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Three Part Question

In [a fitting patient with no intravenous access] can [intranasal midazolam or rectal diazepam] stop [the fit]?

Clinical Scenario

A 14 year old known epileptic attends the Emergency department having had a fit at school. His teacher is with him. She tells you that he was fitting for approximately twenty minutes. She also tells you that they have rectal diazepam at school but the staff were reluctant to administer it. You check the patient and find him to be post-ictal but otherwise well. You wonder if midazolam, which can be administered intranasally, would successfully terminate epileptic fits.

Search Strategy

Medline OVID 1966 to 2005 Feb week 2
Embase OVID 1980-2004 Week 7
[exp epilepsy/ OR epilepsy.mp OR exp seizures/ OR seizure$.mp OR convulsion$.mp. OR fit$.mp.] AND [ exp midazolam/ OR midazolam.mp. OR exp benzodiazepines/ OR benzodiazepines.mp.] AND [exp administration intranasal/ OR nasal$.mp. OR nose.mp.]

Search Outcome

Altogether 36 papers were identified. On reading the abstracts 4 papers were of interest

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
O'Regan ME et al 1996 UK	19 epileptic children in the neurophysiology laboratory given intranasal midazolam	Experimental	Electroencephalographic (EEG) evidence or clinical cessation of fits	15/19 patients showed either EEG changes or clinical improvement	Population different from that seen as an emergency no control of other medications
Kendall JL et al 1997 USA	2 patients in the Emergency Department	Case report	Clinical evidence of cessation of fits	Both patients stopped fitting
Sheepers M et al 1998 UK	2 patients in the Emergency Department	Case report	Clinical evidence of cessation of fits	Both patients stopped fitting
Mahmoudian T and Zadeh MM, 2004 Iran	70 children aged 2 months to 15 years IV diazepam vs intranasal	Clinical Trial	Time to seizure control	2.94 min vs 3.58 min	No randomisation

Comment(s)

The standard of evidence is poor. Properly conducted trials comparing the efficacy of intranasal midazolam are needed.

Clinical Bottom Line

Intranasal midazolam appears to be effective at controlling seizures.

References

1. O'Regan ME, Brown JK, Clarke M. Nasal rather than rectal benzodiazepines in the management of acute childhood seizures? Dev Med Child Neurol 1996;38(11):1037-45.
2. Kendall JL, Reynolds M, Goldberg R. Intranasal midazolam in patients with status epilepticus. Ann Emerg Med 1997;29(3):415-7.
3. Scheepers M, Scheepers B, Clough P. Midazolam via the intranasal route: an effective rescue medication for severe epilepsy in adults with learning disability. Seizure 1998;7(6):509-12.
4. Mahmoudian T, Zadeh MM. Comparison of intranasal midazolam with intravenous diazepam for treating acute seizures in children. Epilepsy and Behavior 2004;5:253-5.