#The Effectiveness of Intranasal Midazolam for Seizure Treatment in Emergency Care: A Systematic Review of Prehospital and Emergency Department

Introduction: Seizures are a critical medical emergency requiring prompt intervention to improve patient outcomes and prevent complications. Intranasal (IN) midazolam has emerged as a promising treatment due to its ease of administration and rapid onset. However, there is a lack of comprehensive systematic reviews assessing its effectiveness, particularly in prehospital settings, compared to other treatments. This study aims to systematically evaluate and compare the effectiveness of intranasal midazolam in acute seizure management and patient outcomes in prehospital care and emergency departments. Methods: A comprehensive search was conducted using the PICOS framework. This systematic review included clinical trials and observational studies published between August 2014 and August 2024 to review published data on intranasal midazolam used in prehospital and emergency departments. Data were extracted using Covidence and organized into summary tables for analysis. Results: Three out of 489 studies included 5062 patients, all of them being under 18, and 4957 in prehospital settings. One clinical study trial and two cohort studies. The main indicator of medication success was seizure termination within ten minutes. One study reported that success rate of 88.2%. The second indicator was the reduction of seizure recurrence. Two studies noted the need for redosing with the intranasal route, with a risk difference of 11% and a 95% CI. Despite the higher frequency of redosing, intranasal midazolam showed comparable efficacy to other routes. Adverse effects, including respiratory depression and nasal irritation, were observed. Additionally, one study reported somnolence and vomiting. Conclusion: The majority of the studies reported that intranasal midazolam might be an effective, safe, and easily applicable treatment for acute seizures in Adolescent and pediatric populations. However, it may require redosing compared to other routes. Additionally, further research is needed to refine its application and to validate and generalize the results.