Tag Archives: seizure

Prehospital IM midazolam for seizures

Intramuscular midazolam is at least as safe and effective as intravenous lorazepam for the prehospital management of status epilepticus. In his blog EM Literature of Note, Dr Ryan Radecki looks forward to a similar trial comparing nasal midazolam, which would reduce the risk from injections. Read his full critique here. Buccal midazolam 0.5 mg/kg is of course also an option, as described in the Advanced Paediatric Life Support manual:
If using the buccal route, draw up the higher dose (0.5mg) of the IV preparation using a needle (to avoid any fragments of glass from the ampoule) and after removing the needle, inject the drug into the buccal area between the lower bottom lip and the gum margin at the side of the mouth. Buccal midazolam is twice as effective as rectal diazepam, but both drugs produce the same level and degree of respiratory depression.

BACKGROUND: Early termination of prolonged seizures with intravenous administration of benzodiazepines improves outcomes. For faster and more reliable administration, paramedics increasingly use an intramuscular route.

METHODS: This double-blind, randomized, noninferiority trial compared the efficacy of intramuscular midazolam with that of intravenous lorazepam for children and adults in status epilepticus treated by paramedics. Subjects whose convulsions had persisted for more than 5 minutes and who were still convulsing after paramedics arrived were given the study medication by either intramuscular autoinjector or intravenous infusion. The primary outcome was absence of seizures at the time of arrival in the emergency department without the need for rescue therapy. Secondary outcomes included endotracheal intubation, recurrent seizures, and timing of treatment relative to the cessation of convulsive seizures. This trial tested the hypothesis that intramuscular midazolam was noninferior to intravenous lorazepam by a margin of 10 percentage points.

RESULTS: At the time of arrival in the emergency department, seizures were absent without rescue therapy in 329 of 448 subjects (73.4%) in the intramuscular-midazolam group and in 282 of 445 (63.4%) in the intravenous-lorazepam group (absolute difference, 10 percentage points; 95% confidence interval, 4.0 to 16.1; P<0.001 for both noninferiority and superiority). The two treatment groups were similar with respect to need for endotracheal intubation (14.1% of subjects with intramuscular midazolam and 14.4% with intravenous lorazepam) and recurrence of seizures (11.4% and 10.6%, respectively). Among subjects whose seizures ceased before arrival in the emergency department, the median times to active treatment were 1.2 minutes in the intramuscular-midazolam group and 4.8 minutes in the intravenous-lorazepam group, with corresponding median times from active treatment to cessation of convulsions of 3.3 minutes and 1.6 minutes. Adverse-event rates were similar in the two groups.
CONCLUSIONS: For subjects in status epilepticus, intramuscular midazolam is at least as safe and effective as intravenous lorazepam for prehospital seizure cessation. (Funded by the National Institute of Neurological Disorders and Stroke and others; ClinicalTrials.gov number, ClinicalTrials.gov NCT00809146.).

Intramuscular versus Intravenous Therapy for Prehospital Status Epilepticus
N Engl J Med. 2012 Feb 16;366(7):591-600

Status epilepticus review

A review on status epilepticus, differentiating complex partial status from generalised convulsive status:

PURPOSE OF REVIEW: Status epilepticus is one of the most common emergencies in neurology, and every third patient does not respond to adequate first-line treatment. Refractory status epilepticus may be associated with increased morbidity and mortality, and new treatment options are urgently required. This review critically discusses recently published data regarding the role of ‘new’ antiepileptic drugs, the efficacy and safety of anesthetic agents, and the overall clinical outcome that is an integral part of treatment decisions.
RECENT FINDINGS: In complex partial status epilepticus, levetiracetam may be administered after failure of first-line and/or second-line agents. Lacosamide may be an interesting new adjunct, but reliable data are pending. In the treatment of refractory generalized convulsive status epilepticus, propofol seems to be as efficient as barbiturates. The latter are associated with prolonged ventilation times due to redistribution kinetics, whereas the former bears the risk of propofol infusion syndrome if administered continuously. Even after prolonged treatment with anesthetics over weeks, survival with satisfactory functional outcome is possible.
SUMMARY: Unambiguous recommendations regarding treatment strategies for refractory status epilepticus are limited by a lack of reliable data. Therefore, randomized controlled trials or at least prospective observational studies based on strict protocols incorporating long-term outcome data are urgently required.

Treatment strategies for refractory status epilepticus
Curr Opin Crit Care. 2011 Apr;17(2):94-100

Isoflurane in refractory status epilepticus

One infrequently used option for refractory status epilepticus is isoflurane anaesthesia. A report of two cases demonstrates progressive MRI changes suggestive of neurotoxicity, that improved after discontinuation of isoflurane. Impossible to prove cause and effect here, since the both patients had status for weeks and were on multiple anticonvulsant medications, for example lorazepam, fosphenytoin, levetiracetam, valproate, and subsequent infusions of midazolam, pentobarbital, and ketamine. Neither patient recovered beyond a minimally conscious state. This article serves as a reminder that:

  1. Persistent status epilepticus may be associated with a poor neurologic outcome
  2. Some cases are extremely refractory to treatment
  3. Isoflurane is one of many options to try when standard anticonvulsant regimens are failing

Prolonged High-Dose Isoflurane for Refractory Status Epilepticus: Is It Safe?
Anesth Analg. 2010 Dec;111(6):1520-4

Paraldehyde in Paediatric Status Epilepticus

Data were collected on 53 episodes of paraldehyde use in tonic-clonic status epilepticus, which showed it appeared to be effective at terminating seizures in 33 of 53 cases. The median dose was 0.79 ml/kg, in keeping with current APLS guidelines (0.4 ml/kg of paraldehyde plus 0.4 ml/kg olive oil given per rectum)
Review of the efficacy of rectal paraldehyde in the management of acute and prolonged tonic-clonic convulsions
Arch Dis Child. 2009 Sep;94(9):720-3