Clinical scenario

An 11 year old girl, known to be epileptic, is brought to the Emergency Department with a prolonged seizure. You have no intravenous access at this point. A colleague recently mentioned that buccal midazolam is an available alternative to rectal diazepam. You are aware that this would be easier and more socially acceptable in the situation, but wonder if it would be as efficacious.

Three part question

In [children with prolonged seizures] does [buccal midazolam or rectal diazepam] lead to [quicker resolution of seizures]?

Search strategy

Medline 1966-01/2005 using the OVID interface and the Cochrane Library, Issue 4, 2004. Medline: [exp status epilepticus OR status epilepticus.mp OR exp seizures/ OR exp seizures, febrile/ or seizure.mp OR fit$.mp] AND [exp midazolam/ OR midazolam.mp OR exp Benzodiazepines] AND [exp Mouth Mucosa/ OR buccal.mp OR exp administration, buccal/] AND [exp diazepam OR diazepam.mp] AND [rectal.mp OR exp Rectum/ OR per rectum.mp OR exp Administration, Rectal] LIMIT to human AND English language. Cochrane: status epilepticus OR buccal.

Search outcome

Medline: Eight papers were identified, two of which were relevant to the three part question (table 1). Cochrane: Nine hits, none of which was relevant.

Comment(s)

Buccal midazolam is gaining in popularity as a treatment for prolonged seizures in children. It overcomes many of the disadvantages associated with rectal diazepam, including difficulty of administration in wheelchair users and in tonic seizures, potentially unpredictable absorption with constipation and bowel movements and social unacceptability, particularly in older children. Nasal midazolam has also been used,³ although the greater surface area of the buccal mucosa could potentially confer advantages with regard to absorption.

One small trial suggests that buccal midazolam is at least as effective as rectal diazepam and one suboptimally designed telephone survey suggested a degree of parental satisfaction with the drug. However, the patient group in the randomised controlled trial is very different from that presenting to emergency departments. There remains a paucity of evidence regarding this topic.

CLINICAL BOTTOM LINE

Buccal midazolam may be equal or superior to rectal diazepam for treatment of prolonged seizures in children but more evidence is needed for emergency patients.