Probably a good call, but remember that febrile convulsions have a benign course; it is
extremely rare for them to result in status or hypoxic brain damage so long as the airway is
maintained. One paper suggests that it is reasonable to wait about 10 minutes for a drug to
work:
Lancet 1999 Feb 20;353(9153):623-6 Related Articles, Books, LinkOut
Buccal midazolam and rectal diazepam for treatment of prolonged seizures in childhood and
adolescence: a randomised trial.
Scott RC, Besag FM, Neville BG
Wolfson Centre, Institute of Child Health, Great Ormond Street Hospital for Children NHS
Trust, London, UK. [log in to unmask]
BACKGROUND: Convulsive status epilepticus is the most common neurological medical
emergency and has high morbidity and mortality. Early treatment before admission to hospital
is best with an effective medication that can be administered safely. We aimed to find out
whether there are differences in efficacy and adverse events between buccal administration of
liquid midazolam and rectal administration of liquid diazepam in the acute treatment of
seizures. METHODS: At a residential school with on-site medical facilities 42 young people
with severe epilepsy were enrolled. Continuous seizures of more than 5 min duration were
randomly treated with buccal midazolam or rectal diazepam. If the seizure did not stop within
10 min additional medication chosen by the attending physician was administered. We
monitored oxygen saturation and blood pressure for 30 min after treatment. The main outcome
measures were efficacy, time from arrival of the nurse to drug administration, time from drug
administration to end of seizure, and incidence of adverse cardiorespiratory events.
FINDINGS: Buccal midazolam was used to treat 40 seizures in 14 students, and rectal diazepam
39 seizures in 14 students. Midazolam stopped 30 (75%) of 40 seizures and diazepam 23 (59%)
of 39 (p=0.16). The median time from arrival of the nurse to administration of medication was 2
min. Time from administration to end of seizure did not differ significantly between the two
treatments. No clinically important adverse cardiorespiratory events were identified in the two
groups. Buccal midazolam was universally acceptable to the nursing and care staff.
INTERPRETATION: Buccal midazolam is at least as effective as rectal diazepam in the acute
treatment of seizures. Administration via the mouth is more socially acceptable and
convenient and may become the preferred treatment for long seizures that occur outside
hospital.
And the original paper:
: Am J Emerg Med 1989 Mar;7(2):168-72 Related Articles, Books, LinkOut
Rectal diazepam in pediatric status epilepticus.
Albano A, Reisdorff EJ, Wiegenstein JG
Emergency Medicine Residency, Michigan State University, Lansing.
Status epilepticus is a neurologic emergency with an 8% to 12% mortality. Rapid ablation of
seizure activity is imperative. Although intravenous administration of diazepam is the
preferred immediate treatment, vascular access is often difficult to achieve. Rectal
administration of diazepam is easily accomplished during status epilepticus. Five cases in
which diazepam administered in the rectal lumen stopped seizure activity are reported. Rectal
diazepam appears to be safe and efficacious. It should be considered as an alternate to
intravenous therapy when immediate vascular access is delayed. Rectal diazepam may have
great benefit in the prehospital setting.
Best wishes,
Rowley Cottingham
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