From the Guidelines
For a child who is still seizing after receiving midazolam, the next best step would be to administer a second-line antiepileptic medication, with fosphenytoin, levetiracetam, or valproate being suitable options, as they have similar efficacy in terminating seizures, as stated in the 2024 clinical policy 1. When a patient continues to have seizures despite initial benzodiazepine therapy (midazolam in this case), a second-line antiepileptic medication is indicated.
- Fosphenytoin is a prodrug that is converted to phenytoin in the body and works by stabilizing neuronal membranes and decreasing seizure activity.
- Levetiracetam and valproate are also effective options, with the choice among them depending on specific patient factors and the clinical scenario. The use of these medications can result in cessation of seizures in approximately half of all patients, with the benefit of early treatment being a reduction in morbidity and mortality, as noted in the 2024 clinical policy 1. It is crucial to prioritize the administration of a second-line agent over repeating or switching to another benzodiazepine, as the patient has already failed benzodiazepine therapy, making another medication from the same class unlikely to be effective. The 2024 clinical policy provides the most recent and highest quality guidance on this matter, superseding earlier recommendations 1.
From the Research
Next Steps for Ongoing Seizures
If a child continues to experience seizures despite the administration of midazolam, a benzodiazepine, the next best steps can be considered based on the available evidence:
- Re-evaluation of the seizure and the child's condition to determine the best course of action 2, 3
- Consideration of alternative routes of midazolam administration, such as intranasal or buccal, which have shown efficacy in stopping seizures in children 2, 4, 5, 6
- Potential use of other benzodiazepines, such as rectal diazepam, although buccal midazolam may be preferred due to its ease of use and high efficacy 3, 4
- Importance of educating parents and caregivers on the management of seizures and the use of rescue therapies, such as benzodiazepines, to ensure prompt and effective treatment 3
Key Considerations
- The choice of route and medication should be based on the individual child's needs and the specific circumstances of the seizure 2, 3
- The efficacy and safety of different routes and medications should be considered, with intranasal and buccal midazolam showing promise in stopping seizures in children 2, 4, 5, 6
- The importance of prompt and effective treatment in reducing the risk of seizure-related morbidity and mortality should be emphasized 3