Efficacy of intramuscular midazolam for the treatment of Status epilepticus in children

Abstract

Background: Status epilepticus (SE) is a life-threatening pediatric neurological emergency requiring rapid seizure control to prevent neuronal injury. Establishing intravenous access in actively convulsing children is often challenging, leading to treatment delays. Intramuscular midazolam, due to its rapid absorption and high bioavailability, offers a practical alternative. Methods: A prospective observational cohort study was conducted at the Department of Pediatrics, Balochistan Institute of Child Health Services, Quetta, from September 2025 to April 2026. Sixty-six children aged 1–12 years presenting with convulsive SE (>5 minutes) were enrolled through consecutive sampling. Patients with prior epilepsy, prehospital benzodiazepine use, or contraindications were excluded. Intramuscular midazolam (0.3 mg/kg; maximum 10 mg) was administered into the vastus lateralis (<2 years) or deltoid muscle (≥2 years). The primary outcome was seizure cessation within 5 minutes. Secondary outcomes included time to cessation, recurrence within 60 minutes, and adverse events. Data were analyzed using SPSS v22.0. Results: Among 66 patients (57.6% male; mean age 6.2 ± 3.8 years), seizure cessation within 5 minutes was achieved in 93.9% (95% CI: 87.1–97.5%). The median time to cessation was 65 seconds (range: 24–310), with a mean door-to-drug time of 58.3 ± 22.4 seconds. Higher efficacy was observed in children aged 7–9 years (100%). Febrile SE and absence of prior seizures were associated with faster control (p < 0.05). Recurrence occurred at 4.8%, while adverse events were mild (9.1%), including transient respiratory depression (3.0%). Conclusion: Intramuscular midazolam (0.3 mg/kg) is a highly effective and safe first-line treatment for pediatric SE when intravenous access is unavailable.