Abstracts

Although rectal diazepam is becoming an acceptable alternative to intravenous use in emergency situations as rescue medication for prolonged or clustering seizures, there are practical problems with administration related to the dignity and social acceptability of the procedure. The long half-life is also associated with significant hangover effect. We report the successful use of midazolam being given buccally or nasally by carers in community settings as an alternative to rectal diazepam to abort prolonged seizures or clusters of seizures in adults and children with epilepsy. Our service covers a remote rural area in south west England where there is a need to explore alternatives to emergency hospital admission. Midazolam is available in the UK in a format that renders such administration convenient, and is preferred to the formulation used for anesthetic induction, which has unacceptably low pH and is supplied in glass containers that are inconvenient outside the clinical setting. Individual guidelines for administration were prepared for each patient and all users were trained in its use. Midazolam was prescribed as Epistatus (Special Products Ltd, UK), sugar-free buccal liquid 10 mg in 1.0 ml, in bottles each containing 4 applications of 10 mg each (standard adult dose) with plastic applicators. No glass needed to be broken for administration. Lower doses were used in children according to body weight. Of 69 patients treated, there were 26 in whom carers had previous experience of using rectal diazepam with the same patient. A customer satisfaction survey showed a strong preference for the use of midazolam by carers with experience of both midazolam and rectal diazepam because of social acceptability (p = [lt]0.0001), ease of administration (p = [lt]0.0001), rapid action (p = 0.0033) and minimal hangover effect consequent on short half-life (p = 0.0009). Despite its short half life there have been no problems with seizure recurrence after use compared with rectal diazepam, and no problems reported with respiratory depression after hundreds of uses in our service. Midazolam given buccally or nasally by carers is an effective rescue medication for prolonged or clustering seizures. A preparation with appropriate pH and with suitable applicators is recommended, along with protocols for individual seizure management, carer training and guidelines for use. (Supported by Cornwall Partnership NHS Trust, as part of clinical practice in the National Health Service.)