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Home > Topics > Medical / Clinical

Study: Injection offers faster help for seizure patients

Results probably will change how seizures are treated by paramedics

By Erin Allday
The San Francisco Chronicle 

SAN FRANCISCO —  Injecting patients in the thigh with a drug-loaded syringe is a safe and effective way to stop a seizure in an emergency, according to results of a national study released Wednesday, a finding that could pave the way toward making such syringes as widely available as EpiPens used to treat severe allergic reactions.

The two-year study, published in the New England Journal of Medicine, concluded that a single stab from an auto-injector was more effective in stopping a prolonged seizure than the traditional method of inserting an intravenous line and delivering the drug directly into the bloodstream.

Full story: Study: Injection offers faster help for seizure patients

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Arron Martínez Arron Martínez Thursday, February 16, 2012 11:07:05 AM You can find the study here: http://www.nejm.org/doi/full/10.1056/NEJMoa1107494. Robert Silbergleit, M.D., Valerie Durkalski, Ph.D., Daniel Lowenstein, M.D., Robin Conwit, M.D., Arthur Pancioli, M.D., Yuko Palesch, Ph.D., and William Barsan, M.D. for the NETT Investigators, N Engl J Med 2012; 366:591-600.
Sue Geyster Sue Geyster Thursday, February 16, 2012 11:10:04 AM Sounds amazing and such an asset to everyone in the healthcare field. Please continue the research on the adverse effects.
Steve Price Lpn Steve Price Lpn Thursday, February 16, 2012 11:12:32 AM Is there a difference between the 2 drugs they should do a study with an auto injector of Valium And use the other drugs in the Iv See if there is a difference between the 2
Chris Kaiser Chris Kaiser Thursday, February 16, 2012 11:14:13 AM Interesting study. I would like to see the comparison done showing how IM Versed (midazolam) does over going the Intranasal (MAD device) route. In a similar study, Intranasal versed was shown to be more effective than IV Valium at stopping seizure activity in pediatric patients when viewed on an EEG.
Paul T Salos Paul T Salos Thursday, February 16, 2012 11:45:53 AM Rectal valium is more quickly absorbed, and is very effective in stopping sz activity quickly.
Johnny Torres Johnny Torres Thursday, February 16, 2012 12:15:15 PM I thought about this method over 10 years ago, glad to finally see it happening...
Roc-Anthony Smith Roc-Anthony Smith Thursday, February 16, 2012 2:12:33 PM Valium is contraindicated in IM use...
Ashley Fox Ashley Fox Thursday, February 16, 2012 2:30:58 PM I love my Epi-Pen. I know that seizure patients will love to have an auto-injector too. :)
Casey Edwards Casey Edwards Thursday, February 16, 2012 7:08:53 PM I'm with Chris...we have the MAD and I'm curious to compare.
Matt Schaper Matt Schaper Thursday, February 16, 2012 9:34:48 PM We used the nasal application with the MAD (with versed) too. It works really well and it is safe. Matt
Michael Krtek Michael Krtek Friday, February 17, 2012 12:06:57 AM Drug and dosage? I don't see it listed...
Para Medic Para Medic Friday, February 17, 2012 4:19:59 AM say what?????
Nathan Stanaway Nathan Stanaway Friday, February 17, 2012 4:33:24 AM I was able to enroll two or three people in this study. Its interesting to finally see the results!
Jr First Jr First Friday, February 17, 2012 5:04:00 AM it might be quicker than IM injection but do you know how many lawsuits would arise from paramedics putting there finger up someones butt in the back of an ambulance.....seriously!? think about. Glad i work for a service that has IM protocol even though we don't have the injectors
Paul T Salos Paul T Salos Friday, February 17, 2012 5:51:02 AM Rectal valium is in our protocols. And has proven effective and no problems have arisen as a result thereof. Our medical director is spot on with us and he is awesome. He used to be a paramedic with FDNY.
Dustin Krtek Dustin Krtek Friday, February 17, 2012 7:02:48 AM How do you inject some one having a seizure without them beating you half to death?
John Morrison John Morrison Friday, February 17, 2012 8:00:03 AM Jr First Rectal Valium is very common. There would be zero lawsuits from it because it's an acceptable and safe route.
John Morrison John Morrison Friday, February 17, 2012 8:00:24 AM Kyle Kindness I would argue, based on my opinion, that it's less difficult than giving IM Versed. For the simple reason of when giving an IM drug you're approaching an out of control patient with a needle. Rectally there is no needle.
Zachary Prejean Zachary Prejean Friday, February 17, 2012 8:09:48 AM I was wondering the same thing. Which drug and dose are they talking about here. Plus thats gonna be another drug abusers dream.. Great idea, but i agree that it needs more research
