What is the recommended dose of Valium (diazepam) for seizure management?

Valium (Diazepam) Dosing for Seizures

For acute seizure management, administer diazepam 0.1-0.3 mg/kg intravenously (maximum 10 mg per dose) slowly over 2 minutes, repeating every 5-10 minutes if seizures persist, up to a maximum total dose of 30 mg. 1, 2

Intravenous Administration (Preferred Route)

Initial dosing:

• Adults: 5-10 mg IV initially for status epilepticus and severe recurrent convulsive seizures 2
• Pediatric patients (≥5 years): 1 mg IV every 2-5 minutes up to maximum 10 mg 2
• Pediatric patients (<5 years but >30 days): 0.2-0.5 mg IV slowly every 2-5 minutes up to maximum 5 mg 2

Repeat dosing:

• May repeat at 10-15 minute intervals up to maximum total dose of 30 mg 2
• If necessary, therapy may be repeated in 2-4 hours, though residual active metabolites persist 2

Administration technique:

• Administer slowly over approximately 2 minutes to avoid local injection site pain 1
• If direct IV administration not feasible, inject slowly through infusion tubing as close as possible to vein insertion 2

Alternative Routes When IV Access Unavailable

Rectal administration:

• Dose: 0.5 mg/kg up to 20 mg maximum 1
• Effective alternative when IV access cannot be established 1, 3
• Use undiluted IV diazepam solution administered per rectum 3

Nasal spray (for adults):

• 50-100 kg: 5-10 mg 4

• 100 kg: 15-20 mg 4

Critical Clinical Considerations

Immediate follow-up treatment required:

• Diazepam must be followed immediately by a long-acting anticonvulsant (phenytoin/fosphenytoin) because seizures frequently recur within 15-20 minutes due to rapid redistribution 4, 1
• This is non-negotiable—diazepam alone provides only temporary seizure control 1

Respiratory monitoring:

• Prepare to support ventilation—increased incidence of apnea occurs with rapid administration or when combined with other sedatives 4, 1
• Monitor oxygen saturation and respiratory effort continuously 4, 1
• Have airway management equipment immediately available 2

Comparative efficacy:

• Lorazepam may be preferred over diazepam due to longer anticonvulsant duration of action 1
• In head-to-head trials, lorazepam (89%) versus diazepam (76%) controlled seizures in status epilepticus, though this difference was not statistically significant 5
• Lorazepam is associated with significantly fewer occurrences of respiratory depression compared to diazepam (RR 0.72,95% CI 0.55-0.93) 6

Common Pitfalls to Avoid

Do not:

• Administer too rapidly—this increases risk of apnea and local injection site reactions 1, 2
• Rely on diazepam alone without transitioning to long-acting anticonvulsant 4, 1
• Use flumazenil routinely for reversal—while it reverses respiratory depression, it also neutralizes anticonvulsant effects and may precipitate seizures 4, 1, 2

Special populations:

• Exercise extreme caution in patients with chronic lung disease or unstable cardiovascular status 2
• Hypotension may occur, particularly with phenytoin but less commonly with diazepam 5

Treatment Algorithm

1. Establish IV access if possible and administer diazepam 0.1-0.3 mg/kg (max 10 mg) slowly over 2 minutes 1, 2

2. If no IV access: Use rectal diazepam 0.5 mg/kg (max 20 mg) or nasal spray (dose by weight) 4, 1

3. If seizures persist after 5-10 minutes: Repeat diazepam dose 1, 2

4. Immediately after seizure control: Initiate loading dose of phenytoin/fosphenytoin (18 mg/kg) or alternative long-acting anticonvulsant 5, 1

5. Continuous monitoring: Maintain oxygen saturation monitoring and be prepared for ventilatory support 4, 1

6. Maximum dosing: Do not exceed 30 mg total dose in initial treatment period 2