Medicines Protocol RECTAL DIAZEPAM RECTAL DIAZEPAM v2.0 1/6 Protocol Details Version 2.0 Legal category Staff grades POM Registered Paramedic Registered Nurse Specialist Paramedic (Urgent and Emergency Care) Specialist Nurse (Urgent and Emergency Care) Nurse Practitioner Advanced Technician Approved by Medicines Management Group Date issued 29/04/2015 Review date 28/04/2017 Clinical Publication Category PROTOCOL (AMBER) - Deviation permissible; if authorised by Senior Clinician On-call. Clinical Requirements Continuing education The clinician is responsible for keeping him/herself aware of any changes to the recommendations for the medicine listed. It is the responsibility of the individual to keep up-to-date with continued professional development and to work within the limitations of their own individual scope of practice.
RECTAL DIAZEPAM v2.0 2/6 Clinical Situation Clinical situation Inclusion criteria Seizures including those of eclamptic or epileptiform origin; Post ROSC seizures; Symptomatic cocaine toxicity. Adults or children experiencing any of the following: Seizures longer than 5 minutes and STILL FITTING; Post ROSC seizure which lasts more than 2-3 minutes or is recurren and is unlikely to be due to hypoxia; Repeated seizures not secondary to an uncorrected hypoxia or hypoglycaemic episode; Status epilepticus Eclamptic fits (initiate treatment if fit lasts >2-3 minutes or if it is recurrent);. Symptomatic cocaine toxicity (severe hypertension, chest pain or fitting. Exclusion criteria Cautions Known hypersensitivity to diazepam Elderly or debilitated patients may require a reduced dose. Respiratory depression (enhanced if diazepam administered with opiates) Muscle weakness and myasthenia gravis Recent doses of diazepam or midazolam by carers/relatives should be taken into account when calculating the maximum cumulative dose. Use with caution if alcohol, anti-depressants or other CNS depressants have been taken as side effects are more likely. Side effects Drowsiness and light-headedness, confusion and unsteadiness (especially in the elderly) Respiratory depression may occur, especially in the presence of alcohol, which enhances the depressive side-effect of diazepam. In addition, opioid drugs also enhance the cardiac and respiratory depressive effect of diazepam. Hypotension may occur. This may be significant if the patient has to be moved from a horizontal position to allow for extrication from an address. Caution should therefore be exercised and consideration given to either removing the patient flat or, if fitting has stopped and is considered safe, allowing a 10 minute recovery period prior to removal.
RECTAL DIAZEPAM v2.0 3/6 Occasionally amnesia may occur. Description of Treatment Generic name Presentation Route Diazepam Rectal tubes 2.5mg and 5mg Rectal. Insert rectal tube nozzle no more than 4-5cm in adults and 2.5cm in children. Administration Supply The earlier diazepam is given the more likely the patient is to respond. The intravenous route is preferred for terminating seizures and thus, where IV access can be gained rapidly, this should be the first choice. Compared with IV diazepam, rectal diazepam is easier to administer, especially in infants and toddlers; is equally efficacious; and is less likely to produce respiratory depression which is why the rectal route is preferred in children, while the I route is sought. Method Consider the PR route when IV access cannot be rapidly and safely obtained In small children the PR route should be considered the first choice treatment and IV access sought subsequently Although respiratory depression is rare with rectal diazepam, clinicians must be prepared to provide respiratory support. There is no value in giving diazepam preventatively if the fit has ceased. In any clearly sick or ill child, there should be a minimal delay at the scene. If it is essential to give diazepam, this should be done en-route to hospital, where possible.
