Pre-Hospital Seizure Management in Children: Optimizing Paramedic Response and OR technicians Coordination with Pediatric Neurology Teams

Abstract

Seizures are among the most common time-critical neurological emergencies in childhood, and the pre-hospital interval is the first and often the most decisive therapeutic window. In that window, paramedics must simultaneously recognize seizure semiology, protect the airway, correct reversible precipitants, and deliver weight-based first-line therapy, normally a benzodiazepine, while navigating scene stresses, limited pediatric exposure, and dosing complexity; their actions directly influence downstream pediatric neurology decisions, escalation to second-line therapy, and, in rare but high-stakes scenarios, urgent neurosurgical preparedness requiring coordination with operating room (OR) teams. Despite robust guidance on status epilepticus (SE) defining the 5-minute “t1” threshold for benzodiazepines and endorsing non-intravenous routes when IV access is delayed, real-world pre-hospital care still shows under-dosing, route inconsistency, and variable protocol adherence that prolongs convulsions and increases the risk of respiratory compromise and intensive care admission (1–4,12–13). Recent randomized and comparative effectiveness trials clarify that intramuscular midazolam is at least as effective as intravenous lorazepam in the field, that intranasal midazolam is a practical and acceptable alternative to rectal diazepam for children, and that ED second-line

choices (levetiracetam`m , valproate, fosphenytoin) offer similar efficacy after benzodiazepine failure, findings that should harmonize EMS formularies and training with hospital algorithms (3,9–11,21–22). Systems solutions—pediatric readiness initiatives for EMS agencies, checklists and dosing aids that go beyond simple length- based tapes, structured EMS-to-ED handover (e.g., SBAR/IMIST-AMBO), and predefined activation pathways that incorporate neurology and OR technicians for refractory cases—represent the most credible levers to improve outcomes at scale (5–8,14–18,27). This review synthesizes pathophysiology, epidemiology, pharmacologic options and dosing pitfalls, communication and handover, and rare neurosurgical escalation, and proposes a pragmatic, multidisciplinary coordination model connecting paramedics, pediatric neurologists, anesthesiology, and OR technicians to shorten time to effective therapy and limit neuroinjury.