IM midazolam 對 pediatric seizure有效!

Nonintravenous Midazolam Effectively Terminates Pediatric Seizures

A meta-analysis reveals that non-IV midazolam is as effective as or superior to IV or rectal diazepam for stopping seizures in children and young adults.

Although intravenous (IV) lorazepam is considered first-line therapy for status epilepticus, this therapy is impractical for patients who do not have IV access. Diazepam can be administered either intravenously or rectally but is less effective and associated with a higher risk for respiratory depression. Midazolam — although not formally recommended for treatment of seizures — can be given via IV, intramuscular (IM), intranasal (IN), or buccal routes.

These authors conducted a meta-analysis of randomized, controlled trials published from 1950 to 2009 that compared non-IV midazolam to diazepam by any route for initial treatment of status epilepticus in emergency department (ED) patients. Six studies involving 774 patients (age range, newborn to 22 years) met inclusion criteria. Three studies compared buccal midazolam (0.5 mg/kg or 10 mg) to rectal diazepam (0.5 mg/kg or 10 mg), and three compared IM or IN midazolam (0.2 mg/kg) to IV diazepam (0.2 or 0.3 mg/kg).

In pooled analysis of medications administered by any route, midazolam was superior to diazepam for terminating seizures, with a number needed to treat (NNT) of 7 to demonstrate midazolam benefit. IM or IN midazolam was as effective as IV diazepam, while buccal midazolam was superior to rectal diazepam in achieving seizure control (NNT, 6). Time to seizure cessation was similar in the midazolam and diazepam groups in the three studies that evaluated this outcome. The analysis was not sufficiently powered to detect differences in frequency of respiratory complications. Sensitivity analysis revealed that dose of medication and duration of seizure had no effect on differences between treatment groups.

Comment: Establishing IV access can significantly delay treatment of status epilepticus. Buccal, intramuscular, or intranasal midazolam is a cheap, easily administered, and effective alternative for children with seizures who present without IV access.

— Katherine Bakes, MD

Published in Journal Watch Emergency Medicine June 18, 2010

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