RCT

RAMPART

Intramuscular versus Intravenous Therapy for Prehospital Status Epilepticus

NEJM, 2012 · Double-blind non-inferiority randomized trial (n=893)

Clinical question

Is intramuscular midazolam via autoinjector non-inferior to intravenous lorazepam for terminating prehospital status epilepticus?

Population: Children and adults in convulsive status epilepticus lasting > 5 minutes
Intervention: Intramuscular Midazolam (10 mg for weight > 40 kg, 5 mg for 13-40 kg)
Comparator: Intravenous Lorazepam (4 mg for weight > 40 kg, 2 mg for 13-40 kg)
Primary outcome: Seizure cessation on arrival at the emergency department without rescue therapy
Result: IM midazolam was superior in seizure termination upon ED arrival (73.4% vs 63.4%; difference 10.0 percentage points; 95% CI 4.0 to 16.1; P<0.001 for non-inferiority and P<0.001 for superiority) due to faster administration time.

What the trial found

IM midazolam terminates prolonged seizures faster than IV lorazepam by eliminating the delay required for intravenous line placement.

Current guideline position

American Epilepsy Society 2016 guidelines recommend IM Midazolam (10 mg for >40 kg) as preferred prehospital first-line therapy when IV access is not established (Level A recommendation).

Clinical interpretation

Established IM midazolam 10 mg as the preferred first-line agent when IV access is not immediately established.

Clinical Context & Relevant Topics (1)

Disease Reference

Status Epilepticus

Recognition and time-sensitive escalation of care for prolonged or repeated seizures.

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