Intranasal and buccal midazolam in the pre-hospital management of epileptic tonic-clonic seizures

This article will compare the use of two common anti-convulsants: midazolam (intravenous, intranasal and buccal formulations) and miazepam (intravenous and per-rectum formulations), in the treatment of prolonged tonic-clonic epileptic seizures. With epilepsy affecting approximately 50 million people worldwide and greater than half a million people within the United Kingdom alone (The Epilepsy Society, 2011), it is important to ensure that paramedics are providing the most effective treatment possible. This article will explore the pathophysiology of epilepsy and an acute seizure, specifically the tonic-clonic presentation as they require rapid therapeutic interventions by paramedics because prolonged seizures may result in complications for the patient. It will then explore the pharmacology of benzodiazepines and compare midazolam administered via intranasal, buccal and intravenous routes with intravenous and rectal diazepam, and the benefits of alternative routes of administration. With recent changes to legislation coming into effect it is important to consider the legal aspects of providing therapeutic interventions with benzodiazepines, which will be discussed later in this article.