Prehospital benzodiazepine use and need for respiratory support in paediatric seizures

Background Paramedics are frequently called to attend seizures in children. High-quality evidence on second-line treatment of benzodiazepine (BZD)-refractory convulsions with parenteral long-acting antiepileptic drugs in children has become available from the ED. In order to address the potential need for an alternative agent, we set out to determine the association of BZD use prehospital and the need for respiratory support. Methods We conducted a retrospective observational study of state-wide ambulance service data (Ambulance Victoria in Victoria, Australia, population: 6.5 million). Children aged 0-17 years assessed for seizures by paramedics were analysed for demographics, process factors, treatment and airway management. We calculated adjusted ORs (AOR) of the requirement for respiratory support in relation to the number of BZD doses administered. Results Paramedics attended 5112 children with suspected seizures over 1 year (1 July 2018 to 30 June 2019). Overall, need for respiratory support was low (n=166; 3.2%). Before ambulance arrival, 509 (10.0%) had already received a BZD and 420 (8.2%) were treated with midazolam by paramedics. Of the 846 (16.5%) patients treated with BZD, 597 (70.6%) received 1 BZD dose, 156 (18.4%) 2 doses and 93 (11.0%) >2 doses of BZD. Patients who were administered 1, 2 and >2 doses of BZD received respiratory support in 8.9%, 32.1% (AOR 4.6 vs 1 dose, 95% CI 2.9 to 7.4) and 49.5% (AOR 10.3 vs 1 dose, 95% CI 6.0 to 17.9), respectively. Conclusions Increasing administration of BZD doses was associated with higher use of respiratory support. Alternative prehospital antiepileptic drugs to minimise respiratory depression should be investigated in future research.