Prehospital management of convulsive status epilepticus in children: a knowledge, attitude and practice survey of UK ambulance service clinicians

PURPOSE: Childhood convulsive status epilepticus (CSE) is a time-critical emergency (incidence 17-23/100,000/yr) requiring prompt treatment to reduce morbidity and mortality. Prehospital midazolam is as safe as diazepam, but more effective. However, legal and logistical barriers limit its use by paramedics. We performed a UK-wide survey of current practice, perceived barriers, and views on intramuscular midazolam (IMMDZ) to inform service development, gauge interest in a potential ambulance-based trial of emergency treatment of childhood CSE and identify opinions to consider in trial study design. METHODS: We conducted a cross-sectional JISC Knowledge-Attitude-Practice survey of personnel across all 13 UK NHS Ambulance Services (21 May-30 June 2025). The survey captured demographics, first-line antiseizure medication (ASM) choices, operational challenges, knowledge of IMMDZ usage, and support for research. RESULTS: 153 respondents across all 13 ambulance services (4-26/service) participated; 146 (95%) were paramedics (100 were generalist). Diazepam (by the rectal or intravenous route) was first-line ASM in nine services; buccal midazolam in three, and IMMDZ in one. 89% reported that alternative ASMs should be available to generalist paramedics. 97% supported research on IMMDZ for emergency treatment of childhood CSE. If approved, 85% thought their Trust would likely support its clinical use. Potential barriers to use included dosing uncertainty (53%), risk of respiratory depression (46%), inappropriate use (37%), and reticence of administering intramuscular medication (24%). CONCLUSION: There is a need to standardize paramedic treatment of seizures in children in the UK. NHS Ambulance clinicians are supportive of investigating IMMDZ as prehospital treatment for childhood CSE.