Pediatric Seizure Management in 2025: 5 Practical Tips for EMS Providers

Key Takeaways for pediatric seizures:

• IN, IM, and buccal midazolam remain first-line medications over IV or rectal routes.
• Intranasal midazolam is now widely accepted as effective and preferred in many EMS systems.
• Underdosing remains a problem; accurate weight-based dosing is critical.
• Glucometry is essential on scene to rule out hypoglycemia.
• Offline protocols support quicker decision-making in seizure cases.
• Length-based dosing tools help avoid medication errors and are a must-have in pediatric EMS care.

Managing pediatric seizures in the field is one of the most challenging situations an EMT or paramedic can face. Thankfully, guidance continues to evolve, helping prehospital clinicians deliver safe and effective care. In 2014, Shah et al. published the first national, evidence-based guideline for pediatric prehospital seizure management. Since then, research and protocol development have advanced significantly. This blog combines the original evidence-based recommendations with newer insights to provide an up-to-date guide for EMS providers in 2025.

Reaffirming the Basics: What Still Holds True for Pediatric Seizure Management in EMS

The 2014 GRADE-based guideline emphasized key practices that remain foundational today:

• Always check capillary blood glucose in a seizing child.
• Treat glucose <60 mg/dL with IV dextrose or IM glucagon.
• Use midazolam via IM, IN, or buccal routes as first-line therapy.
• Avoid IV placement unless transport is prolonged or access is needed for other reasons.
• Favor offline protocols to empower quick action by EMS personnel.

These practices were designed to simplify care, improve outcomes, and reflect real-world EMS challenges—and they still do.

Quick Tip for Pediatric Seizures in EMS

What’s New Since 2014?

1. Intranasal Midazolam: Proven and Preferred

Multiple studies over the last decade confirm the efficacy of IN midazolam in stopping seizures quickly. A large multicenter trial (Silbergleit et al., 2012) found it non-inferior to IV diazepam. EMS systems have increasingly adopted IN midazolam due to:

• Rapid administration without IV access
• High caregiver and provider satisfaction
• Reduced seizure duration and scene time

Many EMS protocols now list IN midazolam as the go-to first-line agent.

2. Dosing Errors Are Still Common

A 2023 study in The Journal of Pediatrics revealed that underdosing benzodiazepines remains a persistent problem in EMS care. Inaccurate weight estimations and provider hesitation contribute to ineffective seizure control.

Tips to Avoid Underdosing:

• Use length-based resuscitation tapes or dosing guides.
• Double-check doses using pediatric drug calculators.
• Don’t be afraid to administer the full recommended dose: 0.2 mg/kg for IN/IM/buccal midazolam.

3. Why Length-Based Tapes Matter

Length-based resuscitation tools are vital in ensuring accurate pediatric dosing under pressure. These tools help estimate weight based on a child’s height and are color-coded for quick use.

Popular Options Include:

• Broselow/ PediaTape – The classic standard in pediatric dosing and resuscitation.
• Pediatric Emergency Ruler (PER) – An alternative with drug and equipment guidelines.
• Retractable EMS Pediatric Dosing Tape – Compact and rugged for prehospital settings.
• Spanish-Language Pediatric Dosing Tapes – Useful for bilingual crews or training diverse teams.

Consider keeping a link to purchase or restock these tools through our affiliate partners on your gear checklist.

4. Glucometry Is Non-Negotiable

Newer EMS-focused studies have validated glucometry as:

• A low-cost, low-risk intervention
• Helpful in identifying a treatable cause of seizures
• Easily performed by EMT-Bs and above

Ensure your glucometer is calibrated and part of your standard seizure response.

5. Offline Protocols Still Rule

Real-world studies confirm that trained EMS personnel effectively administer seizure medications using offline protocols. Waiting for online medical direction can delay care unnecessarily. Having a clear, easy-to-follow protocol boosts confidence and patient outcomes.

Additional Considerations: Febrile Seizures and Fever Management

Febrile seizures account for 2–5% of all seizures in children under age five, making them the most common seizure type in pediatrics (Wylie et al., 2023). These are typically benign and self-limited, but EMS providers should recognize the role of fever in triggering these events. Interestingly, research suggests that the rate of temperature rise, not the peak temperature itself, is the key factor in triggering febrile seizures (Leung, Robson, & Davies, 2012; AAP, 2008). Protocols generally reference managing fever in children to prevent seizures with antipyretics like acetaminophen, ibuprofen, and ketorolac. EMS providers should assess for fever and, when appropriate, educate caregivers about the nature of febrile seizures and supportive care.

Practical Scene Tips for EMTs and Paramedics

• Assess glucose early. It takes seconds and can change your treatment.
• Use non-IV midazolam first. IN, IM, and buccal are all valid options.
• Don’t delay for IV. Focus on seizure control and rapid transport.
• Use a length-based tape. It reduces dosing guesswork and improves safety.
• Communicate clearly. Update caregivers and document times, doses, and responses.
• Prepare for second-line treatment. Know your agency’s backup protocol if the first dose fails.

Today’s EMS providers are better equipped than ever to handle pediatric seizures in the field. Combining foundational evidence from the 2014 guideline with newer research and experience, the focus remains on fast, simple, and effective care.

Remember: Your confidence, skill with non-IV medication routes, and commitment to accurate dosing make a real difference in these critical moments.

References

American Academy of Pediatrics. (2008). Febrile seizures: Clinical practice guideline for the long-term management of the child with simple febrile seizures. Pediatrics, 121(6), 1281–1286. https://doi.org/10.1542/peds.2008-0939

Gausche-Hill, M., et al. (2023). Pediatric Seizure Management in the Field: Are We Dosing Right? The Journal of Pediatrics. https://www.jpeds.com/article/S0022-3476(23)00138-5/abstract

Leung, A. K. C., Robson, W. L. M., & Davies, H. D. (2012). Febrile seizures. Journal of Pediatric Health Care, 26(2), 78–83. https://doi.org/10.1016/j.pedhc.2011.10.006

Ramgopal, S., McCans, K., Martin-Gill, C., & Owusu-Ansah, S. (2021). Variation in Prehospital Protocols for Pediatric Seizure Within the United States. Pediatric Emergency Care, 37(12), e1331-e1338. https://doi.org/10.1097/PEC.0000000000002029

Shah, M. I., Macias, C. G., Dayan, P. S., et al. (2014). An Evidence-based Guideline for Pediatric Prehospital Seizure Management Using GRADE Methodology. Prehospital Emergency Care, 18(sup1), 15–24. https://doi.org/10.3109/10903127.2013.844874

Silbergleit, R., Durkalski, V., Lowenstein, D., Conwit, R., Pancioli, A., Palesch, Y. Y., & Barsan, W. (2012). Intramuscular versus intravenous therapy for prehospital status epilepticus. New England Journal of Medicine, 366(7), 591–600. https://doi.org/10.1056/NEJMoa1107493

Whitfield, D., Bosson, N., Kaji, A. H., & Gausche-Hill, M. (2023). The Effectiveness of Intranasal Midazolam for the Treatment of Prehospital Pediatric Seizures: A Non-inferiority Study. Prehospital Emergency Care, 26(3), 339-347. https://doi.org/10.1080/10903127.2021.1897197

Wylie, T., Sandhu, D. S., & Murr, N. I. (2023, May 8). Status epilepticus. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK430686/