Buccal Midazolam Administration in a Child with Convulsions
Buccal midazolam should not be administered in a safety pouch for a boy in convulsions due to the risk of aspiration. Instead, proper positioning and direct administration techniques should be used to minimize aspiration risk.
Safety Concerns with Buccal Midazolam in Convulsing Patients
Aspiration Risk
- During active convulsions, protective airway reflexes may be compromised
- If airway protective reflexes are impaired, the risk of administering medications may outweigh the benefits 1
- Proper positioning is critical to minimize aspiration risk
Proper Administration Technique
- Place the child on their side in the recovery position before administration 2
- Clear the area around the child to prevent injury
- Direct application to the buccal mucosa between the gum and cheek is the recommended method
- Avoid placing medication in a "safety pouch" as this could increase aspiration risk if the pouch dislodges during convulsions
Advantages of Buccal Midazolam
- Rapid absorption through the buccal mucosa
- Effective seizure control in 84-88% of prolonged seizures 3, 4
- Median time to seizure cessation of approximately 3-4 minutes 3
- More convenient than rectal diazepam with higher parental satisfaction (94% vs 14%) 4
- Does not require intravenous access, which can be challenging in children 4
Administration Guidelines
- Standard dose: 0.3 mg/kg via buccal route 3
- Most effective for seizures lasting less than 30 minutes (100% efficacy) 3
- Reduced efficacy (50%) in established status epilepticus 3
- Drug should be administered directly to the buccal mucosa using a needleless syringe
- Atomizer devices can enhance drug delivery to mucous membranes 1
Monitoring and Precautions
- Monitor oxygen saturation and respiratory effort during and after administration
- Be prepared to support ventilation if needed
- Increased risk of respiratory depression when combined with other sedative agents 1
- Have flumazenil available to reverse life-threatening respiratory depression if necessary 1
Alternative Routes if Buccal Administration is Unsafe
- Intranasal midazolam is an effective alternative with similar efficacy 5, 6
- Intravenous administration (if access available): 0.1-0.3 mg/kg every 5-10 minutes (maximum 10 mg per dose) 1
- Rectal diazepam: 0.5 mg/kg up to 20 mg (if IV access unavailable) 1
Key Takeaway
When administering buccal midazolam to a convulsing child, proper positioning (side-lying/recovery position) and direct application to the buccal mucosa are essential to minimize aspiration risk. Using a "safety pouch" is not recommended as it could potentially increase the risk of aspiration if dislodged during seizure activity.