# Versed For Sz



## MedicPrincess (Sep 20, 2007)

Whats y'alls opinion on giving Versed to seizure patients, whose seizure activity remains refractory to Valium?  

Last night, on my very first shift as a Paramedic, I had 43 yo F patient who after 10mg of Valium had no change in her activity at all.  I called Med Control for an order for Versed, which I got.  5mg later, she was no longer convulsing.

When we got her to the ER, one of the nurses got quite upset that we used Versed on her, because it doesn't actually stop the seizure activity in the brain.  He was all upset that we didn't give the patient Ativan instead.

Well we don't carry Ativan for starters.  My options are Valium, Versed, and RSI.  This patient is known to us, and is 50/50 as to whether or not Valium will be effective.

Versed is not actually listed in our protocols for treatment of seizures, however its is often ordered by Med Control.


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## Grady_emt (Sep 20, 2007)

We just got a new protocol set...er sorry, they are now "Clinical Care Guidelines"  I would post them, but they are the "intellectual property" of our medical director.

If we have a line on a Sz pt, 5mg Valium with option of repeat x 1.  If sz has not resolved after Valium, then call in orders for 2.5 versed with repeat x 1 as needed.

If no line, 5 of Versed standing with repeat option x 1.  If sz still has not resolved and still no IV acccess, Call in orders for IO and 5 of valium repeat x 1, OR 2.5 versed repeat x 1.


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## RALS504 (Sep 20, 2007)

First of all congrats on your new skill set.

Secondly, at my old service we could use Versed IM or IV for siezures, they are both benzos. I have seen a medic use it just like you did for a siezure pt that had a brain tumor (unknown to us at the time) and was siezing for 22 min prior to our arrival. 10 mg valium IV had no effect, but 2 mg versed stop all clonic-tonic activity. I think your nurse friend is full of BS, besides we do not have Tegratol or Dilantin on the rig and Ativan is very rarely carried in EMS. I think you did a good job of managing the pt, I would have done the same.


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## Ridryder911 (Sep 20, 2007)

I personally use Versed over Valium, especially for those that are active. I use nasal Versed, per atomizer. Faster acting, shorter half life, and easier to control, so Neuro can evaluate later. 

The nurse is full of B.S. as well, Benzo's only treat the muscle movement to relax the patient to prevent hypoxia and prevent further injuries. Cerebyx, Dilantin, Tergetol as well as Phenobarb are the only true common anticonvulsants. 

R/r 911


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## RescueShirts.com (Sep 21, 2007)

We switched from Valium to Versed about 3-4 years ago... and upped our dosage of Versed about 2 years ago.

We titrate up to 0.3mg/kg for adults and kids... and up to 0.2mg/kg for over 55yrs, COPD, Renal failure, etc...

And no... that's not a typo... we can give a 100kg person up to 30mg... although we rarely have to go beyond 10mg.

Status seizures are now a thing of the past... we have the tools take care of them.

We can give IM... or better yet, use our Bone Drill for a quick IO and give it that way.


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## mtmedic (Sep 28, 2007)

I had a 5 y/o little girl in status two weeks ago and her mom had already given 15mg rectal valium w/o success.  She told me this was how she knew she was in status and that Ativan is what they use when she "gets this way".  I gave her 2 mg and transport was short but she was still seizing...  At the ED they gave her more Ativan. I am not sure what the dose was...  She didn't stop seizing for 20 more minutes I later found out.  She was back being a 5 y/o the next day.  I am curious to know how she would have responded to the Versed...  We carry all three... Valium, Versed, and Ativan but mom was pretty knowledgable so I went with what she knows...  Live and learn I guess...


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## MedicPrincess (Sep 28, 2007)

We have a 6 year old girl in our county that we are all familiar with.  Valium does not touch her.  The units that run on her automatically call Med Control as they are walking through the door.  It has taken as much as 10mg Versed to get hers to stop.


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## medic3 (Oct 21, 2007)

Versed potentiates the effects of GABA @ GABA receptors.  When GABA receptors are activated, it promotes an influx of Cl- ions, therfore causing hyperpolarization of the membrane, thus increasing membrane threshold potential, and stabalizing the membrane...hence the seizure stops.  In Calgary Canada we use only Versed for tx of Seizures, and have had nothing but success.  We're using 2.5mg IV q 2minutes to a max of 10mg or 0.1mg/kg to a max of 10mg IM.


