Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

What Can EMS Expect From 2014? #3 Real Doses of Seizure Meds – IM Midazolam

 

Why should EMS treat seizures aggressively.

All seizures stop eventually.

True, so does all bleeding, but that does not mean that the patient has a good outcomes.

If we are to provide competent medical care, we should be using the safest and most effective treatments that make a difference for the patient.

The evidence supports aggressive EMS treatment of seizures with large doses of IM (IntraMuscular) midazolam (Versed).
 


Image credit.
 

Third, outcome tends to correlate with seizure duration even after one controls for other factors. Mortality among patients who present in status epilepticus is 15 to 22%; among those who survive, functional ability will decline in 25% of cases.6 [1]

 

This study used 10 mg midazolam IM vs. 4 mg lorazepam (Ativan) IV (IntraVenous).

This is more than most EMS systems use.

The low dosing appears to be out of a misguided fear of respiratory depression from too much benzodiazepine (midazolam or lorazepam or diazepam).

Do EMS medical directors understand the real risks?

 

In the 1998 Veterans Affairs Cooperative Status Epilepticus Study, the intravenous lorazepam dose used was 0.1 mg/kg. This means that many patients enrolled in the current study could have been underdosed based on the 4 mg intravenous lorazepam dose.[2]

 

This comment on the study suggests that the doses were too low.
 

Considering that midazolam had a treatment failure rate of 26.6% in this study, we think that the doses of midazolam that were used (10 mg) were smaller than the doses required for termination of prehospital seizure. It is anticipated that a fixed dose of 20 mg (two autoinjectors) of midazolam is the effective dose in humans.2 [3]

 

This letter on the study suggests that the doses were much too low.
 

Is there any evidence that large doses of benzodiazepines are more of a problem than the seizure?
 

No.

This has been demonstrated by research comparing the use of lorazepam, diazepam (Valium), and placebo to treat seizures.
 

Status epilepticus was terminated by the time of arrival at the emergency department in 59.1 percent of patients given lorazepam, 42.6 percent of patients given diazepam, and 21.1 percent of patients given placebo (P=0.001)[4]

 

How did the benzodiazepines affect outcomes?

 

An out-of-hospital complication (hypotension, cardiac dysrhythmia, or respiratory intervention) occurred in 7 (10.6 percent) of the patients treated with lorazepam, 7 (10.3 percent) of the patients treated with diazepam, and 16 (22.5 percent) of the patients given placebo (P=0.08). The most common complication was a change in respiratory status requiring ventilation assistance by bag valve-mask or an attempt at intubation (7 patients given lorazepam, 6 given diazepam, and 11 given placebo).[4]

 

Respiratory compromise was almost twice as common without benzodiazepines.

 

Our data are consistent with the finding that endotracheal intubation is more commonly a sequela of continued seizures than it is an adverse effect of sedation from benzodiazepines.11 [5]

 

High dose benzodiazepines appear to be more likely to prevent intubation, than to result in intubation.

Why is this so difficult for medical directors to understand?

This was published in February 2012.

The original evidence showing benzodiazepines reduce the rate of intubation of seizure patients was published in August of 2001.

Why are so many EMS protocols still in the Dark Ages?

Medical directors are responsible for the airway management skills of their medics and basic EMTs.

Medical directors should not be choosing brain damage for seizure patients.

This is a misguided fear of the lack of airway management skills in the people the medical directors authorize to treat patients.

This is not competent medical direction.

We do not need to lower the doses of benzodiazepines to protect the anxieties of medical directors.

We need to raise the doses of benzodiazepine to protect the brains of seizure patients.
 

See also Part I, Part II, Part III, Part IV, Part V, Part VI, and Images from Gathering of Eagles Presentation on RAMPART.

Footnotes:

[1] Intramuscular versus intravenous benzodiazepines for prehospital treatment of status epilepticus.
Hirsch LJ.
N Engl J Med. 2012 Feb 16;366(7):659-60. doi: 10.1056/NEJMe1114206. No abstract available.
PMID: 22335744 [PubMed – indexed for MEDLINE]

Free Full Text PDF Download from the RAMPART Group.

[2] Comment from Farid Sadaka, MD
Intramuscular versus intravenous therapy for prehospital status epilepticus.
Silbergleit R, Durkalski V, Lowenstein D, Conwit R, Pancioli A, Palesch Y, Barsan W; NETT Investigators.
N Engl J Med. 2012 Feb 16;366(7):591-600.
PMID: 22335736 [PubMed – in process]

Free Full Text from N Engl J Med.

[3] Intramuscular versus intravenous benzodiazepines for status epilepticus.
Xue FS, Liao X, Cheng Y.
N Engl J Med. 2012 May 17;366(20):1943; author reply 1944. doi: 10.1056/NEJMc1203428#SA1. No abstract available.
PMID: 22591303 [PubMed – indexed for MEDLINE]

Free Full Text from N Engl J Med.

[4] A comparison of lorazepam, diazepam, and placebo for the treatment of out-of-hospital status epilepticus.
Alldredge BK, Gelb AM, Isaacs SM, Corry MD, Allen F, Ulrich S, Gottwald MD, O’Neil N, Neuhaus JM, Segal MR, Lowenstein DH.
N Engl J Med. 2001 Aug 30;345(9):631-7. Erratum in: N Engl J Med 2001 Dec 20;345(25):1860.
PMID: 11547716 [PubMed – indexed for MEDLINE]

Free Full Text from N Engl J Med. with link to PDF Download.

[5] Intramuscular versus intravenous therapy for prehospital status epilepticus.
Silbergleit R, Durkalski V, Lowenstein D, Conwit R, Pancioli A, Palesch Y, Barsan W; NETT Investigators.
N Engl J Med. 2012 Feb 16;366(7):591-600.
PMID: 22335736 [PubMed – in process]

Free Full Text from N Engl J Med.

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