Pediatric emergency medicine trisk 1443 1443
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For patients with no IV access, other options are available. Midazolam is
reliably and rapidly absorbed intramuscularly at the above dosing. Diazepam can
also be given as a rectal gel PR at a dose of 0.2 to 0.5 mg/kg/dose with a
maximum dose of 20 mg/dose.
Both intranasal and buccal routes of midazolam have been described with
successful cessation of seizures, often in prehospital settings. These modes of
administration should be reserved for providers who have administered intranasal
or buccal medication in the past, rather than have their first attempt of using these
routes on an actively seizing child (Fig. 72.2 ).
Diazepam has an advantage in that it can be given rectally, which is useful
when a patient does not have IV access. A rectal gel is available in fixed doses of
5, 7.5, 10, 12.5, 15, 17.5, or 20 mg. The IV preparation of the drug may be used
alternatively. Recommended rectal dosing for children up to 5 years of age is 0.5
mg/kg.
Midazolam can be given intramuscularly (0.2 mg/kg/dose; not to exceed a
cumulative dose of 10 mg) and should be considered if there is delay in IV
access. Midazolam has a theoretical advantage in that patients will return to
baseline more quickly than with lorazepam or diazepam, thus allowing for better
assessment of mental status and the need for CT scan and/or LP.
Phenytoin (Dilantin) is a second-line agent for the treatment of seizures.
Phenytoin blocks sodium channels and thus acts by a different mechanism than
the benzodiazepines. The dose is 15 to 20 mg/kg as an initial load. It has several
limitations as compared with the benzodiazepines. First, peak CNS
concentrations may not be reached until 10 to 30 minutes after its infusion is
completed and, thus, it is much slower in onset. Furthermore, it must be
administered slowly (no faster than 1 mg/kg/min, or 20 minutes for a dose of 20
mg/kg) because of concerns of cardiac conduction disturbances. It cannot be
given in dextrose-containing solutions.
As a result of the limitations in the administration of phenytoin, fosphenytoin
(Cerebyx) was created. It is a prodrug whose active metabolite is phenytoin. The
drug is dosed as phenytoin equivalents (PEs), and the loading dose is 15 to 20 mg
PE/kg. The advantages are that it can be given much more rapidly (up to 3 mg
PE/kg/min, or 7 minutes for a dose of 20 mg PE/kg) and that it may be given in
either normal saline or a 5% dextrose-containing solution or intramuscularly.
Phenobarbital (Luminal) is another second-line agent for the treatment of
seizures. The loading dose is 10 to 20 mg/kg. Its advantage over phenytoin is that
it can be given more rapidly (2 mg/kg/min, or 10 minutes for a dose of 20 mg/kg).
However, it has an extremely long half-life (up to 120 hours) and a pronounced
