National shortage of Valium

[Kaisu]

Correct me if I am wrong, but I was under the impression that Ativan is the benzo of choice for seizures because it stops the seizure activity in the brain. Valium and Versed will affect muscle activity in response to the brain seizure, but the "electrical storm" in the brain continues.

I carry Versed and have used it for sedation (during pacing, combative patient etc.) and RSI and I love the way the drug works. My medication of choice for seizure for the aforementioned reason is Ativan.

I would love to see the studies and other smarter people please chime in.

[tcripp]

A little redirection and a little old, but here is a link to a thread sometime back regarding the same question.

[usalsfyre]

Correct me if I am wrong, but I was under the impression that Ativan is the benzo of choice for seizures because it stops the seizure activity in the brain. Valium and Versed will affect muscle activity in response to the brain seizure, but the "electrical storm" in the brain continues.

I carry Versed and have used it for sedation (during pacing, combative patient etc.) and RSI and I love the way the drug works. My medication of choice for seizure for the aforementioned reason is Ativan.

I would love to see the studies and other smarter people please chime in.

Midaz is a benzo the same as any other benzo, meaning they all affect GABA receptors similarly. My understanding of it is that by binding to and "activating" the receptor it raises the electrical threshold for neuron depolarization, meaning they all "quiet the electrical storm" in the brain. Midazolam terminates seizures as well as any othe agent, as the other thread notes the issue is duration. Midaz is a short acting agent anyway, in patients with baseline increased metabolism or, especially, patients with increased hepatic metabolism (such as patients on phenytoin) they can chew threw midazolam...quickly. I once gave an intubated 8 year old in the neighborhood of 20mgs of midaz in a 45min flight. He had recently started phenytoin and at that service midaz was all I had available. Lorazepam and diazepam's increased half life are very helpful here.

Don't forget these patients will often need long-term anticonvulsant therapy for anything other than a transport to the ED or for seizures that are refractory to benzos. Phenytoin, fosphenytoin and levetiracetam seem to be the choices in the EM environment.

[HellsBells]

Valium and Versed will affect muscle activity in response to the brain seizure, but the "electrical storm" in the brain continues.

It seems to me this is more of a concern when using paralytics to intubate a status seizure pt.

[chbare]

The benzodiazepines as stated, have similar physiological actions. None of them have significant, direct peripheral effects, so this "muscle activity" issue is not a valid concern. As stated, they revolve around the neurotransmitter GABA and it's receptors in the central nervous system. The GABA receptors are known as ionotropic or ligand-gated channels. Ligands can basically interact with metals. I will leave it at that because I really do not feel like going into crystal field theory at this time of the night.

When a GABA receptor is activated by GABA, it basically opens and becomes an ion channel. However, the ion that rushes into the cell is not the well known Sodium cation. It is in fact, Chloride. Chloride carries a negative charge and this decreases the amount of negative charge within the target neuron. This results in a decrease in the potential across the cell membrane. Basically, it is much harder for cell to depolarise. Because the cell is more difficult to depolarise, it is in essence "depressed." This is where you get the notion of CNS depression occurring with benzodiazepines. Clearly, this can help with seizures because you now have neurons that are less likely to depolarise and less likely to transition into the chaotic state of firing that often leads to seizures.

It is a bit more complicated, but hopefully that makes sense.

[systemet]

Just to add to the above, the benzodiazepines bind to the GABA A receptor, at an allosteric site. Under normal conditions they don't directly activate the channel, but instead sensitise it to other agonists, primarily the endogenous ligand, gamma-aminobutyric acid (GABA).

[*If anyone notices the immediate similarity between GABA and gamma-hydroxybutyrte (GHB), this is not a conincidence, GHB was originally developed as a general anesthetic, acting as an agonist here. We've probably all seen that it can be quite effective at inducing analgesia during intentional overdose -- though not without problems, that caused it to be abandoned, including myoclonus and one hell of a synergistic effect with alcohol]

The GABA receptor is pretty important in CNS pharmacology. If you click on the second link below, you can see a nice little diagram of a receptor looking all sciencey with a list of ligands. Note that these include the barbiturates (Pentothal, Phenobarbitol anyone?) and neurosteroids (this would include etomidate). Alcohol also acts here, as do a range of other drugs.

Benzodiazepines are widely used because their effects tend to be limited by a relative lack of direct agonist action at the GABA receptor. This makes them much safer in large doses, compared to barbiturates and other agents that are direct agonists, and tends to limit their effects in overdose -- although at a certain point as the dose increases this becomes less relevant. Unfortunately given the patients we commonly encounter, most of them have coingested alcohol, which has a direct channel-opening effect, and in combination with benzos causes major toxicity at lower doses.

Some good reviews here: (should be free access)

http://www.ncbi.nlm.nih.gov/books/NBK28090/

http://www.ncbi.nlm.nih.gov/books/NBK28090/figure/A1185/?report=objectonly

[systemet]

We've probably all seen that it can be quite effective at inducing analgesia during intentional overdose

Dammit. Should read "anesthesia".

[nypamedic43]

Thank you everyone for the replies. The input and reading I've done has helped put me more at ease about using Versed. You've all helped a lot

[ERDoc]

Just to add my two cents after the fact, Versed is not that much different from valium. I won't go through the differences since they have been added already, but I would agree with many others that I would prefer to get Ativan but I realize that is out of your control. A proper in-service of some sort or at least a good information write up would be a good idea from your medical director. With these national shortages popping up so quick it is sometimes hard to do that in time before needing to switch meds. Just remember that people are hard to kill, you have to really work at it.

[Just Plain Ruff]

There is also a national shortage of Stadol. If your hospital or service still has some stadol, count yourself lucky.

My wife just delivered our baby and she only really responds pain relief wise from Stadol. There was no stadol in the hospital so they went with Nubain.

After 30 minutes of intense labor with her being dilated to only 4cm, and nubain wearing off in 20 minutes for her, she demanded a c-section and got one.

Had a beautiful baby girl, delivered 10/10/2011 at 2058 (or somewhere areound that time)