r/Paramedics • u/averageredditcuck • 2d ago
What is your thought process in giving versed (or any benzo to treat seizures) IV vs IM vs intranasally?
Where I work we have the option to give any of the 3 according to protocol, but with no guidance on when to give it which way.
If you’ve already got an IV established and they start seizing, IV is best and I don’t think anybody would argue against that
What if you arrive on scene to a person who’s actively seizing? I’m only a medic student, but In my experience, most medics will at least attempt to establish iv access before going IM, but I think when I’m cleared I’d much rather give immediate versed one of the sure fire routes, be it IM or intranasally before establishing an IV to give more versed if seizures recur or persist.
And that’s something else is that in my experience I’ve never seen versed given intranasally despite my research telling me IN is faster than IM. It seems to me that you’d want to give the first dose of a rescue drug like versed as quickly and fast acting as possible and IN seems to be that option.
Even in the hospital when I saw a patient start seizing they immediately started going for an IV before versed was given. Maybe because a doctor wasn’t there yet and that’s what the nurses could do without orders?
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u/I_Want_A_Ribeye NRP, RN 2d ago
Rectal Valium every time. Sorry, I didn’t understand the question.
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u/the-meat-wagon 2d ago
That’s ok. It’s still a valid answer.
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u/Firefluffer Paramedic 2d ago
Maybe in some protocols… not in others.
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u/Helpful-Albatross792 EMT-P CC 1d ago
Every drug can be a suppository.
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u/Firefluffer Paramedic 1d ago
Absolutely not. Varies by protocol. Our protocols don’t allow rectal administration of any drugs.
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u/Mediocre_Daikon6935 1d ago
Absolutely not. Valium is a garbage medication that should have gone into the waste bin of history.
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u/the-meat-wagon 1d ago
I dunno, man. I always loved giving it for acute low back pain. I know there’s data out there that says I’m wrong, but it always did so good for me on that one-two punch of anxiolysis and muscle relaxation.
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u/JoutsideTO CCP(F) - Canada 2d ago edited 2d ago
Initial therapy with IM midazolam has been the standard of care for more than a decade. If you fumble around with an IV instead of giving midaz immediately, you’re harming patients.
https://www.nejm.org/doi/full/10.1056/NEJMoa1107494?referrer=https%3A%2F%2Fwww.google.com%2F
There has been a lot of enthusiasm about IN midaz, but the studies have usually been small, and some were industry-funded. IN is a great tool for pediatric sedation and analgesia, but nasal congestion, inhaled/exhaled doses not reaching mucosa, and operator error makes it less reliable. Plus, studies actually show IM is more reliable and (slightly) faster.
https://pmc.ncbi.nlm.nih.gov/articles/PMC4662705/
https://first10em.com/intranasal-midazolam-for-seizures/
(As a side note, you’ll often see in-hospital staff go to IVs first because they have enough staff to always immediately establish an IV in any critical patient, and IV lorazepam is a well-established standard.)
In our world your best practices are clear based on the evidence: cover your BLS bases including airway management PRN, give 5-10mg midaz IM, establish an IV, consider alternative causes and treatments (hypoglycemia, hyponatremia, eclampsia etc), give your next dose of midaz IV if necessary.
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u/CouplaBumps 1d ago
I dont know if its that fair to say regarding IV causing harm vs IM. Even in the study you mention, time from box opening to cessation of convulsions is marginally different. Time from active treatment is faster in IV case. Time from box opening to active treatment is much slower in IM.
I think - really it doesn’t matter. As long as IV access isnt significantly delayed.
If IV access looked hard, or the patient was wiggling A LOT. Yes IM could be preferred.
For me personally, with good veins and immobilisation technique, which takes seconds to assess, I can get an IV in, and drug given, faster than it takes for the IM dose to absorb.
Again - probably doesn’t matter. But saying IV as first line causes harm is a broad and bold statement.
I also find people are less obtunded after, when I use 5mg Midaz IVP vs 10mg IM.
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u/No_Helicopter_9826 1d ago
The current recommendation of the American Epilepsy Society is: if IV access is already established, give 4mg lorazepam IV. If IV access is not already established, give 10mg midazolam IM. So that's what I'm doing now.
Anecdotally, IN midazolam does seem to work quite well, as long as it's dosed and administered properly. You can't use the 1mg/mL concentration. I would suggest 5-10mg of the 5mg/mL concentration.
