Intramuscular midazolam versus intravenous diazepam for treatment of seizures in the pediatric emergency department: A randomized clinical trial

Portela, J.L.; García, Pedro Celiny Ramos; Piva, Jefferson Pedro; Barcelos, Andrea Lucia Machado; Bruno, Francisco; Branco, Ricardo Garcia; Tasker, Robert C.

doi:10.1016/j.medin.2014.04.003

Cited by 21 publications

(7 citation statements)

References 26 publications

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“…Intramuscular midazolam was compared with IV diazepam in three class III studies (36, 43, 55). In all three studies, IM midazolam had a shorter interval to seizure cessation, but there was no significant difference in overall efficacy for termination of seizures (36, 43, 55).…”

Section: Resultsmentioning

confidence: 99%

“…Two of the class III IM or intranasal midazolam studies reported significant respiratory depression (36–39, 43, 45, 46, 53). Single children in each study (6.25% and 2%) in the IM midazolam group experienced respiratory failure resulting in artificial ventilation (51, 55).…”

Section: Resultsmentioning

confidence: 99%

“…Class III trials identified similar rates of respiratory depression with IV benzodiazepine use (35,49,55). One class III trial reported 21% of patients receiving IV diazepam and 4% of patients receiving IV lorazepam were reported to have respiratory depression defined as poor respiratory effort, reduced rate of breathing, or requiring oxygen administration via face mask (35).…”

Section: Pediatric Studiesmentioning

confidence: 99%

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Evidence-Based Guideline: Treatment of Convulsive Status Epilepticus in Children and Adults: Report of the Guideline Committee of the American Epilepsy Society

Glauser

Shinnar

Gloss³

et al. 2016

Epilepsy Curr

978

937

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CONTEXT: The optimal pharmacologic treatment for early convulsive status epilepticus is unclear. OBJECTIVE: To analyze efficacy, tolerability and safety data for anticonvulsant treatment of children and adults with convulsive status epilepticus and use this analysis to develop an evidence-based treatment algorithm. DATA SOURCES: Structured literature review using MEDLINE, Embase, Current Contents, and Cochrane library supplemented with article reference lists. STUDY SELECTION: Randomized controlled trials of anticonvulsant treatment for seizures lasting longer than 5 minutes. DATA EXTRACTION: Individual studies were rated using predefined criteria and these results were used to form recommendations, conclusions, and an evidence-based treatment algorithm. RESULTS: A total of 38 randomized controlled trials were identified, rated and contributed to the assessment. Only four trials were considered to have class I evidence of efficacy. Two studies were rated as class II and the remaining 32 were judged to have class III evidence. In adults with convulsive status epilepticus, intramuscular midazolam, intravenous lorazepam, intravenous diazepam and intravenous phenobarbital are established as efficacious as initial therapy (Level A). Intramuscular midazolam has superior effectiveness compared to intravenous lorazepam in adults with convulsive status epilepticus without established intravenous access (Level A). In children, intravenous lorazepam and intravenous diazepam are established as efficacious at stopping seizures lasting at least 5 minutes (Level A) while rectal diazepam, intramuscular midazolam, intranasal midazolam, and buccal midazolam are probably effective (Level B). No significant difference in effectiveness has been demonstrated between intravenous lorazepam and intravenous diazepam in adults or children with convulsive status epilepticus (Level A). Respiratory and cardiac symptoms are the most commonly encountered treatment-emergent adverse events associated with intravenous anticonvulsant drug administration in adults with convulsive status epilepticus (Level A). The rate of respiratory depression in patients with convulsive status epilepticus treated with benzodiazepines is lower than in patients with convul-

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Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

Section: Pediatric Studiesmentioning

confidence: 99%

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Evidence-Based Guideline: Treatment of Convulsive Status Epilepticus in Children and Adults: Report of the Guideline Committee of the American Epilepsy Society

Glauser

Shinnar

Gloss³

et al. 2016

Epilepsy Curr

978

937

View full text Add to dashboard Cite

show abstract

“…Paraldehyde is delivered intramuscularly (IM) or rectally and may have fewer respiratory suppressive effects relative to diazepam, but is not widely available, and though an older agent, is prohibitively expensive in many settings. IM midazolam has shown a shorter interval of seizure termination when compared to IV diazepam in three paediatric randomized controlled trials (RCT’s), but there was no significant difference in overall efficacy for termination of seizures [22] , [23] , [24] . Midazolam can be administered via IV, IM, intranasal or buccal routes with good effect for seizure cessation.…”

