Seizure termination in children,best benzodiazepine & route of administration:A network metaanalysis

What is it about?

This network meta-analysis aimed to compare various benzodiazepines and their route of administration using the data published exclusively in randomized controlled trials (RCTs). Children presenting with an episode of seizure to ER or to a paramedic where they were administered a benzodiazepine as the first-line treatment were included. The primary outcome was the number of successful seizure cessation. Secondary outcomes were the time interval between drug administration and seizure cessation, the time interval between patient arrival and seizure cessation and the number of episodes of seizure recurrence after drug administration. For the number of successful cessations, intramuscular midazolam showed the highest mean and best rank probability with a value of .881 (.065) and 57.9%, respectively. For the time of cessation, both intravenous lorazepam (IVL) and intravenous diazepam showed a mean of 3.30 (1.30) with IVL having the highest rank probability of 32%. For total time for cessation, intranasal midazolam showed the best mean and rank probability with a value of 4.3 (1.1) and 55%, respectively. Buccal midazolam showed the lowest mean with a value of .106 (.084) for rate of recurrence. Although there was no significant difference between the treatments, based on the rank probability even though IVL showed more promising results for patients who already have an established intravenous line, and for patients presenting in the ER without an intravenous line, the first line of treatment should be INM as it shows the highest rank probability in total time with second-highest successful cessation rate.

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Photo by Hiroshi Tsubono on Unsplash

Photo by Hiroshi Tsubono on Unsplash

Why is it important?

To prevent the complication of prolonged seizures, time is of the essence. Our analysis manifests that non-IV midazolam has a better rate of seizure cessation (IMM and INM), takes the lowest total time for cessation (INM, IMM, and BM), and has the lowest recurrence rate (BM) in contrast to lorazepam or diazepam administered through any route. This can be supported by the reality of the difficulties faced while obtaining IV access in an unconscious convulsing child. It would be in the best interest of the patient to terminate the seizure as quickly as possible which can be aided by administering the drug outside the hospital setting; this favors the INM and IMM route as it can be safely and effectively administered by those around the patient. INM is a more practical choice in a predicament for the general population, school nurses, and the paramedics as it does not involve obtaining an IV line before moving the patient to a hospital setting.