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Podcast 106 - When Benzos Won't Stop The Seizure

Sometimes seizing patients don't respond to benzodiazepines. In the RAMPART study they found that 18.5% of the midazolam group and 25.8% of the lorazepam group were still seizing upon arrival at the ED.

We know that rapid termination of status epilepticus (SE) is important, but what should EMS do when they are maxing out benzo's, blood pressure is getting soft, and the patient is still seizing?! At the 2020 NAEMSP meeting results of a pilot study evaluating prehospital use of ketamine for SE showed promising results!

In this episode we discuss the role of ketamine in SE patients that are refractory to front line treatments! Join Sam, Brian, and I as we unpack some of the literature and logistics of when benzodiazepines don't stop the seizure.


1. Logroscino G, Hesdorffer DC, Cascino G, Annegers JF, Hauser WA. Short-term mortality after a first episode of status epilepticus. Epilepsia, 1997; 38(12): 1,344–9. 

2. Treiman DM, Meyers PD, Walton NY, et al. A Comparison of Four Treatments for Generalized Convulsive Status Epilepticus. N Engl J Med, 1998; 339(12): 792–8.

3. Maegaki Y, Kurozawa Y, Hanaki K, Ohno K. Risk factors for fatality and neurological sequelae after status epilepticus in children. Neuropediatrics, 2005; 36(3): 186–92.

4. Silbergleit R, Lowenstein D, Durkalski V, Conwit R; Neurological Emergency Treatment Trials (NETT) Investigators. RAMPART (Rapid Anticonvulsant Medication Prior to Arrival Trial): a double-blind randomized clinical trial of the efficacy of intramuscular midazolam versus intravenous lorazepam in the prehospital treatment of status epilepticus by paramedics. Epilepsia, 2011; 52 (suppl 8): 45–47.

5. Kapur J, Elm J, Chamberlain JM, et al. Randomized Trial of Three Anticonvulsant Medications for Status Epilepticus. N Engl J Med, 2019; 381: 2,103–13.

6. Scheppke KA, Braghiroli J, Shalaby M, Chait R. Prehospital use of IM ketamine for sedation of violent and agitated patients. West J Emerg Med, 2014 Nov; 15(7): 736–41. 

Peter Antevy, MD, is EMS medical director for the Coral Springs Fire Department, Davie Fire Rescue, Southwest Ranches, and American Ambulance in Florida. He is a member of the EMS World editorial advisory board.

Eric Scheppke, BS, is an ER scribe for Tallahassee Memorial Healthcare in Tallahassee, Fla. He is a 2019 graduate of Florida State University. 

FOAMfrat is a group of like-minded individuals who are focused on innovating new ways to frame EMS education. If you are interested in checking out our EMS refresher course, click the photo above to learn more!


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