# IV lorazepam vs midazolam for seizure tx



## coolidge (May 29, 2010)

IV lorazepam vs IV midazolam for seizure tx?
And why.  Thanks


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## Shishkabob (May 29, 2010)

Why not Diazepam?



And what exactly are you asking?  Which one we prefer?  Which one is faster?  Which one last longer?  Which one is better?


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## coolidge (May 29, 2010)

Anecdotal or evidence based information as to the benefits or risks of either medication when used IV.


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## usafmedic45 (May 30, 2010)

I prefer lorazepam because it has less of a tendency to depress respiratory function and has a better efficacy in controlling seizures.  It also has better function when given rectally compared to diazepam (the traditional rectal anticonvulsant).  I can back my stance up with: 
Appleton R, Sweeney A, Choonara I, Robson J, Molyneux E. Lorazepam versus diazepam in the acute treatment of epileptic seizures and status epilepticus. Dev Med Child Neurol. 1995 Aug;37(8):682-8.

Lorazepam was compared with diazepam for the treatment of acute convulsions and status epilepticus in 102 children in a prospective, open, 'odd and even dates' trial. *Convulsions were controlled in 76 per cent of patients treated with a single dose of lorazepam and 51 per cent of patients treated with a single dose of diazepam. Significantly fewer patients treated with lorazepam required additional anticonvulsants to terminate the seizure.* *Respiratory depression occurred in 3 per cent of lorazepam-treated patients and 15 per cent of diazepam-treated patients*. No patient who received lorazepam required admission to the intensive care unit for either respiratory depression or persisting status epilepticus. *Rectally administered lorazepam appeared to be particularly valuable (100 per cent efficacy) when venous access was not possible*.


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## usafmedic45 (May 30, 2010)

coolidge said:


> Anecdotal or evidence based information as to the benefits or risks of either medication when used IV.


Pubmed is your friend.


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## Akulahawk (May 30, 2010)

usafmedic45 said:


> I prefer lorazepam because it has less of a tendency to depress respiratory function and has a better efficacy in controlling seizures.  It also has better function when given rectally compared to diazepam (the traditional rectal anticonvulsant).  I can back my stance up with:
> Appleton R, Sweeney A, Choonara I, Robson J, Molyneux E. Lorazepam versus diazepam in the acute treatment of epileptic seizures and status epilepticus. Dev Med Child Neurol. 1995 Aug;37(8):682-8.
> 
> Lorazepam was compared with diazepam for the treatment of acute convulsions and status epilepticus in 102 children in a prospective, open, 'odd and even dates' trial. *Convulsions were controlled in 76 per cent of patients treated with a single dose of lorazepam and 51 per cent of patients treated with a single dose of diazepam. Significantly fewer patients treated with lorazepam required additional anticonvulsants to terminate the seizure.* *Respiratory depression occurred in 3 per cent of lorazepam-treated patients and 15 per cent of diazepam-treated patients*. No patient who received lorazepam required admission to the intensive care unit for either respiratory depression or persisting status epilepticus. *Rectally administered lorazepam appeared to be particularly valuable (100 per cent efficacy) when venous access was not possible*.


I've seen that happen. It was during my clinical time. Kid came in. Started having active sz activity. He'd get a dose of lorazepam, stop physically seizing, and would start up again about 5-8 min later. He needed diazepam to bring his sz activity to a stop for a longer period of time. He was with us in the ED for a couple hours. After the head CT, he was admitted and I wasn't able to follow up on him. 

I've heard some good things about lorazepam, and frankly, I'd be OK with using it vs diazepam or midazolam, but because of what I'd seen in the ED, I'd want a backup to it.

The details of that case... well that was about 10 years ago.


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## usafmedic45 (May 30, 2010)

Akulahawk said:


> I've seen that happen. It was during my clinical time. Kid came in. Started having active sz activity. He'd get a dose of lorazepam, stop physically seizing, and would start up again about 5-8 min later. He needed diazepam to bring his sz activity to a stop for a longer period of time. He was with us in the ED for a couple hours. After the head CT, he was admitted and I wasn't able to follow up on him.
> 
> I've heard some good things about lorazepam, and frankly, I'd be OK with using it vs diazepam or midazolam, but because of what I'd seen in the ED, I'd want a backup to it.
> 
> The details of that case... well that was about 10 years ago.


