UMEM Educational Pearls

Title: IV vs. Non-IV Benzodiazepines for Cessation of Seizures

Category: Neurology

Keywords: seizure, status epilepticus, benzodiazepine, RAMPART, pediatric (PubMed Search)

Posted: 9/13/2017 by WanTsu Wendy Chang, MD (Updated: 9/14/2017)
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IV vs. Non-IV Benzodiazepines for Cessation of Seizures

A meta-analysis by Alshehri et al. included 11 studies with a total of 1633 patients, comparing IV vs. non-IV benzodiazepines from any route (buccal, intranasal, intramuscular) for seizure cessation in status epilepticus.
They found that non-IV benzodiazepine is more effective than IV benzodiazepine in patients presenting without IV access.
The largest and highest quality study included in the meta-analysis was the RAMPART study, which was also the only study to include adults.
When considering pediatric studies only, there is no difference between IV vs. non-IV benzodiazepine in seizure cessation for status epilepticus.

Benzodiazepine is first-line therapy for treatment of status epilepticus.
The RAMPART study in 2012 by Silbergleit et al. demonstrated that prehospital treatment of status epilepticus with IM midazolam was more effective than IV lorazepam, even though the time from drug administration to seizure cessation was shorter for IV lorazepam.
It is important to note that there is a 30% treatment failure rate for a single appropriately dosed benzodiazepine in treatment of status epilepticus.

Alshehri A, Abulaban A, Bokhari R, et al. Intravenous vs. nonintravenous benzodiazepines for the cessation of seizures: a systematic review and meta-analysis of randomized controlled trials. Acad Emerg Med 2017;24(7):875-83.
Silbergleit R, Durkalski V, Lowenstein D, et al. Intramuscular versus intravenous therapy for prehospital status epilepticus. N Engl J Med 2012;366(7):591-600.

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