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BMJ 2012; 344 doi: (Published 22 February 2012) Cite this as: BMJ 2012;344:e1248

Paramedics: intramuscular midazolam is a good choice for status epilepticus

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Status epilepticus is defined as prolonged or repetitive seizures without recovery between episodes. About one in five patients who experience this condition die and a quarter of those who survive have reduced functional ability. Early termination of seizures with benzodiazepines improves outcomes. For practical reasons, paramedics often exchange intravenous lorazepam—the preferred treatment in hospital—for intramuscular midazolam, with insufficient evidence to support this practice.

A trial recruited 1023 children and adults who had been convulsing for at least five minutes and were still doing so when the ambulance arrived. Paramedics gave either midazolam via an intramuscular autoinjector or lorazepam as an intravenous infusion. A 10% margin was preset for non-inferiority of midazolam against lorazepam.

This goal was well exceeded. On reaching hospital, 73.4% (329/448) of participants given midazolam intramuscularly had stopped convulsing, compared with 63.4% (282/445) of those given lorazepam intravenously (difference 10%, 95% CI 4.0% to 16.1%; P<0.001 for both non-inferiority and superiority).

In participants who reached hospital seizure-free, intramuscular treatment was quicker to administer but took longer once administered to take effect (median times 1.2 and 3.3 minutes, respectively) compared with intravenous treatment (4.8 and 1.6 minutes, respectively). The need for endotracheal intubation was comparable between the groups (14.1% with midazolam v 14.4% with lorazepam), as was recurrence of seizures (11.4% v 10.6%).

Intramuscular autoinjectors for midazolam should soon become widely available says an editorial (p 659). Promising alternative routes of administration, such as nasal or buccal routes, which could be introduced as home treatment, also need to be studied.

Physical activity improves children’s cardiometabolic health regardless of sedentary time

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Both lack of physical activity and sedentary behaviour have been linked with cardiovascular disease and cardiometabolic risk factors such as waist circumference, blood pressure, insulin, and blood lipids. Most studies …

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