Intramuscular Midazolam not inferior to Intravenous Lorazepam in treating Status Epilepticus
Terminating prolonged seizures in patients with status epilepticus is of paramount importance. If seizures are not terminated early, it may lead to brain injury, prolonged hospitalization and even death in extreme cases. It is estimated that almost 55,000 patients develop status epilepticus annually in the US alone. The standard practice to control the seizures during pre-hospital emergency care is through intravenous injection of lorazepam. However, it is often difficult to accomplish, even by trained paramedics, because of the aggressive movements of the patient during seizures. There has been a growing support for administering anti-seizure medicines intramuscularly instead of intravenous route. A new study, published in the New England Journal of Medicine has found that intramuscular injection of midazolam is at least as safe and effective as an intravenous injection of lorazepam, in bringing the seizures under control, in pre-hospital emergency treatment of status epilepticus.
The study, called as the Rapid Anticonvulsant Medication Prior to Arrival Trial (RAMPART), involved 900 patients suffering from status epilepticus. 4,314 paramedics and 79 hospitals in the US participated in the study. The patients, who had been having seizures for more than 5 minutes and who were still having seizures when the paramedics arrived, were randomly given anti-seizure medication by either intramuscular autoinjector or intravenous infusion.
73.4% of the patients who received intramuscular treatment were free of seizures at the time of arrival in the emergency department, compared to 63.4% of the patients who received intravenous lorazepam. Almost equal number of patients from both the groups suffered from recurrence of seizures or required endotracheal intubation. The median time between delivery of medication and cessation of seizures was 3.3 minutes for the intramuscular group although the time taken to deliver the treatment was 1.2 minutes on an average. In the intravenous group, the average time taken to deliver the treatment was 4.8 minutes while the time between treatment and cessation of seizures was 1.6 minutes.
On the basis of the study, the authors have opined that intramuscular midazolam is non-inferior to intravenous lorazepam in pre-hospital emergency treatment for status epilepticus. References: