam (follow seizure protocol) |
| 2nd choice: diazepam 5–10mg IV, MR at 5min to max 15mg | 3rd choice: lorazepam 1–2mg IV Q10min PRN to max 8mg | ||||
| Santa Cruz County | Yes | N/A | 0.2 mg/kg to max 10mg | 0.1 mg/kg to max 5mg | Midazolam (follow seizure protocol) |
| Sierra Sacramento Valley EMS | Yes | 0.2 mg/kg to max 8mg MR ×1 at 5min | 0.2 mg/kg to max 8mg MR ×1 at 5min | 0.1 mg/kg to max 4mg MR ×1 at 5min | Midazolam (follow seizure protocol) |
| Solano County | Yes | N/A | 4mg | 2mg | Midazolam (follow seizure protocol) |
| Tuolumne County | No | 1–2mg Q3min PRN to max to max 10mg by all routes | 2mg Q10min to max 10mg by all routes | 1–2mg Q3min PRN to max to max 10mg by all routes | Midazolam (follow seizure protocol), THEN Magnesium 2g IV after base contact |
| Ventura County | Yes | N/A | 0.1 mg/kg to max 5mg | 2mg repeat 1mg Q2min PRN to max 5mg | Mag 2g IV over 5min, MUST repeat ×1, midazolam if persistent seizures > 2 min |
| Yolo County | No | 5mg may NOT repeat | 0.1 mg/kg to max 6mg may NOT repeat | 2mg repeat 1mg Q5min PRN to max 6mg | ---- |
BZD, benzodiazepine; IN, intranasal; IM, intramuscular; IV/IO, intravenous/interosseous; mg, milligram; mg/kg, milligram per kilogram; MAX, maximum; MAG, magnesium; MR, may repeat; PRN, as needed; Q, every; BH, base hospital; MIN, minute; SZ, seizure; GTT, drops; BHO, base hospital; NTG, nitroglycerin; HTN, hypertension; BHPO, base hospital physician; EMT-II, emergency medical technician; DM, diabetes mellitus; CBG, capillary blood glucose; PR, per rectum; SMC, San Mateo County