Buccal midazolam and rectal diazepam for treatment of prolonged seizures in childhood and adolescence: a randomised trial

Background Convulsive status epilepticus is the most common neurological me dical emergency and has high morbidity and mortality. Early treatment befor e admission to hospital is best with an effective medication that can be ad ministered safely. We aimed to find out whether there are differences in ef ficacy and adverse events between buccal administration of liquid midazolam and rectal administration of liquid diazepam in the acute treatment of sei zures. Methods At a residential school with on-site medical facilities 42 young pe ople with severe epilepsy were enrolled. Continuous seizures of more than 5 min duration were randomly treated with buccal midazolam or rectal diazepa m. If the seizure did not stop within 10 min additional medication chosen b y the attending physician was administered. We monitored oxygen saturation and blood pressure for 30 min after treatment. The main outcome measures we re efficacy, time from arrival of the nurse to drug administration, time fr om drug administration to end of seizure, and incidence of adverse cardiore spiratory 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 ar rival of the nurse to administration of medication was 2 min. Time from adm inistration to end of seizure did not differ significantly between the two treatments. No clinically important adverse cardiorespiratory events were i dentified 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 s ocially acceptable and convenient and may become the preferred treatment fo r long seizures that occur outside hospital.