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| The seizure of Roger de Mortimer 1287-1330 in Nottingham Castle, 19th October 1330, from Illustrations of English and Scottish History Volume I. Image taken from this [link] |
IV Diazepam or Lorazepam are the first choice of medication for termination of seizure activity if it is not spontaneously aborted. Protocols varies when to start the medication. However, seizure that occurs for five minutes are unlikely to abort spontaneously and often treated as status epilepticus.
Complications of prolonged seizures include impaired
ventilation and subsequent pulmonary aspiration, cardiac dysrhythmias,
derangements of metabolic and autonomic function, and direct injury to the
nervous system (Loweinstein DH 1998)
.
The randomized, controlled Prehospital Treatment of Status Epilepticus (PHTSE) trial compare
the IV Diazepam, Lorazepam and placebo for seizure termination and both of the
medication are effective in pre hospital care. However, both of them requires
intravenous access to deliver the medication. Obtaining an IV access is
difficult as all the muscle are contracting at this point. Setting an IV line
in a convulsive patient also increase the risk of needle prick injury to the
health care provider. Both Diazepam and lorazepam are poorly absorbed if given
intramuscularly or across the mucous membrane.
Another disadvantage of lorazepam is, the medication
need to be stored inside the refrigerator.
In the prehospital setting, both IV medication shows
good outcome in terminating the seizure activities. However, it is least
feasible to be used due to the problem mentioned above. Furthermore, it is also
not a friendly user involving the mass casualty.
In contrast to both of the medication, Midazolam is
a highly lipophilic agent that is rapidly absorbed intramuscularly and
subsequent rapid distribution in to the central nervous system. It is proven to
be effective if given as a first line treatment or as a second line agent for
refractory SE.
The Rapid
Anticonvulsant Medications Prior to Arrival Trial (RAMPART) is a study used to compare IM midazolam and IV
lorazepam in a prehospital basis. This study was published in The New England
Journal of Medicine 2012 with a conclusion of: For subjects in status
epilepticus, intramuscular midazolam is at least as safe and effective as
intravenous lorazepam for prehospital seizure cessation. The dosage used is 10 mg IM Midazolam in patient
with estimated weight of more than 40kg and 5 mg if the estimated body weight
is 13-40 kg.
Usage of IM
Midazolam in children is not something controversial. A prospective randomized
study done by Chamberlain JM et al in
1997 shows that IM midazolam is an effective anticonvulsant for children
with motor seizures. Compared to IV diazepam, IM midazolam results in more
rapid cessation of seizures because of more rapid administration. The IM route
of administration may be particularly useful in physicians' offices, in the
prehospital setting, and for children with difficult IV access.
I think that we should consider this alternative in
treating the prolong seizure. IM Midazolam can be safely replaced IV Diazepam or
Lorazepam as a first line management for prolong seizure.
Reference
1. Chamberlain JM, Altieri MA, Futterman C, Young GM,
Ochsenschlager DW, Waisman Y "A prospective, randomized study comparing
intramuscular midazolam with intravenous diazepam for the treatment of seizures
in children.", Pediatr Emerg Care. 1997 Apr;13(2):92-4.
2. Robert Silbergleit et al, "Intramuscular
versus Intravenous Therapy for Prehospital Status Epilepticus", The New
England Journal of Medicine: 366;7, 2012
3. Shah I, Deshmukh CT, "Intramuscular midazolam
vs intravenous diazepam for acute seizures.", Indian J Pediatr. 2005
Aug;72(8):667-70.
4. Towne AR, DeLorenzo RJ, "Use of intramuscular
midazolam for status epilepticus.", J Emerg Med. 1999 Mar-Apr;17(2):323-8.
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