Seizure rescue medications: routes, monitoring and caregiver teaching

Match the route to the setting and the person giving it

Outside hospital, rescue medicines are designed for caregivers who cannot place an IV. Rectal diazepam gel comes in a prefilled syringe with a plastic tip and is given with the person lying on their side. Intranasal midazolam and diazepam sprays are given into the nostril, and buccal diazepam film is placed inside the cheek, where it dissolves without being chewed or swallowed.

In hospital, an IV benzodiazepine is often used because access is already established and the response can be titrated under the local status epilepticus pathway. The exam point is that the route follows the setting: an individual seizure action plan names the specific product, route and circumstances for use, and the nurse follows that plan rather than improvising.

Build the caregiver plan around timing and position

A written seizure action plan should state what the usual seizures look like, when the rescue medicine is used, and what to do afterwards. Teach caregivers to time the seizure from its start, keep the person safe from injury and avoid putting anything in the mouth other than a prescribed buccal product placed as directed.

Turning the person onto their side protects the airway and is the position used for rectal administration. Caregivers should practise with a trainer device or demonstration where available, and the nurse should confirm technique with teach-back. Check expiry dates, storage away from children and that a supply travels with the person to school, respite care and on trips.

Families also need a plan for what happens after the seizure stops. Teach them to stay with the person until fully alert, to note any injury, and to avoid giving food or drink until swallowing is clearly safe. A follow-up call with the nurse or prescriber after any rescue use helps review whether the plan worked.

Monitor breathing and sedation after every dose

Benzodiazepines can cause serious or life-threatening breathing problems, profound drowsiness or coma, and the risk increases when they are combined with opioid pain or cough medicines, alcohol or other sedatives. After a rescue dose, stay with the person, keep them on their side and watch breathing rate, effort and colour until they are rousable and back to their usual state.

Teach caregivers that sleepiness after a seizure is expected, but slow or difficult breathing, blue or grey lips, or unresponsiveness is an emergency. Product information advises calling emergency services if a seizure continues a set time after the dose, if seizures worsen, or if breathing or skin colour changes. A second dose is given only when the plan explicitly allows it.

Recognise misuse, dependence and documentation needs

Rescue benzodiazepines can be habit-forming, and frequent use suggests that maintenance seizure control needs review. Teach families not to use the medicine more often than the prescriber has authorised and to record every use. A log showing date, time, seizure length, product used and the response gives the neurology team evidence for adjusting treatment.

Ask about other sedating medicines at each review, including newly prescribed opioids after surgery or injury. School nurses and care staff need current copies of the plan and training records. In hospital, document seizure onset, the time of administration, vital signs and recovery so the team can judge whether escalation to a second-line agent is needed.

Work a hypothetical caregiver scenario

Imagine a hypothetical child at school whose tonic-clonic seizure has continued past the time named in the action plan. The choices are to wait for the parent, to give the prescribed intranasal midazolam and then monitor, or to place the child upright so the spray reaches the nose. Giving the prescribed rescue medicine according to the plan and monitoring is strongest, because prolonged seizures need prompt treatment.

Waiting for the parent delays care the plan already authorises. Sitting a convulsing child upright risks injury and airway compromise. After the dose the child is kept on their side, breathing is observed continuously, and emergency services are called according to the plan if the seizure persists or breathing becomes slow or laboured.

Sources and further reading

MedlinePlus: Diazepam Rectal. Caregiver administration, side-lying position, breathing and sedation risks with opioids, and when to call emergency services.

MedlinePlus: Midazolam Nasal Spray. Emergency seizure use, second dose only as directed, habit-forming risk and emergency warning signs.

MedlinePlus: Diazepam Buccal. Film placed inside the cheek to dissolve, breathing and sedation warnings and limits on frequency of use.