Quick, the patient in room 2 started seizing. They do not have IV access. What do you ask for?
If you say Ativan, keep reading.
2mg IM Midazolam (Versed) did not need rescue therapy when administered by EMS 73.4 % of the time compared to 63.4 % for 2mg of IV Ativan for pre-hospital seizures. The primary reason I have heard from attendings to lean towards Ativan rather than Versed has been that Versed would be more likely to have a recurrence of seizures given that it is short acting. The reality is that there is a 11.4% vs 10.6% recurrence and the need for an advanced airway is 14.1 % vs 14.4 % (for Versed and Ativan, respectively). The caveat being that if they have an IV, time to cessation of convulsions for Ativan is 1.6 minutes vs 3.3 minutes for IM Versed (I’d imagine IV Versed would be less than 3.3 minutes, but alas, that was not studied). Adverse event rates were similar in the two groups.
Importantly, intubation and recurrence are the same. However, less rescue therapy is required in the Versed group, so, in theory, I could see this saving a few hospitalizations just based on the fact that a provider is uncomfortable discharging someone that required two or more meds / rounds of meds for stabilization.
Intramuscular versus intravenous therapy for prehospital status epilepticus. PMID: 22335736