Rogue Medic Rogue Medic Saturday, February 18, 2012 9:38:54 AM "'This auto-injection should be the new standard of care,' said Dr. James Quinn, a professor of surgery and emergency medicine at Stanford who led the study there. 'It's great when you can do a study and it's probably going to change how we do things.'". No. IM midazolam should be the standard of care, not the expensive "fool-proof" device. From the study - "Similarly, an autoinjector was used in this study to optimize the speed and efficiency of intramuscular delivery, but it is not possible to determine the importance of using this tool for intramuscular injections, as compared with conventional intramuscular injections." Why does Dr. Quinn claim so much more knowledge of results than the study is capable of providing. This study reinforces the results of the many previous studies of IM midazolam..
Rogue Medic Rogue Medic Saturday, February 18, 2012 9:46:59 AM Roc-Anthony Smith, Diazepam (Valium) is not contraindicated IM. It just is not commonly used that way. EMS has just had a fascination with rectal administration. "Dosage should be individualized for maximum beneficial effect. The usual recommended dose in older children and adults ranges from 2 mg to 20 mg IM or IV, depending on the indication and its severity." "In the convulsing patient, the IV route is by far preferred. This injection should be administered slowly. However, if IV administration is impossible, the IM route may be used." From the FDA label, available at DailyMed. http://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?id=9112 .
Rogue Medic Rogue Medic Saturday, February 18, 2012 10:00:08 AM Paul T. Salos, Please provide some evidence that rectal diazepam works more quickly than IM midazolam. IV medication is more quickly absorbed. Should we only give IV medication? What good reason is there for EMS to be giving rectal medications? .
Rogue Medic Rogue Medic Saturday, February 18, 2012 10:11:03 AM Sue Geyster, "The frequencies of endotracheal intubation, recurrent seizures, and other predefined safety outcomes were similar in the two study groups (Table 2)." "the proportion of subjects admitted was significantly lower (and the proportion discharged from the emergency department was significantly higher) in the intramuscular group than in the intravenous group (P=0.01)." This is a very large study that shows that IM midazolam has fewer side effects than IV lorazepam. .
Rogue Medic Rogue Medic Monday, February 20, 2012 5:36:52 PM Paul T. Salos, These are just the first 5 papers I looked at comparing rectal diazepam with other treatments. Rectal diazepam is SLOWER. Rectal diazepam is LESS EFFECTIVE. Perhaps your medical director should review the research on rectal diazepam, because there is no good reason to continue to use it. Rectal diazepam has only been demonstrated to be superior to is placebo - in other words, it does work, but not as well as any of the other treatments available. - Intranasal midazolam vs rectal diazepam in acute childhood seizures. Bhattacharyya M, Kalra V, Gulati S. Pediatr Neurol. 2006 May;34(5):355-9. PMID: 16647994 [PubMed - indexed for MEDLINE] http://www.ncbi.nlm.nih.gov/pubmed/16647994 - Buccal midazolam and rectal diazepam for treatment of prolonged seizures in childhood and adolescence: a randomised trial. Scott RC, Besag FM, Neville BG. Lancet. 1999 Feb 20;353(9153):623-6. PMID: 10030327 [PubMed - indexed for MEDLINE] http://www.ncbi.nlm.nih.gov/pubmed/10030327 - Intranasal midazolam vs rectal diazepam for the home treatment of acute seizures in pediatric patients with epilepsy. Holsti M, Dudley N, Schunk J, Adelgais K, Greenberg R, Olsen C, Healy A, Firth S, Filloux F. Arch Pediatr Adolesc Med. 2010 Aug;164(8):747-53. PMID: 20679166 [PubMed - indexed for MEDLINE] http://www.ncbi.nlm.nih.gov/pubmed/20679166 - Effects of intranasal midazolam and rectal diazepam on acute convulsions in children: prospective randomized study. Fisgin T, Gurer Y, Teziç T, Senbil N, Zorlu P, Okuyaz C, Akgün D. J Child Neurol. 2002 Feb;17(2):123-6. PMID: 11952072 [PubMed - indexed for MEDLINE] http://www.ncbi.nlm.nih.gov/pubmed/11952072 - Safety and efficacy of buccal midazolam versus rectal diazepam for emergency treatment of seizures in children: a randomised controlled trial. McIntyre J, Robertson S, Norris E, Appleton R, Whitehouse WP, Phillips B, Martland T, Berry K, Collier J, Smith S, Choonara I. Lancet. 2005 Jul 16-22;366(9481):205-10. PMID: 16023510 [PubMed - indexed for MEDLINE] http://www.ncbi.nlm.nih.gov/pubmed/16023510 .
Rogue Medic Rogue Medic Monday, February 20, 2012 5:46:59 PM Zachary Prejean, Worrying more about the potential for drug abuse than about the care of patients is a very bad idea. How do you know so much about drug abuse and what drug abusers dream about? Why do you have so little concern for seizure patients? How is this " gonna be another drug abusers dream.. "? There has been a lot of research on this. Maybe you should read some of the research before you comment. How would you know what needs research? I listed a dozen earlier studies of IM midazolam in the link below. http://roguemedic.com/2012/02/intramuscular-midazolam-for-siezures-part-i/ .
Rogue Medic Rogue Medic Monday, February 20, 2012 5:49:43 PM Jr First, Rectal diazepam is NOT quicker than IM midazolam. .