RECTAL DIAZEPAM v2.0 4/6 Patients aged 80 years and over are often particularly sensitive to the effects of central depressant drugs and may experience confusion, especially if organic brain changes are present; the dosage of diazepam is therefore one-half of that recommended for younger adults. Post ROSC Management Administer as per CG07 http://intranet.swast.nhs.uk/swasft%20instructions/swasft%20c nical%20guidelines/cg07_cardiac_arrest.pdf Rectal doses (British National Formulary, 64, September 2013) Dose AGE Adult (12 years and over) Elderly > 80 years Child 2 11 yrs Child MAXIMUM INITIAL RECTAL DOSE* (Maximum dose that may be given in conjunction with an IV dose) DOSE INTERVA L 10mg 10 minutes Concentration 5mg in 2.5ml RECTAL TUBES 2 X 5mg TOTAL MAXIMUM RECTAL DOSE (Maximum dose that may be given if patient cannot be cannulated so IV dose not possible) 20mg 5mg 10 minutes 5mg in 2.5ml 1 X 5mg 10mg 5-10mg 10 5mg in 1or2 X 20mg minutes 2.5ml 5mg <2yrs * minutes 2.5ml 2.5mg 2.5-5mg 10 2.5mg in 1or2 X 10mg Birth ** 1.25-10 2.5mg in A half 5mg 2.5mg minutes 2.5ml to 1 X 2.5mg * The Initial rectal dose is the maximum rectal dose that may be given before an intravenous dose. * * Rectal tubes are not licensed for children under one year but prehospital use is supported by JRCALC 2013.
RECTAL DIAZEPAM v2.0 5/6 IV Doses See JRCALC An initial rectal dose may be repeated rectally every 10mins if still fitting until the total maximum rectal dose is administered. If the total maximum rectal dose is given then an intravenous dose may not be administered. If patient receives up to the maximum initial rectal dose and is subsequently cannulated, a single IV dose may be given but this must be titrated slowly to effect. Frequency Maximum Dose Summary Intravenous only dose Administer dose as per JRCALC, i.e. Adults & children aged 12 years and over given only IV diazepam may be administered up to 20mg. Children 11 years and under given IV diazepam only, dose as chart. Rectal dose followed by an intravenous dose Administer up to the maximum initial rectal dose then administer intravenous dose as per JRCALC, e.g Adults & children aged 12 years and over given up to initial rectal dose of diazepam (10mg maximum) + IV diazepam from JRCALC 10mg (single dose). Total diazepam dose 20mg. Children 11 years and under given rectal diazepam + IV diazepam: Birth: rectal diazepam up to total initial rectal dose 2.5mg + JRCALC IV dose diazepam 1mg. Total diazepam dose 3.5mg. Child<2 years: rectal diazepam up to total initial rectal dose 5mg + JRCALC IV dose diazepam for age as per chart. Child 2 to 11 years: rectal diazepam up to total initial rectal dose 10mg + JRCALC IV dose diazepam for age as per chart. Duration of treatment Single episode of care Follow Up Referral arrangements The senior clinician on scene is responsible for deciding whether admission to an ED is required. Reference must be made to Trust
and safety netting Advice to patients Records RECTAL DIAZEPAM v2.0 6/6 and JRCALC guidance. Only patients with known epilepsy who make a full recovery and who can be adequately supervised should be considered to be left at home. Ensure that there is a communication to the patient s registered GP to inform him/her about the consultation, the outcomes of that consultation and any treatment given using local mechanisms. This information must also be available to other healthcare professionals who may be required to administer care to the patient following the consultation. Request follow-up where necessary. Where arrangements exist for patients to be left at home they must be left in the care of a responsible adult. The responsible adult must be told to call 999 immediately if the patient experiences further seizures or their condition deteriorates in any way. Diazepam may cause drowsiness which can persist until the following day. If the patient is left at home, advise them not to drive or operate machinery if affected. The sedative effect is increased by taking alcohol, opioid analgesics, antihistamines, antipsychotics, some antivirals, certain ulcer healing drugs (esomeprazole and omeprazole) and other muscle relaxants such as baclofen or tizanidine. Advise the patient that diazepam interacts with most antihypertensive drugs to increase their hypotensive effect which may make them feel light-headed or dizzy. Ensure patient receives a manufacturer s patient information; leaflet and discuss where necessary; Advise not to drive or operate machinery for a full day after treatment Complete patient clinical record Diazepam is a lower schedule controlled drug. Staff must carry out a stock check when supplying or administering this drug. Any discrepancy in the stock level that is discovered must be reported to your line manager and an investigation instigated as detailed in the Trust s Medicines Management Policy. References British National Formulary (BNF) 68 September 2014 to March 2015 UK Ambulance Service Clinical Practice Guidelines 2013 (JRCALC)