Dr. Paul Auerbach is the world's leading outdoor health expert. His blog offers tips on outdoor safety and advice on how to handle wilderness emergencies.See all posts »
Stopping Seizures in the Field
Seizures, particularly of the grand mal variety, are serious business in any setting and particularly when they occur away from access to urban medical support. The vigorous, sometimes violent, muscle contractions, alteration of consciousness, difficulty breathing, tongue biting, and all the other manifestations of epilepsy or a seizure from another cause put the patient and sometimes his companions and rescuers at risk. So, it’s important to try to terminate seizures as soon as possible for the benefit of the patient and those around him. Unless a seizure terminates spontaneously, this is usually accomplished by administering a medication.
The most common drugs used to stop grand mal seizures are the benzodiazepine class of medication, such as lorazepam or diazepam. The optimal route that has been used historically to achieve the most rapid effect has been intravenous (IV)—injecting the drug directly into the bloodstream. This is done because a seizing patient cannot purposefully swallow, and so the oral route is not practical. Furthermore, giving anything by mouth to a person with altered mental status introduces the risk of choking. Starting an IV line (commonly called an “IV”) requires finding a patent vein and introducing into it a catheter. This takes skill to be accomplished on a non-agitated, non-moving patient, and may be nearly impossible if the patient is moving around. Furthermore, it is not a layperson skill.
A good alternative is giving an intramuscular (IM, or directly into the muscle) injection. In an article entitled “Intramuscular versus Intravenous Therapy for Prehospital Status Epilepticus” (New England Journal of Medicine 2012;366:591-600), Dr. Robert Silbergleit and colleagues found that for persons in status epilepticus (continuous seizures), IM midazolam was at least as safe and effective as IV lorazepam for pre-hospital seizure cessation. They did this research by having the paramedics use intramuscular autoinjectors (such as is used to deliver epinephrine from an EpiPen) for the midazolam. For this study, the enrollees needed to be adults or children weighing more than an estimated 40 kg (approximately 88 pounds) in order to receive a 10 mg midazolam IM dose. Importantly, adverse-event rates (such as need to insert a breathing tube) were similar for the two groups.
It was noted in an accompanying editorial that some of these drugs can be given by an intranasal or buccal (cheek-mucous membranes) application, but that these routes can be unreliable in a seizure setting, where there may be spitting, snorting, and so forth. So, the IM route seems ideal. I look forward to the day when medical professionals and well-trained rescuers (including family members of patients who suffer seizures) might have auto-injectors of midazolam available to expedite the treatment of persons suffering prolonged or continuous grand mal seizures.
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