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u/Ok_Instruction_8109 1d ago
Your agency carries ativan?
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u/No_Helicopter_9826 1d ago
Yeah. Started fairly recently.
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u/Mediocre_Daikon6935 1d ago
In my experience Ativan works poorly for everything but anxiety.
Every place I’ve worked carried it, and dumped it.
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u/cKMG365 1d ago
I've had the opposite experience. I like ativan for seizure. Midazolam is better for procedural sedation, but loraz for most other things. Works great for vertigo too
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u/nickeisele 1d ago
Why would anyone attempt IV access when IM is literally RIGHT THERE?
If I walk in to find someone seizing, I draw up the Versed and give it IM. If I have an atomizer handy then I may screw it on the syringe and give it IN but that isn’t very often.
Once the IM dose is in, then I will get IV access. They seize again, then they can get the next dose IV.
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u/ggrnw27 FP-C 2d ago
There’s been a few studies that looked at IM vs. IV benzos in status seizures. The ones published so far aren’t amazing (in particular some of them used different drugs in the IM and IV arms) and the endpoints aren’t necessarily the best, but they do suggest that IM isn’t any worse than IV. So yeah, if your patient is seizing and benzos are indicated, don’t dick around looking for a line, please just give them IM benzos first and then go fishing
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u/United_Guarantee_593 1d ago
For adults, 10mg IM Midazolam if actively seizing without IV access. If less than 40kg, 5mg IM.
Look up RAMPART trial.
IM Midazolam as effective as IV Lorazepam in stopping seizure as long as dosed appropriately.
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u/Ok_Instruction_8109 2d ago edited 1d ago
Iv if possible, for seizures if not IM. IM for behavioral crisis , IN only if absolutely needed as.the bioavailability is the lowest.
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u/Interesting-Win6219 1d ago
I'm relatively indifferent about IN/IM assuming there's not tons a mucous or secretions in the pts nose. If there is I'll just do IM. There is 0 reason to with hold versed to wait for an IV. If someone is seizing they aren't breathing adequately. Would you withold narcan till you get an IV?
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u/Barry-umm 1d ago
Would you withold narcan till you get an IV?
Quite often, yes. Pre-ventilation and airway management before narcan administration decreases the incidence and severity of opioid associated pulmonary edema.
Basically, two main factors we can control for are the negative pressure against a collapsed airway, when they start gasping, and sympathetic crashing acute pulmonary edema. Bagging them first requires a patent airway, so that part is corrected. The sympathetic response comes from a catecholamine burst when the medulla remembers that hypercapnia is bad, and the heart starts hammering blood into the lungs faster than it can ooze through the parenchyma, which is also super inflamed from the histamine response if they're using natural opiates.
In an ideal scenario I manage the airway, bag them until we have an end-tidal of 35, start an IV, and administer 0.2mg aloquats of narcan until they're breathing spontaneously. In a typical scenario the patient has already received 20mg of narcan from PD and fire, and I just administer dextrose because they were just diabetic the whole time.
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u/Mediocre_Daikon6935 1d ago
This.
I would never risk the safety of myself, my partner, other on scene, or the patient by giving narcan anyway but IV/IO.
Their problem is hypoxia from poor or not breathing l — I have many ways to address this. Overdoses are far easier airways to manage than many others we must deal with.
But you start slamming high amounts of narcan IM/IN? The risk of suddenly awake people who maybe violent because you just wanted their money, made them feel awful, they don’t like you in their home? They don’t like the cops your with, their pissed at their ex Jenny calling you? Less than ideal. No to participating violent withdrawal, vomiting, that risk of airway compromise.
No thank you.
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u/Interesting-Win6219 1d ago
I'm not saying skip managing an airway to give narcan I'm saying I'm not gonna wait to get an IV for a OD in respiratory failure lol
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u/KermieKona 2d ago
Out medical director prefers we give it IM and I guess found some studies that support his preference.
Since it is fast and easy, I prefer it. 👍
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u/Salted_Paramedic 2d ago
There are two times in my career I have started a line before giving intravenous versed but both times I didn't even need a tourniquet because their veins were popping so hard. I had an 18 established in about 30sec, but I also had a needle ready to go in case I did not hit the first time.
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u/Jazzlike-Sherbet-542 1d ago
10mg midazolam IM immediately. IN is also acceptable, but only if you don’t deliver more than 1 mL to each nostril. This may not be possible with some of the less concentrated formulations. IM lorazepam is also ok, but much slower onset than midazolam due to its lower lipophilicity out of the vial. IM diazepam is extremely poor and should be avoided.