Rogue Medic Rogue Medic Monday, February 20, 2012 5:51:46 PM John Morrison, There were no reported problems using IM midazolam. Why do you assume that there would be easier to pull down the patient's pants, lubricate a catheter, inject the drug in the rectum, and keep the medication from leaking out of the rectum? .
Rogue Medic Rogue Medic Monday, February 20, 2012 5:55:33 PM Michael Krtek, "All adults and those children with an estimated body weight of more than 40 kg received either 10 mg of intramuscular midazolam followed by intravenous placebo or intramuscular placebo followed by 4 mg of intravenous lorazepam. In children with an estimated weight of 13 to 40 kg, the active treatment was 5 mg of intramuscular midazolam or 2 mg of intravenous lorazepam.
Zachary Prejean Zachary Prejean Monday, February 20, 2012 6:12:58 PM Without even taking the time to read your link, i know about drug abuse because i have a family member that has had problems his entire life. Thanks for the asshole response though...where in any way, shape, or form did i say i had little concern for seizure patients. Again..thanks for the asshole assumption. And I have an opinion just as well as to what needs research as you. Who are you to call me out on that? :)
Rogue Medic Rogue Medic Monday, February 20, 2012 6:16:41 PM Zachary Prejean, So you know a drug abuser and you think that is an excuse to discourage use of this safe, effective, and well studied treatment for seizures. Apparently, you do not know a thing about the studies and you wish to keep it that way. .
Zachary Prejean Zachary Prejean Monday, February 20, 2012 6:34:39 PM Guess your just butthard for this drug. Because obviously it does need more research since its not being used in this form currently. so do not call me out with you posts that have nothing to do with my initial comment. I never discouraged the use of it at all. So guess you just keep having fun bein an internet troll.
Zachary Prejean Zachary Prejean Monday, February 20, 2012 6:37:35 PM In fact, i said "great idea". So where did you get that im downing the use of such a great, powerful drug?
Rogue Medic Rogue Medic Monday, February 20, 2012 7:22:14 PM Zachary Prejean, "Great idea, but . . ." That is not support. That is a backhanded compliment. Not only is IM midazolam well studied, but it is commonly used as an IM treatment for seizures. You would have to read a bit about the subject to know that. Why do you keep making false statements about the lack of research on IM midazolam? I provided a link to a dozen studies, but you are too smart to look. Here is just one. From 1992. Were you working in EMS then? Were you born yet? The study shows that this IM midazolam nothing new or unsupported by research. Midazolam in treatment of epileptic seizures. Lahat E, Aladjem M, Eshel G, Bistritzer T, Katz Y. Pediatr Neurol. 1992 May-Jun;8(3):215-6. PMID: 1622519 [PubMed - indexed for MEDLINE] http://www.ncbi.nlm.nih.gov/pubmed/1622519 Just because the use of a drug is off-label does not mean that it is not appropriate. A lot of the medications used in EMS are used off-label. .
Michael Krtek Michael Krtek Monday, February 20, 2012 9:26:17 PM Rogue Medic _ Thank you for your answer. About how long before you get an effect from IM injection? I guess this is mostly for status or prophylaxes for re-occurrence?
Rogue Medic Rogue Medic Monday, February 20, 2012 11:10:18 PM Michael Krtek, Yes, this is for status or re-occurrence. "Subjects were enrolled if they were having convulsive seizures at the time of treatment by paramedics and were reported by reliable witnesses to have been continuously convulsing for longer than 5 minutes or if they were having convulsive seizures at the time of treatment after having intermittent seizures without regaining consciousness for longer than 5 minutes." - "The median time to administration of active treatment was significantly shorter by the intramuscular route than by the intravenous route (1.2 vs. 4.8 minutes), but the onset of action (i.e., termination of convulsions) occurred sooner after intravenous administration than after intramuscular administration (1.6 vs. 3.3 minutes)." If an IV is already in place, it is better to give the IV medication (midazolam should also be quicker IV). Without an IV, the time to start an IV plus the time to stop the seizure takes much longer than the time for IM administration plus the time to stop the seizure. IO (IntrOsseous) access was permitted for the IV group, but they do not provide any information on how many patients had IO access or how long it took to place the IOs in the patients during the seizures. The total mean time to termination of seizure - 6.4 minutes with IV lorazepam. vs. 4.5 minutes with IM midazolam. 2 minutes (1.9) may not be a lot for most things, but during a seizure, it may be important. More important than the mean time is the success rate - 63.4% with IV lorazepam. vs. 73.4% with IM midazolam. An extra 10% failure rate with IV lorazepam is a very important difference. .

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