Contributor: Alec Coston, MD
Educational Pearls:

• Most generalized seizures terminate spontaneously, with up to 90% stopping within 4 minutes.

• The American Epilepsy Society defines 0–5 minutes as the stabilization phase of a seizure.

• • If a seizure continues for 5 minutes, begin treatment for status epilepticus with a benzodiazepine.

  • If the patient becomes hypoxic or otherwise unstable, intervene immediately.

• Waiting can help avoid unnecessary benzodiazepine administration and the resulting sedation, which can be difficult to distinguish from a postictal state.

• When benzodiazepines are indicated, adequate initial dosing is important:

• • Lorazepam (Ativan): 0.1 mg/kg IV, maximum 4 mg

  • Midazolam (Versed): 10 mg IM for adults >40 kg when IV access is unavailable

• Midazolam dosing differs by route. Although weight-based doses such as 0.2 mg/kg are used in some settings, the American Epilepsy Society guideline specifically recommends 10 mg IM for patients >40 kg, based largely on the RAMPART trial.

• Benzodiazepines are commonly underdosed in status epilepticus, which may decrease the likelihood of terminating the seizure and delay administration of second-line antiseizure medications.

References:

1. Glauser T, Shinnar S, Gloss D, et al. Evidence-Based Guideline: Treatment of Convulsive Status Epilepticus in Children and Adults. Epilepsy Curr. 2016;16(1):48-61. doi:10.5698/1535-7597-16.1.48.

2. Silbergleit R, Durkalski V, Lowenstein D, et al. Intramuscular versus Intravenous Therapy for Prehospital Status Epilepticus. N Engl J Med. 2012;366(7):591-600. doi:10.1056/NEJMoa1107494.

3. Sathe AG, Underwood E, Coles LD, et al. Patterns of Benzodiazepine Underdosing in the Established Status Epilepticus Treatment Trial. Epilepsia. 2021;62(3):795-806. doi:10.1111/epi.16825.

Summarized by Sam Pahl | Edited by Sam Pahl & Ahmed Abdel-Hafiz, NREMT-P

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Contributor: Travis Barlock, MD

Educational Pearls:

Kidney stones: hard deposits that form inside the kidneys when urine becomes too concentrated

• The most common type is calcium oxalate

• Stones can travel from the kidney to the ureter → causes obstruction and renal colic

Stone size predicts likelihood of spontaneous passage → the smaller the stone, the more likely it is to spontaneously pass

• These are approximate estimates, not absolute cutoffs. Published studies use different size categories and follow-up periods.

• • ≤5 mm: 68–90%+

  • 5–7 mm: ~50–70%

  • >7 mm: ~30% but varies by location (more likely to require intervention)

Stone size does not correlate with pain severity

• Pain is driven largely by increased pressure, ureteral spasm, and inflammation

• Pain can vary with anatomy and obstruction

• A very small stone can cause excruciating pain and a larger stone can cause relatively minimal discomfort

The most important thing: rule out infection!

• Always evaluate for a urinary tract infection in a patient presenting with a suspected obstructing stone

• Obtain urinalysis and look for leukocyte esterase, nitrites, pyuria, and bacteriuria as well as clinical signs of infection such as fever, chills, or tachycardia

References

1. Coll DM, Varanelli MJ, Smith RC. Relationship of spontaneous passage of ureteral calculi to stone size and location as revealed by unenhanced helical CT. AJR Am J Roentgenol. 2002 Jan;178(1):101-3. doi: 10.2214/ajr.178.1.1780101. PMID: 11756098.

2. Gourlay K, Splinter G, Hayward J, Innes G. Does pain severity predict stone characteristics or outcomes in emergency department patients with acute renal colic? Am J Emerg Med. 2021 Jul;45:37-41. doi: 10.1016/j.ajem.2021.02.049. Epub 2021 Feb 23. PMID: 33647760.

Summarized by Meg Joyce, MS3 | Edited by Meg Joyce & Ahmed Abdel-Hafiz, NREMT-P

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Contributor: Aaron Lessen, MD

Educational Pearls:

• Febrile work-ups in the emergency department require obtaining a urine sample to assess for UTI.

• • In non-toilet trained children, this often means using catheterization.

  • Depending on the volume of urine in the bladder, there may not be enough present to get an adequate sample.

• Performing a bladder scan before catheterization may be helpful in determining if there is enough urine there in the first place to get a sample.

• A recent systematic review and meta-analysis of three randomized control trials found that performing a POCUS prior to catheterization in 337 children aged 36 months and younger led to higher success in obtaining a sample.

• • The success of getting a sample on the first attempt increased from 72.5% to 89.7%.

  • The rate of dry taps decreased from 23.9% to 3.6%.

• POCUS before catheterization is an easy tool providers can use to ensure an adequate first attempt and reduce unnecessary discomfort for the child.

References:

1. Vieira da Silva HF, Watanabe ET, Tavares MC, Ramos Bicalho AC, Ferraro LSD, Simões E Silva AC. Point-of-care ultrasound for pediatric urethral catheterization: a systematic review and meta-analysis of randomized controlled trials. Acad Emerg Med. 2026;33(6):e70342. doi:10.1111/acem.70342

Summarized by Ashley Lyons, OMS4 | Edited by Ashley Lyons & Ahmed Abdel-Hafiz, NREMT-P

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