Table 2.
Pediatric seizure protocols.
| Midazolam | |||||
|---|---|---|---|---|---|
|
|
|||||
| LEMSA | CBG Prior to 1st dose BZD | IN | IM | IV/IO | Febrile |
| Alameda County | No after benzos | 0.2 mg/kg | 0.1 mg/kg to max 5mg, give full dose IM | 0.1 mg/kg in 1–2mg increments (no specified frequency, max single dose 5mg) | cooling after benzos |
| 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 | ---- |
| Coastal Valleys EMS | Yes | 0.1 mg/kg MR ×1 at 5min to max 5mg | 0.1 mg/kg MR ×1 at 5min to max 5mg | 0.1 mg/kg MR ×1 at 5min to max 5mg | cool if febrile |
| Contra Costa County | Yes | N/A | 0.1 mg/kg to max 5mg | 1mg increments to max 0.1 mg/kg | remove clothing to “address cooling” |
| El Dorado County | Yes | 0.1 mg/kg max total 3mg | 0.1 mg/kg max total 3mg | 0.1 mg/kg max total 3mg | external cooling with water, Tylenol or Ibuprofen |
| Imperial County | Yes | 0.2 mg/kg (not listed in peds drug guide) | 0.2 mg/kg in max 1–2mL increments | 0.1 mg/kg to max 5mg | ---- |
| Inland Counties EMA | Yes | 0.2 mg/kg to max 5mg MR at 10min | 0.2 mg/kg to max 5mg MR at 10min | 0.1 mg/kg to max 2.5mg MR at 5min | cooling before benzos |
| Kern County | Yes | 1st line: midazolam 0.2mg/kg IM MR at 15min, IV/IO/IN to max 6mg | 2nd line: lorazepam 0.1 mg/kg IV/IM/IO MR at 5min to max 0.2 mg/kg not to exceed 4mg | 3rd line: diazepam 0.3 mg/kg IV/IO MR Q25min to max 5mg, 0.5 mg/kg PR to max 10mg | ---- |
| Los Angeles County | Yes | 0.1 mg/kg MR ×1 at 5min to max 5mg by all routes | 0.1 mg/kg MR ×1 at 5min to max 5mg by all routes | 0.1 mg/kg MR ×1 at 5min to max 5mg by all routes | cooling before benzos |
| Marin County | Yes | 0.2 mg/kg to max 5mg | 0.1 mg/kg MR × 1 at 10min | 0.05 mg/kg (max 1mg/dose) Q3min PRN to max 5mg | “treat fever prior to benzos” |
| Merced County | Yes | N/A | 0.2 mg/kg to max 8mg, may NOT repeat | 0.1 mg/kg to max 4mg, MR ×1 at 15min | ---- |
| Monterey County | Yes | 0.2 mg/kg to max 2mg, repeat by BHO only | 0.2 mg/kg to max 2mg, repeat by BHO only | 0.1 mg/kg to max 2mg, repeat by BHO only | External cooling with water, fans |
| Mountain Valley EMS | Yes | N/A | 0.2 mg/kg to max 5mg MR ×1 at 10min | 0.1 mg/kg to max 5mg MR ×1 at 10min | ---- |
| Napa County | Yes | 0.2 mg/kg to max 5mg, may NOT repeat | 0.1 mg/kg to max 5mg, may NOT repeat | 1mg then titrate 1mg increments to max 5mg (no specified frequency) | ---- |
| Nor-Cal EMS | Yes | 0.2 mg/kg to max 10mg, MR ×1 to 10mg w/BHPO; PR 0.3 mg/kg MR ×1* | N/A | 0.1 mg/kg * *patient weight > 20kg, if less requires BHPO | ---- |
| EMT-II | Diazepam 0.2 mg/kg IM/IV/IO MR ×1 to max 10mg w/BHPO | ||||
| North Coast EMS | Yes | 0.1 mg/kg | 0.1 mg/kg subsequent up to 0.4 mg/kg to max 5mg, net max 10mg | 0.05 mg/kg max 5mg, net max 10mg | Cool with moist towels |
