Status+Epilepticus

RAMPART Study (Silbergleit R et al, "Intramuscular versus Intravenous Therapy for Prehospital Status Epilepticus." NEJM 2012; 336(7):591.) - midaozolam 10mg IM v s lorazepam 4mg IV for pts >40kg, midazolam 5mg or lorazepam 2mg if <40kg - RCT, noninferiority, intention-to-treat - n=893 - Inclusion criteria: Children and adults in status epilepticus treated by paramedics. Convulsions >5 minutes, still convulsing after paramedics arrived - Exclusion criteria: major trauma, hypoglycemia, cardiac arrest, heart rate < 40 beats per minute, pregnancy, known allergy to intervention, or estimated weight < 13 kg (28.6 lbs).

- Primary outcome: absence of sz at time of arrival in ED without need for rescue therapy - Results: IM midazolam (73.4%) outperformed IV lorazepam (63.4%) at terminating seizures at time of arrival in ED without need for rescue tx (p < 0.001, NNT 10) - Other outcomes: Lower rate of hospitalization with IM midazolam (57.6% vs 65.6%, p<0.05, NNT 13). Lower rate ICU admission with IM midazolam (28.6% vs. 36.2%, p<0.05, NNT 14). No significant difference in intubation within 30 minutes or seizure recurrence within 12 hours of ED arrival.

- Notes: 99% of midazolam group received midazolam, but only 63% of lorazepam group received lorazepam (b/c convulsions stopped prior to tx in 64%, paramedics failed to start IV in 28%.