Section: Discussionmentioning

confidence: 99%

Management of acute seizures in children: A review with special consideration of care in resource-limited settings

Ciccone

Mathews

Birbeck

2017

African Journal of Emergency Medicine

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IntroductionWe sought to review recent evidence-based guidelines and where applicable, primary data to extrapolate insights into the appropriate management of acute seizures in children in resource-limited settings.MethodsPubMed and Google scholar searches were conducted with attention to publications from the last three to five years, including a focused search for acute seizure management guidelines relevant to resource limited settings. Since all guidelines to date, except the World Health Organization’s, assume ready access to invasive ventilation and advanced diagnostic testing, guidelines and primary data were used to propose management appropriate for resource-limited settings where respiratory suppression from treatment presents a major challenge in management.ResultsAcute seizures are among the commonest medical emergencies encountered in the African settings. Seizure management must occur simultaneously with the diagnostic assessment, which should include addressing life threatening causes (e.g. hypoglycaemia, malaria) and with attention given to the most likely aetiology in a particular region or setting. For ongoing seizures, initial treatment with benzodiazepines is indicated. There is evidence of efficacy for several agents and delivery modes. Longer-acting antiepileptic drugs (AEDs) should be on hand if acute seizures fail to respond to two doses of benzodiazepines. There is little direct evidence comparing the relative efficacy of different long-acting AEDs for acute seizure management in African children. Findings suggest that generalising data from Western settings, where different aetiologies and risk factors for seizures prevail, may be inappropriate.DiscussionThough treatment options and diagnostics may be dictated by available medications and capacity, it is possible for virtually any healthcare setting to develop a relevant and feasible local guideline for seizure management. Clear specifications on when to refer to a higher level of care should be part of the care plan.

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“…It is important to note that some patients in these studies received commercially available buccal midazolam (Epistatus ® ) while others received injectable midazolam buccally, which may have impacted the results. Buccal diazepam has less variability in achieving maximum concentrations compared to rectal diazepam, but the time to reach maximum concentrations is longer [69,80]. One important factor to consider is that food, saliva secretion, and local pH may alter the absorption of the buccal films and it may reduce their maximum concentration [60].…”

Section: Evidence For Routes Of Administrationmentioning

confidence: 99%

Time Is Brain: Acute Control of Repetitive Seizures and Status Epilepticus Using Alternative Routes of Administration of Benzodiazepines

Almohaish

Sandler

Brophy

2021

JCM

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Time plays a major role in seizure evaluation and treatment. Acute repetitive seizures and status epilepticus are medical emergencies that require immediate assessment and treatment for optimal therapeutic response. Benzodiazepines are considered the first-line agent for rapid seizure control. Thus, various routes of administration of benzodiazepines have been studied to facilitate a quick, effective, and easy therapy administration. Choosing the right agent may vary based on the drug and route properties, patient’s environment, caregiver’s skills, and drug accessibility. The pharmacokinetic and pharmacodynamic aspects of benzodiazepines are essential in the decision-making process. Ultimately, agents and routes that give the highest bioavailability, fastest absorption, and a modest duration are preferred. In the outpatient setting, intranasal and buccal routes appear to be equally effective and more rapidly administered than rectal diazepam. On the other hand, in the inpatient setting, if available, the IV route is ideal for benzodiazepine administration to avoid any potential absorption delay. In this article, we will provide an overview and comparison of the various routes of benzodiazepine administration for acute control of repetitive seizures and status epilepticus.

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Intramuscular midazolam versus intravenous diazepam for treatment of seizures in the pediatric emergency department: A randomized clinical trial

Cited by 21 publications

References 26 publications

Evidence-Based Guideline: Treatment of Convulsive Status Epilepticus in Children and Adults: Report of the Guideline Committee of the American Epilepsy Society

Evidence-Based Guideline: Treatment of Convulsive Status Epilepticus in Children and Adults: Report of the Guideline Committee of the American Epilepsy Society

Management of acute seizures in children: A review with special consideration of care in resource-limited settings

Time Is Brain: Acute Control of Repetitive Seizures and Status Epilepticus Using Alternative Routes of Administration of Benzodiazepines

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