| EMT-II | Diazepam 0.1–0.3 mg/kg IVP or 0.5 mg/kg PR to max 20mg | ||||
| Orange County | No | 0.1 mg/kg to max 5mg, MR ×1 at 3mins | 0.1 mg/kg to max 5mg, MR ×1 at 3mins | N/A | ---- |
| Riverside County | Yes | (Per Broselow) | (Per Broselow) | (Per Broselow) | cooling measures before benzos |
| May substitute lorazepam or diazepam | |||||
| Sacramento County | Yes | 0.2 mg/kg to max 6mg | 0.1 mg/kg to max 4mg | 0.1 mg/kg to max 4mg in 1–2mg increments | undress pt for cooling |
| May substitute diazepam (in context of midazolam shortage) 0.1 mg/kg IM/IV/IO to max 5mg, MR IM ×1 | |||||
| San Benito County | Yes | 0.1 mg/kg to max 3mg, additional per BH | 0.2 mg/kg to max 3mg, additional per BH | 0.1 mg/kg to max 3mg, additional per BH | ---- |
| San Diego County | No | (Per Broselow) | (Per Broselow) | (Per Broselow) | “Versed not required for simple febrile seizures” |
| San Francisco County | Yes | 0.2 mg/kg total max dose 2mg* | 0.1 mg/kg total max dose 2mg* | 0.1 mg/kg total max dose 2mg* *may substitute Diastat rectal gel if available | “Cooling measures if fever present” |
| San Joaquin County | Yes | 0.2 mg/kg to max 5mg | 0.1 mg/kg to max 5mg | 0.1 mg/kg to max 5mg | “initiate cooling if febrile” |
| San Luis Obispo County | No | 0.1 mg/kg to max 5mg all routes MR ×1 at 10min | 0.1 mg/kg to max 5mg all routes MR ×1 at 10min | 0.1 mg/kg to max 5mg all routes MR ×1 at 10min | ---- |
| San Mateo County | Yes | N/A | (Per SMC reference card to max 5mg) | (Per SMC reference card to max 5mg) | cooling before benzos |
| Santa Barbara County | If known h/o DM | N/A | 0.1 mg/kg to max 5mg | 0.1 mg/kg to max 1mg | passive cooling measures |
| Santa Clara County | Yes | 0.1 mg/kg to max 5mg | 0.1 mg/kg to max 5mg | 0.1 mg/kg to max 5mg | remove clothing to address cooling |
| 2nd choice: diazepam IV 0.25 mg/kg to max 5mg age < 5y, max 10mg > 5y; PR 0.5 mg/kg to max 10mg; 3rd choice: lorazepam 0.1 mg/kg to max 2mg MR ×1 at 5–10min to net max 4mg | |||||
| Santa Cruz County | Yes | N/A | 0.2 mg/kg to max 3mg total | 0.1 mg/kg to max 3mg total | remove clothing to address cooling |
| 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 in 1–2mg increments to max 4mg MR ×1 at 5min | remove clothing to address cooling |
| Solano County | Yes | N/A | 0.2 mg/kg to max 4mg | 0.1 mg/kg titrated in 1mg increments Q3min to max 5mg | cooling if febrile |
| Tuolumne County | No | 0.2 mg/kg to max 2mg | 0.1 mg/kg to max 1mg | 0.1 mg/kg to max 1mg | ---- |
| Ventura County | Yes | N/A | 0.1 mg/kg to max 5mg | N/A | passive cooling measures |
| Yolo County | No | 0.2 mg/kg to max 8mg MR ×1 at 5min with BHO | 0.2 mg/kg to max 8mg MR ×1 at 5min with BHO | 0.1 mg/kg in 1–2mg increments repeat Q5min, max single dose 4mg | cooling only AFTER seizures stop/controlled |
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