Episode 964: Ketamine & Midazolam for Prehospital Seizure Management

Contributor: Aaron Lessen, MD

Educational Pearls:

• Prehospital seizures are typically managed with intramuscular midazolam (Versed)
• Seizures theoretically involve the NMDA pathway, and ketamine is a potent NMDA antagonist
• A recent retrospective cohort study analyzed a Florida EMS protocol that uses ketamine in seizures refractory to midazolam
  • One group received two doses of midazolam for seizure control
  • The other group received a dose of midazolam followed by a dose of ketamine
• After matching, 82% of the midazolam-only group patients had resolution of convulsions prior to ED arrival
  • 94.4% of patients in the midazolam + ketamine group experienced resolution
  • Absolute difference between groups was 12.4% (95% CI 3.1% to 21.7%)
• Limitations to the study include its prehospital setting and limited long-term follow-up

References

1. Zitek T, Scheppke KA, Antevy P, et al. Midazolam and Ketamine for Convulsive Status Epilepticus in the Out-of-Hospital Setting. Ann Emerg Med. 2025;85(4):305-312. doi:10.1016/j.annemergmed.2024.11.002

Summarized & Edited by Jorge Chalit, OMS4

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