Pre-hospital paediatric seizures: midazolam versus diazepam

Current UK ambulance service clinical practice guidelines (Association of Ambulance Chief Executives, 2013) include rectal (PR) and intravenous (IV) diazepam for use by paramedics to terminate seizures. The guidelines also advocate use of patient's own buccal midazolam (BM), but this is not currently carried out by UK paramedics (Association of Ambulance Chief Executives, 2013). Many patients with seizures will only require supportive care and limited intervention from the pre-hospital clinicians (Warden and Frederick, 2006). However, those patients who have complex, prolonged seizures or are found to be in status epilepticus, require drug therapy to terminate the seizure and prevent neurological insult (Warden and Frederick, 2006; Association of Ambulance Chief Executives, 2013). Before the guidelines were updated in 2013, paramedics were able to administer two doses of PR diazepam to account for difficulty in establishing IV access and facilitating prompt termination of seizures. Since the update in 2013, the second dose of PR diazepam was removed and emphasis was placed on early IV access and administration of IV diazepam. Diazepam is quickly able to cross the blood-brain barrier, but dosing may last just 30 minutes, resulting in the need for further drug administration. With repeat dosing, diazepam can accumulate and persist, sometimes causing unexpected side effects, including central nervous system (CNS) depression and impaired respiratory function (Aneja, 2012). Seizures are a common neurological emergency encountered in children and are associated with significant morbidity and mortality (Aneja, 2012). A primary goal of treatment is prompt seizure termination, and good evidence exists for the use of midazolam via the intranasal (IN) and buccal routes for the termination of paediatric seizures (Warden and Frederick, 2006; Aneja, 2012). The IN and buccal routes have proven effective, safe and are more socially acceptable than current PR diazepam (Scott et al, 1999).