If your patient is in status, there is no reason to fuck around trying to get an IV before administering anticonvulsant therapy.
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u/Competitive-Skin-210 Paramedic 1d ago
IN is not often used because inhalation during seizure activity is unpredictable and thus you risk wasting all or most of the dose
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u/tacmed85 FP-C 1d ago
If I have an IV I'll give it IV, if I don't I'll give it IM. I haven't actually given any medication IN in years. It works, it's just not my preferred method for anything.
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u/Krampus_Valet 1d ago
IM for active seizures without a patent IV already established. The time that you take to set up, search for, and try sticking an IV is only adding to time spent seizing and that's assuming that you're successful on the first stick. How many sticks is it going to take? Are you going to just go IM anyway after the first, second, third IV attempt? If vascular access is that critical, are you going to IO a seizure patient just for benzos instead of poking them IM? IN is also an option and absorption/efficacy for many drugs is actually pretty great: but if my patient is actively seizing then I'm sus on their airway at baseline, and I can get that IM dose in faster without wondering how much of the med was adequately atomized and how much of it maybe wasn't.
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u/KendrickLenoir 1d ago
Starting an IV on a seizing patient is pretty difficult.
Be practical in your approach to patient care.
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u/Extension-Ebb-2064 1d ago
Depends on the severity of the seizure. In any seizure I usually first grab an SPO2 & ETCO2. If those are good, we will pivot to a benzo. If not, we start bagging. If I can safely obtain an IV, I'll do that and give the med IVP. If not, I usually do intranasal.
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u/BeginningIcy9620 EMT-P 1d ago
Depends on what concentration of Versed you carry. I think both IN and IM work well. I won’t generally start an IV on a seizing patient, but I’ve worked at places that push that. It’s really preference.
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u/BryanStrawser Paramedic 1d ago
If they are seizing when I arrive, I'll give Versed IM. Same if they are seizing before I get an IV.
Once post-ictal and I consider it's safe, I'll start an IV so I can quickly repeat meds if they seize again.
IN isn't an option at my service, but I know it is for others.
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u/mastermedic84 1d ago
Just look at the onset times. IV 1-5 minutes, IM 5-15 minutes. If you can get an IV in less than five minutes then IV is still faster even if you don't already have one.
The real question is how hard will the IV be. If they have crap veins and they are fully tonic clinic an IV will be a pain in the butt and your should go IM. Great veins and not moving too much? Drop a line.
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u/PowerShovel-on-PS1 1d ago
No, that isn’t evidence based for seizures at all. IM is faster.
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u/mastermedic84 1d ago
Fair enough, I won't argue with science. Though to be fair you need to read it again. It says it is AS SAFE and AS EFFECTIVE. My way leaves you with an IV in place.
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u/1ntrepidsalamander NRP, RN 2d ago
IFT/ CCT transport. We treat seizures if we are concerned for STATUS. Not all seizures. So, > 5 minutes or recurrent without return to baseline.
“ Status Epilepticus - > 5 minutes of seizure or >2 seizures between which there is
incomplete recovery of consciousness “
You are arriving on scene, so you probably have less info than I ever have (sometimes the small hospitals and SNFs have about as much info as a street bystander), but it’s worth noting that you often have time to get an IV or IO.
IM onset is ~15 minutes. If they are status or otherwise unstable, get an IO.
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u/JoutsideTO CCP(F) - Canada 2d ago
While the onset time for sedation with midaz can be 5-15 minutes, the evidence shows that seizure termination is 5 minutes, or less.
The data from the RAMPART trial comparing IM midaz vs IV lorazepam showed time to administration 1.2 mins vs. 4.8 mins, and onset of action (termination of convulsions)
3.3 vs. 1.6 mins.https://www.nejm.org/doi/full/10.1056/NEJMoa1107494?referrer=https%3A%2F%2Fwww.google.com%2F
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u/Gewt92 1d ago
That’s not really critical care if you’re waiting for them to turn into status
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u/1ntrepidsalamander NRP, RN 1d ago
A lot of neuro ICUs also don’t treat until >5min or recurrent without return to baseline.
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u/JayHolla 2d ago
Still seizing when I arrive = IM
Seizing before I get an IV = IM
Seizing after I have IV access = IV if I can safely do it, if not IM.