Sweeping changes to the National Standard Curriculum in 1994 allowed EMT-Basics to assist patients with self-administration of lifesaving rescue medications. Prior to 1997, no rescue medication was available for a life-threatening condition like status epilepticus or prolonged seizure activity. The development of Diastat® in the mid-1990s has provided an easily administered, efficient and safe method of treating prolonged seizure activity. Given the safety and efficacy of this medication and procedure, it is the next logical step in the expanding scope of practice for EMT-Basics and should be added to the approved list of assisted rescue medications contained in the next revision of the National EMS Education Standards and Instructional Guidelines.
In 1994, the National Highway Traffic Safety Administration released its revised National Standard Curriculum for EMT-Basics, with a number of new cognitive and manipulative skill sets that included assisting patients with the self-administration of prescribed rescue medications like nitroglycerin, oral glucose, inhalers and epinephrine auto-injectable pens. The rationale behind basic level-assisted administration was that the patient had already been evaluated by a physician and prescribed the medications for self-administration. Second, the benefit of timely administration of these prescribed medications far outweighed any inherent risks that could be recognized in the prehospital setting. Strict guidelines and protocols have been attached to these new responsibilities, which continue to be outlined in the 2009 National EMS Education Standards and Instructional Guidelines.
Diazepam Use in Seizures
Diastat®--diazepam rectal gel and its trademark administration system-- was first approved for use by the Food and Drug Administration in the United States in 1997 as a treatment for breakthrough seizures in adults and children over age 2. This Schedule IV CDS is currently the only FDA-approved treatment for status epilepticus (SE) or other life-threatening seizures in this age group.1 It was specifically developed for use by parents, caregivers and other nonmedical personnel, and is therefore designed to be easy and safe to administer outside a clinical setting.2
Most seizure patients, no matter how well managed through maintenance medication, will likely experience breakthrough seizures throughout their lifetime. Possibly as many as 35% of patients on antiseizure medications may not be adequately controlled.3 Although these occasional breakthrough seizures are mostly benign, extended, cluster or repetitive seizure activity can lead to life-threatening consequences. Cluster seizures, also referred to as acute repetitive seizures, are best defined as numerous seizures that occur over a time period from minutes to hours and generally fall outside of what would be considered normal for that patient.4 Progression of these types of seizures can manifest as status epilepticus, which should be considered a true medical emergency that can be identified by a number of clinical scenarios. Any generalized seizure lasting more than five minutes or any three consecutive seizures over a one-hour period would be classified as status in nature. SE would also include any type of recurrent seizure without a recognizable postictal recovery period. Finally, any other type of seizure (e.g., partial complex or focal) lasting more than 30 minutes would be defined as SE.5 Between 50,000 and 200,000 generalized convulsive status epilepticus (GCSE) seizures occur every year in the United States, with an overall mortality rate of 20%.6 Additional statistics show that status seizures lasting more than one hour have a mortality rate of 32%, compared with 2.7% for seizures of shorter duration.7 Although the etiology of the seizure and age of the patient are contributing factors, it is clear that morbidity and mortality associated with status epilepticus are directly related to duration of the seizure activity. Therefore, timely administration of an effective anti-convulsant and subsequent termination of seizure activity would be considered a lifesaving intervention.