A modified Delphi consensus on the use of intramuscular midazolam for early status epilepticus treatment (ESET) in
Hui-Yin Yow1, Kheng-Seang Lim2, Si-Lei Fong2
1Department of Pharmaceutical Life Sciences, Faculty of Pharmacy, Universiti Malaya, Kuala Lumpur, 50603, Malaysia; Neuroscience Research Group (NRG), Faculty of Pharmacy, Universiti Malaya, Kuala Lumpur, 50603, Malaysia.
Objectives:
Despite intramuscular (IM) midazolam being recommended as a primary treatment for status epilepticus (SE), its usage in Malaysian prehospital settings remains suboptimal. This study aimed to explore the awareness, practice, and barriers among healthcare professionals regarding the use of IM midazolam as a rescue medication for prehospital SE in Malaysia and provide a consensus for its implementation.
Methods:
An online cross-sectional survey and modified Delphi study was conducted among healthcare professionals across Malaysia from 22 March to 31 August 2024. A modified Delphi process was used to develop a consensus from existing literature, with two Delphi rounds assessing the relevance, clarity, and importance of each question. Consensus was achieved if 90 % or more participants agreed.
Results:
Among 137 responses, 89.1 % of healthcare professionals were aware of rescue medications. However, only 62.0 % recognized the superior absorption and bioavailability of IM midazolam over rectal diazepam, and 78.1 % were aware of its efficacy in terminating seizures. Of those (69.3 %) involved in SE management, 29.5 % (n = 28) were engaged in prehospital management of SE. Only 35.7 % (n = 10) reported that prehospital personnel were permitted to use IM midazolam for SE management and all required physician endorsement. Notably, 78.9 % of participants reported that 25 % or fewer patients with SE were treated with IM midazolam. The main barriers include unfamiliarity (64.2 %) and lack of protocols (62.1 %). A strong consensus was reached on the recommendation of IM midazolam as a first-line treatment for SE management.
Conclusion:
While Malaysian healthcare professionals are aware of rescue medications for prehospital seizure emergencies, they lack an understanding of IM midazolam's benefits. Key barriers include unfamiliarity and lack of protocols despite strong consensus on its first-line use.
Insights
Intramuscular midazolam is recommended for status epilepticus (SE) but underused in Malaysia. Barriers include lack of familiarity and protocols, despite consensus on its first-line use for prehospital SE management.
Area of Science:
- Emergency Medicine
- Neurology
- Pharmacology
Background:
- Intramuscular (IM) midazolam is recommended for status epilepticus (SE) but its use in Malaysian prehospital settings is suboptimal.
- Understanding awareness, practice, and barriers is crucial for improving prehospital SE management.
Purpose of the Study:
- To explore healthcare professionals' awareness, practice, and barriers regarding IM midazolam for prehospital SE in Malaysia.
- To establish a consensus for the implementation of IM midazolam as a rescue medication.
Main Methods:
- An online cross-sectional survey and a modified Delphi study were conducted among Malaysian healthcare professionals (March-August 2024).
- Two Delphi rounds assessed literature-based questions, with 90% agreement required for consensus.
Main Results:
- While 89.1% were aware of rescue medications, only 62.0% recognized IM midazolam's superior absorption and 78.1% knew its seizure-terminating efficacy.
- Only 35.7% reported prehospital personnel could use IM midazolam, requiring physician endorsement. 78.9% indicated IM midazolam was used in ≤25% of SE cases.
- Key barriers identified were unfamiliarity (64.2%) and lack of protocols (62.1%). A strong consensus supported IM midazolam as first-line SE treatment.
Conclusions:
- Malaysian healthcare professionals have awareness of rescue medications but lack understanding of IM midazolam's specific benefits for prehospital seizure emergencies.
- Unfamiliarity and absence of clear protocols are significant barriers to IM midazolam use, despite a consensus supporting its role as a first-line treatment.
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