You did see the first two words in that sentence right?  In both that study and my experience, it's more common to see someone have to go to phenytoin or one of the barbiturates after diazepam than have seen the same issue with lorazepam. 

Midazolam, on the other hand, is not something I would use to attempt to control seizures.


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## Smash (May 30, 2010)

usafmedic45 said:


> Midazolam, on the other hand, is not something I would use to attempt to control seizures.



Why is that?  Midazolam is the sole drug used to treat seizures in thre prehospital setting where I work, usually IM but also IN, and it is very effective and safe.  IT is   It can also be given buccal and IV.  It is absorbed very rapidly and effectively from the IM route, unlike lorazepam, which is nice if you have no IV access.  It has a short duration of action which allows reasonably rapid return of consciousness post termination of seizure or it can be given in increments or as an infusion for status epilepticus if required.


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## usafmedic45 (May 30, 2010)

Just haven't seen it perform as well in the field or in hospital as lorazepam.  It's a personal preference more than anything else.  That same short acting aspect you enjoy, I find to be annoying in patient who are prone to recurrent seizures.  Our most frequent flyer was one of those so using something short acting was not a good idea.  Lorazepam is the well established first line therapy [Arif and Hirsch: Treatment of status epilepticus. Seminars in Neurology, 2008: 28(3):342-5]  and I see no reason to stray away from it given the multitude of routes available to deliver it (nasally, IM, IV, PR).

Usually lorazepam was the front line drug, followed by phenytoin or propofol with midazolam or (if the doc was feeling adventurous in the ED) pentobarbital.


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## MrBrown (May 30, 2010)

We also use midaz only and its great

Would you rather we went back to the late 90s and used PR stesolid?


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## usafmedic45 (May 30, 2010)

> Would you rather we went back to the late 90s and used PR stesolid?



Nah, I'd rather just squirt the lorazepam up the nose like you can do with every other benzo if I don't have an IV.  The option of IM delivery and a nice long half-life makes the lorazepam very appealing to my sensibilities in treating seizures.

As for PR diazepam/lorazepam, etc, I personally have never had a problem with it (other than poor absorption in the case of the diazepam).  Then again, I may be a little weird in that it doesn't bother me to give a medication rectally.


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## MrBrown (May 30, 2010)

Yeah we got rid of it and went to IN midazolam

Kind of reminds you of that bit from Family Guy when Peter got CPR certified, now sir, sir, I have to check if you soiled yourself!


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## FLEMTP (May 30, 2010)

We carry both at the agency I work at. The ativan is refrigerated and the versed is not... so we keep versed in our first in bags... so if they are actively seizing when I walk into the room, versed. 

If I had both medications available, (ie: in the ambulance) I'd prefer the ativan... less of a histamine reaction so less of an effect on the blood pressure.


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## 8jimi8 (May 30, 2010)

and no one has mentioned that benzos actually lower the seizure threshold...  We had a guy come in who OD'd on ativan at home.  Once the drug levels in his body got low enough, seizures became more and more reccurrent.


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## Akulahawk (May 30, 2010)

usafmedic45 said:


> *You did see the first two words in that sentence right*?  In both that study and my experience, it's more common to see someone have to go to phenytoin or one of the barbiturates after diazepam than have seen the same issue with lorazepam.
> 
> Midazolam, on the other hand, is not something I would use to attempt to control seizures.


Yes, I did. My comment was that I'd seen a patient get multiple doses of lorazepam before longer term control was obtained by diazepam. Lorazepam does work, and works well. Studies do show that. I'd be perfectly OK using lorazepam as a first-line drug for seizures. A backup med should also be available in the event that lorazepam (or whatever other benzo you're using) doesn't terminate the seizures. If I'm in the field, I would prefer to be at the ED by then. Why? The ED has a pharmacy backing them up and all I have is a small cabinet or lock box... That's all I'm saying about lorazepam.


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