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Seizure (Adult)

Date Last Search Run: Jan 14, 2025
Table last updated: Sep 16, 2023
Data last added: Sep 13, 2023

Recommendation RECOMMENDATION FOR INTERVENTION
STRENGTH OF EVIDENCE FOR INTERVENTION   SUPPORTIVE (Green) NEUTRAL (Yellow) AGAINST (Red) NOT YET GRADED (White)
1 (strong evidence exists)    
2 (fair evidence exists)    
3 (weak evidence exists)    


Interventions

Diazepam-Buccal
Level Direction Primary Outcome Patient/Process Setting Reference

Diazepam-IM
Level Direction Primary Outcome Patient/Process Setting Reference
II Supportive (Green) Length of stay Patient ICU Rao SK, Mahulikar A, Ibrahim M, Shah A, Seraji-Bozorgzad N, Mohamed W. Inadequate benzodiazepine dosing may result in progression to refractory and non-convulsive status epilepticus. Epileptic disorders, international epilepsy J with videotape 2018; 20(4) 265-9. Medline

Diazepam-IV
Level Direction Primary Outcome Patient/Process Setting Reference
I Supportive (Green) Termination of seizure by Ed arrival Patient PH-Paramedic Alldredge BK., Gelb AM., Isaacs SM., et al. A comparison of lorazepam, diazepam, and placebo for the treatment of out-of-hospital status epilepticus. N Engl J Med 2001; 345(9):631-7. Medline
I Supportive (Green) Seizure cessation Patient PH-Paramedic Cruickshank M, Imamura M, Booth C, Aucott L, Counsell C, Manson P, et al. Pre-hospital and emergency department treatment of convulsive status epilepticus in adults: an evidence synthesis. Heal Technol Assess 2022; 26(20):1–76. Medline
I Supportive (Green) Termination of seizure Patient In-Patient Treiman DM., Meyers PD., Walton NY., et al. A comparison of four treatments for generalized convulsive status epilepticus. New Eng J Med 1998; 339(12):793-798. Medline
I Supportive (Green) Termination of seizure Patient Wu W., Zhang L., Xue R. Lorazepam or diazepam for convulsive status epilepticus: A meta-analysis. J Clin Neurosci 2016; 29:133-138. Medline
II Supportive (Green) Time to seizure termination Patient PH-Paramedic Haut SR., Seinfeld S., Pellock J. Benzodiazepine use in seizure emergencies: A systematic review. Epilepsy Behav 2016; 63:109-17. Medline

Diazepam-PR
Level Direction Primary Outcome Patient/Process Setting Reference
II Supportive (Green) Time to administration Process PH-Paramedic Fitzgerald BJ., Okos AJ., Miller JW. Treatment of out-of-hospital status epilepticus with diazepam rectal gel. Seizure 2003; 12(1):52-5. Medline
III Supportive (Green) Seizure suppression Patient In-Patient de Haan GJ., van der Geest P., Doelman G., Bertram E., Edelbroek P. A comparison of midazolam nasal spray and diazepam rectal solution for the residential treatment of seizure exacerbations. Epilepsia 2010; 51(3):478-82. Medline

Ketamine
Level Direction Primary Outcome Patient/Process Setting Reference
X Not Yet Graded (White) - Scheppke, K. A., Pepe, P. E., Garay, S. A., Coyle, C. W., Antevy, P. M., Perlmutter, M. C., Scheppke, E. K., & Crowe, R. P. (2024). Effectiveness of Ketamine As a Rescue Drug for Patients Experiencing Benzodiazepine-Resistant Status Epilepticus in the Prehospital Setting. Critical care explorations, 6(12), e1186. https://doi.org/10.1097/CCE.0000000000001186 Medline

Lorazepam-Buccal
Level Direction Primary Outcome Patient/Process Setting Reference

