The drugs used in status epilepticus, primary care in the community, secondary hospital care, and tertiary or intensive care are reviewed from the Royal Hospital for Sick Children, Edinburgh. The two preferred drugs recommended for first line care are rectal diazepam and intramuscular paraldehyde. In second line care at a hospital emergency room, intravenous diazepam is preferred in a dosage of 0.25 to 0.3 mg/kg with a glass syringe. Third line management in intensive care includes 20% mannitol given over 20 minutes in a dose of 7 ml/kg for cerebral edema. EEG monitoring is essential to demonstrate seizure activity, paradoxical reactions to drugs such as diazepam, and overdosage with drugs, eg barbiturates causing burst suppression. The authors stress the need to consider Hemophilus influenzae and pneumococcal meningitis as an underlying cause of status epilepticus and caution that lumbar puncture must never be done in an unconscious child without a CT scan to exclude signs of brain swelling or edema. The need for tertiary intensive care is usually a sign of failure of early control resulting from inappropriate anticonvulsant medication rather than drug resistance. [1]

COMMENT. The primary care of seizures is all important so that status epilepticus of prolonged duration may be avoided. Mortality from status epilepticus is usually the result of the underlying disease with an 8% incidence at the above institution. A paradoxical convulsant response to the anticonvulsant diazepam should be considered in children whose seizures are not rapidly controlled, and an alternative anticonvulsant should be used (Livingston and Brown, 1988).

The home use of rectal diazepam for cluster and prolonged seizures is reported from the Department of Neurology, Hennepin County Medical Center; Department of Pharmacy Practice, University of Minnesota, Minneapolis; and the Department of Pediatric Neurology, Gillette Children’s Hospital St. Paul, Minnesota [2]. Rectal diazepam was effective in controlling seizures in 85% of patients. Adverse reactions were mild and consisted of drowsiness and/or behavioral changes. Improvements in quality of life associated with the availability of rectal diazepam were observed by 58% of users and 27% of nonusers. In addition to improved management of seizures there was increased flexibility in family activities and less parental anxiety. The diazepam injectable solution in a dose ranging from 0.3 to 0.5 mg/kg was used for rectal administration. It was administered with a needleless lubricated 3 ml plastic syringe inserted 2 to 4 cm into the rectal cavity. Effective serum concentrations are usually reached within ten minutes.