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## daemonicusxx (Nov 5, 2007)

Standing orders for both pedi and adult. .3mg/kg to a max of 5. and i sure as hell like the "IN" route for this med alot better than tryin to get an IV on a floppy fish. they give us the diazepam in the adult protocol, but as i said, im not messin around with the IV. much easier up the nose.


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## bstone (Nov 5, 2007)

medic3 said:


> Versed potentiates the effects of GABA @ GABA receptors.  When GABA receptors are activated, it promotes an influx of Cl- ions, therfore causing hyperpolarization of the membrane, thus increasing membrane threshold potential, and stabalizing the membrane...hence the seizure stops.  In Calgary Canada we use only Versed for tx of Seizures, and have had nothing but success.  We're using 2.5mg IV q 2minutes to a max of 10mg or 0.1mg/kg to a max of 10mg IM.



What's the mechanism for the GABA  to be potentiate? I just took biochem and so I have a bit of a mind for this stuff.


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## medic001918 (Nov 5, 2007)

RALS504 said:


> ...Ativan is very rarely carried in EMS.



We carry versed and ativan.  Our protocols allow for 2mg every five minutes to a max of 8mg.  Most services in the area carry ativan and it's considered front line for seizures.

And ativan won't stop the actual seizure itself any differently than versed.  The nurse who made a comment was full of it.

Shane
NREMT-P


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## sissyjo (Nov 5, 2007)

I am a new medic, and i must admit that this is very helpful info. I dont recall ever hearing anything about versed for sz. So of course I am at work now and run straight to the protocol book, and nothing there about using versed. Just to contact medical control for further orders. I will be bringing this info to my directors attention and see about getting it changed. Thanks


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## medic3 (Nov 7, 2007)

bstone said:


> What's the mechanism for the GABA  to be potentiate? I just took biochem and so I have a bit of a mind for this stuff.



All benzodiazepines modulate GABA’s activity.  When a benzo (like Versed) binds to a specific site on a GABA receptor, it does not stimulate it directly. Instead, it makes it more efficient by increasing the frequency with which the chlorine channel opens when GABA binds to its own site on this receptor. The resulting increase in the concentration of Cl- ions in the post-synaptic neuron immediately hyperpolarizes the neuron which makes it less excitable.


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## So. IL Medic (Nov 10, 2007)

bstone said:


> What's the mechanism for the GABA  to be potentiate? I just took biochem and so I have a bit of a mind for this stuff.



How much do you want to know and how much biochem have you taken? LOL

The GABAb receptors are G protein coupled, dimeremic (2 subunits - alpha type and beta or gamma type). GABAa are heteromultimers of alpha, beta, gamma, delta, epsilon types. GABAc do not interact with benzodiazepines.

The receptors gennerally have seven transmembrane segments with a long extracellular N terminus. They have a large extracellular domain for ligand binding, can couple intracellularly with Gi and Go proteins to stimulate K+ channels and inhibit Ca2+ channels. The GABAb receptor also has a C-terminal tail that interacts with CREB proteins that responds to cAMP and activating transcription factors. 

Versed appears to act as an allosteric modulator of GABA receptors. That is, the binding of Versed to an adjacent protein complex causes a conformational change in the GABA receptor thus increasing GABA affinity. Current theories state two benzodiazepine receptor subtypes for the protein complexes.

The increased affinity means more GABA binding. This increases the activity of K+ and decreases Ca2+ channel activity, hyperpolarizing the membrane and increasing the threshold. Less propagation of the electrochemical signals can occur, decreasing neuronal activity, stopping the seizure.

Probably more than you wanted.


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## Comedic (Nov 11, 2007)

Our seizure protocol Adult 1-10mg 
Peds 0.3mg/kg IV. Or 0.5mg/kg rectally
And if no IV access 
Versed 1-5mg IM titrate to effect peds 0.1mg/kg All standing Orders.

I have in the pass gave Versed to help control the tonic clonic seizure. Some with success and some without. I think Atvain would be great to use if we carried it.

I would have done the same.


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## MSDeltaFlt (Nov 11, 2007)

For those of you who didn't know that Versed was for seizures. 

The benzodiazepines (pronounced [ˌben-zō-dī-ˈa-zə-ˌpēn], or "benzos" for short) are a class of psychoactive drugs considered minor tranquilizers with varying hypnotic, sedative, anxiolytic, anticonvulsant, muscle relaxant and amnesic properties, which are mediated by slowing down the central nervous system.[1] Benzodiazepines are useful in treating anxiety, insomnia, agitation, seizures, and muscle spasms, as well as alcohol withdrawal.

