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Treatment with an intravenous (IV) benzodiazepine, most commonly lorazepam, is the preferred first line treatment for prolonged epileptic seizures in the emergency department, but IV medication can be difficult for first responders to administer. An alternative is for paramedics to give intramuscular midazolam in place of IV drugs and this treatment is commonly used, due to its speed and relative simplicity of administration. The RAMPART randomized trial compared intramuscular midazolam vs. IV lorazepam given by paramedics prior to hospital arrival in 893 children and adults with seizures lasting for > 5 minutes that persisted after the arrival of the paramedics. Doses were midazolam 10 mg or lorazepam 4 mg for adults and children > 40 kg (88 lbs), and midazolam 5 mg or lorazepam 2 mg for smaller children. Blinding was maintained by the use of IV placebo for the midazolam group and intramuscular placebo for the lorazepam group. Patients were excluded for major trauma, hypoglycemia, cardiac arrest, heart rate < 40 beats per minute, pregnancy, known allergy to intervention, or estimated weight < 13 kg (28.6 lbs).
The randomized intervention was given to 99% of the midazolam group, but only 63% of the lorazepam group. Of those not receiving lorazepam, convulsions stopped prior to treatment in 64%, and paramedics failed to start the IV in 28%. All randomized patients were included in an intention-to-treat analysis. Seizures were terminated without need for rescue medication in 73.4% for intramuscular midazolam vs. 63.4% for IV lorazepam (p < 0.001, NNT 10) (level 2 [mid-level] evidence). Intramuscular midazolam was associated with lower rates of hospitalization (57.6% vs. 65.6%, p < 0.05, NNT 13) and intensive care admission (28.6% vs. 36.2%, p < 0.05, NNT 14). There were no significant differences in endotracheal intubation within 30 minutes or seizure recurrence within 12 hours of emergency department arrival. Similar results were obtained in per-protocol analyses. (N Engl J Med 2012 Feb 16;366(7):591).
For more information, see the Status epilepticus topic in DynaMed.
Presenting the Benefits of Surgery in Terms of Absolute Risk instead of Relative Risk Appears to Decrease the Likelihood of Patients Electing Surgery
A recent randomized trial investigated how different approaches to explaining the benefits of surgery may affect patients’ likelihood of choosing to have surgery. A total of 420 adults attending an appointment at a neurology clinic for reasons unrelated to carotid artery disease were randomized to view a 30-second video presentation describing treatment options in a hypothetical clinical scenario of asymptomatic 70% carotid artery stenosis. The videos used 1 of 5 methods to describe how much the risk of stroke would be reduced by the addition of surgery to best medical therapy. These descriptions were: 50% relative risk reduction over 5 years; absolute risk of stroke at 5 years of 5% with surgery vs. 11% without surgery; absolute 5-year event-free survival of 95% vs. 89%; annualized absolute risk of 1% vs. 2% per year; or a qualitative description (“risk significantly less” without numerical presentation). The sex and race of the video presenter were also randomized, giving a total of 20 different scenarios. After the video, participants completed a survey regarding treatment choice of surgery plus medication vs. medication alone. No participants had any history of carotid stenosis.
About half of the participants reported that they would choose surgery plus medication, but the likelihood of choosing surgery varied with presentation method. Participants who saw videos explaining the benefits of surgery in terms of absolute risk reduction were significantly less likely to choose surgery than were those viewing the relative risk and qualitative conditions (p < 0.001) (level 3 [lacking direct] evidence). Surgery was chosen by 63% for relative risk reduction, 43% for absolute risk, 37% for absolute event-free survival, 35% for annualized absolute risk, and 64% for qualitative presentation. Sex and race of the presenter were not associated with treatment choice (Neurology 2012 Jan 31;78(5):315).
These data may help clinicians better understand how patients’ choices can be affected by how their treatment options are framed.
For more information, see the Carotid artery stenosis repair topic in DynaMed.