Lorazepam-IM
Level Direction Primary Outcome Patient/Process Setting Reference
II Supportive (Green) Length of stay Patient ICU Rao SK, Mahulikar A, Ibrahim M, Shah A, Seraji-Bozorgzad N, Mohamed W. Inadequate benzodiazepine dosing may result in progression to refractory and non-convulsive status epilepticus. Epileptic disorders, international epilepsy J with videotape 2018; 20(4) 265-9. Medline

Lorazepam-IN
Level Direction Primary Outcome Patient/Process Setting Reference

Lorazepam-IV
Level Direction Primary Outcome Patient/Process Setting Reference
I Supportive (Green) Termination of seizure by ED arrival Patient PH-Paramedic Alldredge BK., Gelb AM., Isaacs SM., et al. A comparison of lorazepam, diazepam, and placebo for the treatment of out-of-hospital status epilepticus. N Engl J Med 2001; 345(9):631-7. Medline
I Supportive (Green) Seizure cessation Patient PH-Paramedic Cruickshank M, Imamura M, Booth C, Aucott L, Counsell C, Manson P, et al. Pre-hospital and emergency department treatment of convulsive status epilepticus in adults: an evidence synthesis. Heal Technol Assess 2022; 26(20):1–76. Medline
I Supportive (Green) Termination of seizure Patient PH-Paramedic Silbergleit R., Durkalski V., Lowenstein D., Conwit R., Pancioli A., Palesch Y., et al. Intramuscular versus intravenous therapy for prehospital status epilepticus. N Engl J Med 2012; 366(7):591-600. Medline
I Supportive (Green) Termination of seizure Patient In-Patient Treiman DM., Meyers PD., Walton NY., et al. A comparison of four treatments for generalized convulsive status epilepticus. New Eng J Med 1998; 339(12):793-798. Medline
I Supportive (Green) Termination of seizure Patient Wu W., Zhang L., Xue R. Lorazepam or diazepam for convulsive status epilepticus: A meta-analysis. J Clin Neurosci 2016; 29:133-138. Medline
II Neutral (Yellow) Time to administration Process PH-Paramedic Fitzgerald BJ., Okos AJ., Miller JW. Treatment of out-of-hospital status epilepticus with diazepam rectal gel. Seizure 2003; 12(1):52-5. Medline

Lorazepam-PR
Level Direction Primary Outcome Patient/Process Setting Reference

Midazolam-Buccal
Level Direction Primary Outcome Patient/Process Setting Reference

Midazolam-IM
Level Direction Primary Outcome Patient/Process Setting Reference
I Supportive (Green) Seizure cessation Patient PH-Paramedic Cruickshank M, Imamura M, Booth C, Aucott L, Counsell C, Manson P, et al. Pre-hospital and emergency department treatment of convulsive status epilepticus in adults: an evidence synthesis. Heal Technol Assess 2022; 26(20):1–76. Medline
I Supportive (Green) termination of seizure Patient PH-Paramedic Silbergleit R., Durkalski V., Lowenstein D., Conwit R., Pancioli A., Palesch Y., et al. Intramuscular versus intravenous therapy for prehospital status epilepticus. N Engl J Med 2012; 366(7):591-600. Medline
II Supportive (Green) Need for repeat Midazolam dose Patient PH-Paramedic Guterman EL, Sanford JK, Betjemann JP, Zhang L, Burke JF, Lowenstein DH, et al. Prehospital midazolam use and outcomes among patients with out-of-hospital status epilepticus. Neurology 2020; 95(24):e3203-12. Medline
II Supportive (Green) Reduced mortality & LOS from earlier treatment of status epilepticus. Patient PH-Paramedic Halliday AJ, Santamaria J, D’Souza WJ. Pre-hospital benzodiazepines associated with improved outcomes in out-of-hospital status epilepticus: A 10-year retrospective cohort study. Epilepsy Res 2021; 179:106846. Medline
II Supportive (Green) Length of stay (LOS) Patient ICU Rao SK, Mahulikar A, Ibrahim M, Shah A, Seraji-Bozorgzad N, Mohamed W. Inadequate benzodiazepine dosing may result in progression to refractory and non-convulsive status epilepticus. Epileptic disorders, international epilepsy J with videotape 2018; 20(4) 265-9. Medline
X Not Yet Graded (White) - Fouche PF, Nichols M, Abrahams R, Maximous K, Bendall J. Evaluating the effectiveness of the maximum permitted dose of midazolam in seizure termination: Insights from New South Wales, Australia. Emerg Med Australas June 2024. Medline

