BNF for Children 2011-2012

232 4.8.2 Drugs used in status epilepticus BNFC 2011–20124 Central nervous systemoccurs. Intramuscular phenytoin should not be used(absorption is slow and erratic).Alternatively, fosphenytoin (a pro-drug of phenytoin)can be given more rapidly, and when given intravenouslycauses fewer injection-site reactions than phenytoin.Intravenous administration requires ECG monitoring.Although it can also be given intramuscularly,absorption is too slow by this route for treatment ofstatus epilepticus. Doses of fosphenytoin should beexpressed in terms of phenytoin sodium.Paraldehyde given rectally causes little respiratorydepression and is therefore useful where facilities forresuscitation are poor.For neonatal seizures, see p. 217.Non-convulsive status epilepticus The urgency totreat non-convulsive status epilepticus depends on theseverity of the child’s condition. If there is incompleteloss of awareness, oral antiepileptic therapy should berestarted or continued. Children who fail to respond tooral antiepileptic therapy or have complete lack ofawareness can be treated in the same way as convulsivestatus epilepticus, although anaesthesia is rarelyneeded.CLONAZEPAMCautions see Clonazepam, section 4.8.1; facilities forreversing respiratory depression with mechanicalventilation must be at hand (but see also notes above)Intravenous infusion Intravenous infusion of clonazepam ispotentially hazardous (especially if prolonged), calling forclose and constant observation and best carried out inspecialist centres with intensive care facilities. Prolongedinfusion may lead to accumulation and delay recoveryContra-indications see Clonazepam, section 4.8.1;avoid injections containing benzyl alcohol in neonates(see under preparations below)Hepatic impairment see Benzodiazepines, section4.8.1Renal impairment see Benzodiazepines, section 4.8.1Pregnancy see Benzodiazepines, section 4.8.1Breast-feeding see Benzodiazepines, section 4.8.1Side-effects see Clonazepam, section 4.8.1; hypotensionand apnoeaIndication and doseStatus epilepticus. By intravenous injection over at least 2 minutesNeonate 100 micrograms/kg repeated after 24hours if necessary (avoid unless there is no saferalternative)Child 1 month–12 years 50 micrograms/kg(max. 1 mg) repeated if necessaryChild 12–18 years 1 mg repeated if necessary. By intravenous infusionChild 1 month–12 years initially 50 micrograms/kg (max. 1 mg) by intravenous injection then byintravenous infusion 10 micrograms/kg/houradjusted according to response; max. 60 micrograms/kg/hourChild 12–18 years initially 1 mg by intravenousinjection then by intravenous infusion 10 micrograms/kg/houradjusted according to response;max. 60 micrograms/kg/hourOther forms of epilepsy section 4.8.1Administration for intravenous injection, dilute to aconcentration of 500 micrograms/mL with Water forInjectionsFor intravenous infusion, dilute to a concentration of12 micrograms/mL with Glucose 5% or SodiumChloride 0.9%; incompatible with bicarbonate;adsorbed on PVC—glass infusion apparatus preferred(if PVC apparatus used, complete infusion within 2hours)Rivotril c (Roche) KInjection, clonazepam 1 mg/mL in solvent, net price1-mL amp (with 1 mL water for injections) = 60pExcipients include benzyl alcohol (avoid in neonates unless there is nosafer alternative available, see Excipients, p. 2), ethanol, propylene glycolOral preparationsSection 4.8.1DIAZEPAMCautions respiratory disease, muscle weakness andmyasthenia gravis, history of drug or alcohol abuse,marked personality disorder; avoid prolonged use(and abrupt withdrawal thereafter); when given parenterally,close observation required until full recoveryfrom sedation; when given intravenously, facilitiesfor reversing respiratory depression with mechanicalventilation must be at hand (but see also notes above);porphyria (section 9.8.2); interactions: Appendix 1(anxiolytics and hypnotics)Skilled tasks Drowsiness may affect performance of skilledtasks (e.g. driving); effects of alcohol enhancedContra-indications respiratory depression; markedneuromuscular respiratory weakness includingunstable myasthenia gravis; acute pulmonary insufficiency;sleep apnoea syndrome; not for chronic psychosis;should not be used alone in depression or inanxiety with depression; avoid injections containingbenzyl alcohol in neonates (see under preparationsbelow)Hepatic impairment see Benzodiazepines, section4.8.1Renal impairment see Benzodiazepines, section 4.8.1Pregnancy see Benzodiazepines, section 4.8.1Breast-feeding see Benzodiazepines, section 4.8.1Side-effects drowsiness and lightheadedness the nextday; confusion and ataxia; amnesia; dependence;paradoxical increase in aggression (see also section4.1); muscle weakness; occasionally: headache,vertigo, hypotension, salivation changes, gastrointestinaldisturbances, visual disturbances, dysarthria,tremor, changes in libido, incontinence, urinaryretention; blood disorders and jaundice reported; skinreactions; on intravenous injection, pain, thrombophlebitis,and rarely apnoea; overdosage: see EmergencyTreatment of Poisoning, p. 30Licensed use Diazepam Rectubes c and StesolidRectal Tubes c not licensed for use in children under1 yearIndication and doseStatus epilepticus, febrile convulsions (section4.8.3), convulsions caused by poisoning. By intravenous injection over 3–5 minutesNeonate 300–400 micrograms/kg repeated onceafter 10 minutes if necessary