From Wikipedia.org

A benzo is a benzo is a benzo.  Ativan, Versed, Valium, etc are benzos.  Ativan needs to be refrigerated.  It takes more valium than Versed to do the job.  I like Versed for Sz myself.  It's not prone to hypotension as Valium either.


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## Aileana (Nov 11, 2007)

yes, a benzo is a benzo, but there are subtle differences. Midazolam stops seizures over twice as fast as diazepam. According to a study in the Indian Journal of Pediatrics, "The mean interval to cessation of convulsions with IM midazolam was 97.22 seconds whereas in diazepam group without prior IV access it was 250.35 seconds and in diazepam group with prior IV access it was 119.4 seconds." 
article 
Midazolam can be given IM, and diazepam cannot (I don't think, atleast-please correct me if I'm wrong). Subtle differences like that determine which to use, I suppose. Also, I hadn't realized that ativan needs to be refrigerated. In which form is that necessary? I've only ever seen the sublingual pills given to treat anxiety/insomnia in the past, and have never seen ativan used in an emergency setting.


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## Ridryder911 (Nov 11, 2007)

Diazepam (Valium) can be administered intramuscularly and is routinely done so. Not highly recommended during seizure activity due to circulation time, as well it also can be administered per rectal. 

Lorazepam (Ativan) can also be administered I.M., etc. Newer brands are now made where registration is not needed, however; is more expensive and has shorter expiration date due to it has to be reconstituted. 

R/r 911


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## Aileana (Nov 11, 2007)

ohh ok, thanks for the clarification. 
How would you go about giving diazepam PR while pt is actively seizing?


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## MMiz (Nov 11, 2007)

Ridryder911 said:


> Diazepam (Valium) can be administered intramuscularly and is routinely done so. Not highly recommended during seizure activity due to circulation time, as well it also can be administered per rectal.
> 
> Lorazepam (Ativan) can also be administered I.M., etc. Newer brands are now made where registration is not needed, however; is more expensive and has shorter expiration date due to it has to be reconstituted.
> 
> R/r 911


Stupid BLS question, but wouldn't I.M. be used more as a chemical restraint instead of for the treatment of seizure activity?  I can't see it being effective via that route in a seizure.


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## Ridryder911 (Nov 11, 2007)

Remember, all benzo's are acting as a muscle relaxant. and truly are not interfering with the true seizure activity. It is only "masking" seizure activity and preventing severe muscular contractions and potential danger to patients hemodynamic and respiratory system. 

Anticonvulsants and seizure medications such as Dilantin, Cerebyx, Phenobarb. is truly for the seizure activity. I was employed at an EMS where the protocol for those that was under Dilantin therapy, was to administer Dilantin in prehospital setting after obtaining sample for Dilantin level. 

To answer your question, Valium is Valium and both desired effects is relaxation of the muscles. Valium is not a psychotropic medication, rather the side effect is sedation. Yes, I would first attempt to administer an alternative medication or potential different route. There is time, when one has multiple seizure(s) non-status that I may administer Diazepam I.M. due to the increased length and duration of the medication, so I do not have to continually medicate. Remembering, this may hamper neuro examinations... so a pertinent history and detailed examination is essential. 

R/r 911


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## medic3 (Nov 20, 2007)

Ridryder911 said:


> Remember, all benzo's are acting as a muscle relaxant. and truly are not interfering with the true seizure activity. It is only "masking" seizure activity and preventing severe muscular contractions and potential danger to patients hemodynamic and respiratory system.
> 
> As I stated in an earlier post..."Versed potentiates the effects of GABA @ GABA receptors. When GABA receptors are activated, it promotes an influx of Cl- ions, therfore causing hyperpolarization of the membrane, thus increasing membrane threshold potential, and stabalizing the membrane...hence the seizure stops."  So benzo's DO stop the seizure activity in the brain, not just the muscular contractions.


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## Ridryder911 (Nov 21, 2007)

Actually it is GABA(a)  such as the same effects from Ketamine. 

R/r 911


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## natrab (Nov 23, 2007)

We stopped carrying Valium a while ago.  When we had it as our front line drug for seizures, it would usually kick in and sedate the patient at about the same time as we arrived at the hospital.  It also cost more and expired faster than versed.  The only time I've seen valium stop seizure activity quickly is in peds patients with 5mg administered rectally.

Now we have versed and only versed.  We carry 8mg total, and administer 1-2mg for seizure activity.  I haven't had a patient who didn't go down from 2mg yet.  Only problem I've seen is the occasional loss of respiratory drive usually lasting less than a minute.  We just keep a BVM and some bls airways handy when administering versed.


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