Midazolam-IN
Level Direction Primary Outcome Patient/Process Setting Reference
II Neutral (Yellow) treatment with a second benzodiazepine dose Patient PH-Paramedic Guterman EL, Sanford JK, Betjemann JP, Zhang L, Burke JF, Lowenstein DH, et al. Prehospital midazolam use and outcomes among patients with out-of-hospital status epilepticus. Neurology 2020; 95(24):e3203-12. Medline
III Supportive (Green) Seizure suppression Patient In-Patient de Haan GJ., van der Geest P., Doelman G., Bertram E., Edelbroek P. A comparison of midazolam nasal spray and diazepam rectal solution for the residential treatment of seizure exacerbations. Epilepsia 2010; 51(3):478-82. Medline
III Supportive (Green) Termination of seizure Patient ED-MD Kendall JL., Reynolds M., Goldberg R. Intranasal midazolam in patients with status epilepticus. Ann Emerg Med 1997; 29(3):415-7. Medline
III Neutral (Yellow) Need for second dose Patient PH-Paramedic Guterman EL, Sanford JK, Betjemann JP, Zhang L, Burke JF, Lowenstein DH, et al. Prehospital midazolam use and outcomes among patients with out-of-hospital status epilepticus. Neurology 2020; 95(24):e3203-12. Medline

Midazolam-IV
Level Direction Primary Outcome Patient/Process Setting Reference
II Supportive (Green) seizure duration and hospital length of stay Patient PH-Paramedic Halliday AJ, Santamaria J, D’Souza WJ. Pre-hospital benzodiazepines associated with improved outcomes in out-of-hospital status epilepticus: A 10-year retrospective cohort study. Epilepsy Res 2021; 179:106846. Medline
II Supportive (Green) Length of stay Patient ICU Rao SK, Mahulikar A, Ibrahim M, Shah A, Seraji-Bozorgzad N, Mohamed W. Inadequate benzodiazepine dosing may result in progression to refractory and non-convulsive status epilepticus. Epileptic disorders, international epilepsy J with videotape 2018; 20(4) 265-9. Medline
III Supportive (Green) Supportive Patient PH-Paramedic Guterman EL, Sanford JK, Betjemann JP, Zhang L, Burke JF, Lowenstein DH, et al. Prehospital midazolam use and outcomes among patients with out-of-hospital status epilepticus. Neurology 2020; 95(24):e3203-12. Medline
III Neutral (Yellow) Requirement for second dose Patient PH-Paramedic Guterman EL, Sanford JK, Betjemann JP, Zhang L, Burke JF, Lowenstein DH, et al. Prehospital midazolam use and outcomes among patients with out-of-hospital status epilepticus. Neurology 2020; 95(24):e3203-12. Medline
X Not Yet Graded (White) - Fouche PF, Nichols M, Abrahams R, Maximous K, Bendall J. Evaluating the effectiveness of the maximum permitted dose of midazolam in seizure termination: Insights from New South Wales, Australia. Emerg Med Australas June 2024. Medline

Propofol
Level Direction Primary Outcome Patient/Process Setting Reference
III Supportive (Green) Safety and efficacy Patient Kuisma M., Roine RO. Propofol in prehospital treatment of convulsive status epilepticus. Epilepsia 1995; 36(12):1241-3. Medline

Status epilepticus scale
Level Direction Primary Outcome Patient/Process Setting Reference
II Supportive (Green) Predictive value Process ED-MD Requena M, Fonseca E, Olivé M, Abraira L, Quintana M, Mazuela G, et al. The ADAN scale: a proposed scale for pre-hospital use to identify status epilepticus. European J of neurology 2019; 26(5) 760-e55. Medline


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