Prehospital Intranasal Midazolam for the Treatment of Pediatric Seizures

Abstract

The IN-MAD midazolam controlled seizures better than PR diazepam in the prehospital setting and resulted in fewer respiratory complications and fewer admissions.

Intranasal Delivery of Antiepileptic Medications for Treatment of Seizures

“…21 In addition to the aforementioned advantages from Bhattacharyya et al, 40 the investigators demonstrated that midalozam-treated patients were less likely to be seizing on presentation to the emergency department, needed less additional seizure medication, had a lower incidence of intubation, or were less likely to be admitted to the hospital or intensive care unit.…”

“…13 Increased nasal mucus production is commonly observed with actively seizing patients and could be clinically relevant to intranasal drug administration for treatment of seizures. Holsti et al 21 recognized this consideration in their pre-hospital treatment protocol that called for suction of mucus from the nasal cavity prior to administration of intranasal midazolam. Pre-treatment nasal cavity suctioning was likely contributory to the success observed in rapidly aborting seizure activity after intranasal midazolam administration.…”

Treatment of Acute Seizures: Is Intranasal Midazolam a Viable Option?

“…Of those 13 (Table). 1,8,12,13 Bhattacharyya and colleagues 12 compared intranasal midazolam to rectal diazepam in 46 children who presented to the ED with febrile or afebrile seizures. Baseline characteristics were similar between the 2 groups.…”

“…Prospective and retrospective evidence shows that intranasal midazolam terminates seizures at least as fast as rectal diazepam. 1,5,8,[12][13][14][15] Most clinical studies have used a 5 mg/mL midazolam solution dosed at 0.2 mg/ kg (divided into each nostril) administered via an intranasal mucosal atomization (IN-MADD) device or nasal dropper as suggested by Kyrkou and colleagues. 16 Three open-labeled studies prospectively evaluated the time to seizure cessation with a dose of nasal midazolam (Table).…”

“…Increases in mucus production and changes in mucociliary clearance rates could affect midazolam's bioavailability. 6,8 Midazolam's small molecular weight of 325.8 Da allows for easy permeation of nasal mucosa. 6 Midazolam dissolves in water at a low pH, but at physiologic pH it becomes lipophilic, allowing the medication to cross the blood-brain barrier.…”