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

Diazepam Dosage for Seizure Management

For acute seizure control, 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, followed immediately by a long-acting anticonvulsant due to diazepam's short duration of action. 1, 2

Intravenous Administration (Preferred Route)

• Administer 0.1-0.3 mg/kg IV slowly over approximately 2 minutes (maximum 10 mg per dose) 1, 2
• Inject slowly, taking at least one minute for each 5 mg (1 mL) given to avoid local injection site pain and respiratory depression 2
• May repeat the dose every 5-10 minutes if seizures continue 1
• Maximum total dose is 30 mg 2

Pediatric-Specific IV Dosing

• Infants over 30 days and children under 5 years: 0.2-0.5 mg slowly every 2-5 minutes up to maximum 5 mg 2
• Children 5 years or older: 1 mg every 2-5 minutes up to maximum 10 mg 2
• Repeat in 2-4 hours if necessary, but be aware that residual active metabolites may persist 2

Alternative Routes When IV Access Unavailable

• Rectal administration: 0.5 mg/kg (maximum 20 mg) when IV access cannot be established 1
• Intramuscular route may be used if IV is impossible, though it is less preferred for status epilepticus 2
• For tetanus in infants over 30 days: 1-2 mg IM or IV slowly, repeated every 3-4 hours as necessary 2

Critical Management Considerations

Immediate Follow-Up Treatment Required

• Diazepam must be followed immediately by a long-acting anticonvulsant (phenytoin/fosphenytoin 18 mg/kg IV) because seizures frequently recur within 15-20 minutes due to rapid redistribution 1
• Lorazepam may be preferred over diazepam due to longer anticonvulsant duration (89% vs 76% seizure control, though not statistically significant) 1

Respiratory Monitoring and Support

• Higher incidence of apnea occurs with rapid IV administration or when combined with other sedative agents 1
• Respiratory assistance must be readily available before administration 2
• Monitor oxygen saturation and respiratory effort continuously 1
• Be prepared to provide ventilatory support immediately 1

Reversal Agent Caution

• Flumazenil may reverse life-threatening respiratory depression but will also neutralize anticonvulsant effects and may precipitate seizures 1
• Do not use flumazenil routinely for sedation reversal in seizure patients 3

Treatment Algorithm for Status Epilepticus

1. Establish IV access and administer diazepam 0.1-0.3 mg/kg (max 10 mg) slowly over 2 minutes 1, 2
2. If no IV access: give rectal diazepam 0.5 mg/kg (max 20 mg) 1
3. Monitor continuously and repeat diazepam dose at 5-10 minute intervals if seizures persist 1
4. Immediately initiate loading dose of phenytoin/fosphenytoin (18 mg/kg) after initial seizure control 1
5. If seizures continue after benzodiazepine and phenytoin: consider phenobarbital 15-20 mg/kg IV 3

Common Pitfalls to Avoid

• Do not delay long-acting anticonvulsant administration—diazepam's anticonvulsant effect is brief (15-20 minutes) despite prolonged sedation 1
• Avoid using small veins (dorsum of hand/wrist) and take extreme care to prevent intra-arterial administration or extravasation 2
• Do not mix or dilute diazepam with other solutions or drugs in syringe or infusion container 2
• In children with chronic lung disease or unstable cardiovascular status, exercise extreme caution due to respiratory depression risk 2

Special Populations

• Neonates (full-term): Continuous infusion at 0.3 mg/kg/hour (approximately 1-1.5 mg/hour) may be required for refractory seizures, with close respiratory monitoring 4
• Hypotension may occur but is less common with diazepam than with phenytoin 1