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Rectal diazepam for prehospital pediatric status epilepticus
1Department of Emergency Services, San Francisco General Hospital.
Insights
Rectal diazepam is a feasible, effective, and safe prehospital treatment for pediatric status epilepticus. It is easier to administer than intravenous diazepam and causes less respiratory depression, though both have short durations of action.
Area of Science:
- Pediatric Emergency Medicine
- Neurology
- Pharmacology
Background:
- Status epilepticus in children presents a significant prehospital challenge.
- Intravenous (IV) diazepam is a common treatment but can be difficult to administer in the field.
- Alternative routes of administration are needed for effective prehospital seizure management.
Purpose of the Study:
- To compare the feasibility, effectiveness, and safety of rectal diazepam versus IV diazepam for pediatric prehospital status epilepticus.
- To evaluate seizure cessation rates and adverse events associated with each route.
- To assess the ease of administration and need for respiratory support.
Main Methods:
- Retrospective analysis of ambulance-transported children (<18 years) with status epilepticus.
- Comparison of outcomes for patients receiving rectal diazepam (n=16) versus IV diazepam (n=15).
- Paramedic administration of diazepam via rectal (0.2-0.5 mg/kg) or IV (0.1-0.3 mg/kg) routes, with cardiopulmonary monitoring.
Main Results:
- Rectal diazepam successfully terminated seizures in 81% of children after a single dose; recurrence occurred in 30.8%.
- IV diazepam terminated seizures in 100% of children after one dose; recurrence occurred in 60%, with two requiring prehospital intubation for respiratory depression.
- No child treated with rectal diazepam required prehospital intubation, though three non-responders had comorbidities.
Conclusions:
- Rectal diazepam is a simple, effective, and safe prehospital option for pediatric status epilepticus.
- Rectal administration is easier, particularly for infants and toddlers, and associated with less respiratory depression compared to IV diazepam.
- Both routes have limitations, including short duration of action, necessitating preparedness for respiratory support.
Study Objectives:
To compare the feasibility, effectiveness, and safety of rectal diazepam and intravenous diazepam in the treatment of pediatric prehospital status epilepticus.
Design And Setting:
Retrospective analysis of a 30-month consecutive sample of ambulance-transported children in a large urban emergency medical service region.
Type Of Participants:
Study group included 324 patients with seizure who were less than 18 years of age; 36 had status epilepticus, of whom 16 received rectal diazepam and 15 received IV diazepam.
Interventions:
For children with status epilepticus, paramedics administered the 5-mg/mL IV solution of diazepam by one of two routes: rectally either through a 5F feeding tube with an attached syringe or by lubricated tuberculin syringe inserted 4 to 5 cm into the rectum at a one-time dose of 0.2 to 0.5 mg/kg or intravenously using a one-time dose of 0.1 to 0.3 mg/kg. Cardiopulmonary status was carefully monitored in the field and emergency department.
Measurements And Main Results:
Thirteen of 16 children (81%) who received rectal diazepam stopped seizing after a single dose ranging from 0.16 to 0.57 mg/kg. Convulsions recurred before arrival at the ED in four of the 13 (30.8%). All of three patients who did not respond to rectal diazepam initially were 3 to 5 years old and had serious underlying comorbidity; two required endotracheal intubation in the ED and multiple anticonvulsants to terminate the seizure. No child treated with rectal diazepam required prehospital endotracheal intubation. All children who received IV diazepam stopped seizing after one dose ranging from 0.04 to 0.33 mg/kg. Convulsions recurred before arrival at the ED in nine of 15 children (60%); two required prehospital endotracheal intubation for profound respiratory depression.
Conclusion:
Rectal diazepam is a simple, effective, and safe method of prehospital management of pediatric status epilepticus. Compared with IV diazepam, rectal diazepam is easier to administer, especially in infants and toddlers; is equally efficacious; and is less likely to produce respiratory depression. Although respiratory depression is rare with rectal diazepam, prehospital personnel must be prepared to provide definitive respiratory support. Short duration of action is an important limitation of both treatments.