Levetiracetam Clonazepam midazolam diazepam it's mechanism dose indications contraindications how to give how munch to dilute in emergency side effects in easy way table form detail in easy way
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Emergency seizure medicines: simple comparison table
For trained clinicians only. A convulsive seizure lasting 5 minutes or more, or repeated seizures without regaining consciousness, is an emergency. Give oxygen, monitor ECG/BP/SpO₂, check glucose, obtain IV/IO access, and be ready for bag-mask ventilation. Do not delay first-line benzodiazepine while obtaining access. After 2 adequate benzodiazepine doses, move to a second-line antiseizure drug such as levetiracetam. This sequence is consistent with NICE status epilepticus guidance.
| Medicine | Main role in emergency seizure | Easy mechanism |
|---|---|---|
| Midazolam | Fast first-line treatment when no IV access: IM, intranasal, buccal. Can also be IV. | A benzodiazepine. It strengthens the brain’s natural “brake,” GABA-A, by increasing chloride-channel opening. |
| Diazepam | Fast first-line treatment, especially IV or rectal when appropriate. | Same benzodiazepine mechanism as midazolam. Stops seizure quickly but its anticonvulsant action may wear off, so follow with a longer-acting antiseizure drug. |
| Clonazepam | IV alternative first-line benzodiazepine in some countries/hospitals. Often used for some seizure types long term too. | Same GABA-A “brain brake” mechanism. |
| Levetiracetam | Second-line loading medicine after benzodiazepines, or early alongside them in prolonged seizures. | Binds SV2A, a protein on nerve-vesicle terminals. This reduces excessive release of excitatory neurotransmitters. |
1. Emergency doses and administration
A. Benzodiazepines: give first
| Drug and route | Adult emergency dose for ongoing convulsive seizure/status epilepticus | Pediatric emergency dose | How to give | Repeat? |
|---|---|---|---|---|
| Midazolam IM | 10 mg IM once if >40 kg | 0.2 mg/kg IM, maximum 10 mg | Inject into lateral thigh or deltoid. Best option when IV access is delayed. | Usually one adequate dose, then follow protocol. |
| Midazolam IV | 0.1 to 0.2 mg/kg IV, usual maximum 10 mg | 0.1 to 0.2 mg/kg IV, max 10 mg | Give slowly over about 2 minutes with respiratory monitoring. | May repeat once after 5 minutes if seizure continues and local protocol permits. |
| Midazolam intranasal (IN) | 0.2 mg/kg IN, maximum 10 mg | 0.2 mg/kg IN, maximum 10 mg | Divide dose between both nostrils. Use a mucosal atomization device if available. | One repeat dose may be used after 5 to 10 min according to protocol. |
| Diazepam IV | 0.15 to 0.2 mg/kg IV, usual maximum 10 mg per dose | 0.15 to 0.2 mg/kg IV, maximum 10 mg | Give slowly, about 5 mg/min maximum. Use a large vein if possible. | May repeat once after 5 minutes. |
| Diazepam rectal | 0.2 mg/kg PR, maximum 20 mg | 0.2 to 0.5 mg/kg PR, depending on age/weight and product protocol | Use prefilled rectal gel if available. Useful outside hospital or with no IV access. | May repeat after 4 to 12 h only as product/local protocol states. |
| Clonazepam IV | 1 mg IV slow, often at 0.5 mg/min | Specialist/local pediatric protocol required. A commonly used reference dose is 0.05 mg/kg IV slow, maximum commonly 1 mg per dose. | Give slowly with full airway and cardiovascular monitoring. | Repeat only under local protocol/senior supervision. |
Key point: Do not keep giving small benzodiazepine doses repeatedly. Two adequate doses can cause respiratory depression without stopping the seizure. Then give levetiracetam, fosphenytoin, or valproate as second-line therapy. Textbook sources describe benzodiazepines as the immediate agent followed by a longer-acting antiseizure medicine, and list levetiracetam 60 mg/kg, maximum 4,500 mg, as a common second-line load in established status epilepticus. See Rosen's Emergency Medicine, and Lippincott Illustrated Reviews: Pharmacology.
B. Levetiracetam: give after benzodiazepine
| Use | Adult dose | Pediatric dose | How to give |
|---|---|---|---|
| Established convulsive status epilepticus | 60 mg/kg IV loading dose, maximum 4,500 mg | 60 mg/kg IV, maximum 4,500 mg | Infuse over 10 to 15 minutes. Do not delay this after 2 benzodiazepine doses. |
| IV replacement for usual oral therapy, not an acute loading dose | Usually 500 to 1,500 mg IV every 12 h, matching the oral regimen | Weight and indication dependent | Give as a 15-minute IV infusion. Adjust maintenance doses in renal impairment. |
Levetiracetam is mainly renally eliminated and has few drug interactions, but maintenance dosing requires renal adjustment. The FDA labeling describes a 100 mg/mL injection that must be diluted for infusion and gives a 15-minute administration time in standard use. See the FDA levetiracetam injection label.
2. Dilution table: what to dilute and how much
Always check the exact vial strength and your hospital compatibility chart before drawing up. Brand formulations differ.
| Drug | Usual injection strength | Dilution needed? | Practical emergency administration |
|---|---|---|---|
| Levetiracetam IV | 100 mg/mL | Yes, dilute before IV infusion. Compatible diluents commonly include 0.9% saline, 5% dextrose, or lactated Ringer’s, depending on product label. | A simple common method: add the calculated dose to a 100 mL compatible infusion bag and run over 10 to 15 min. Some product labels allow final concentrations of about 15 to 100 mg/mL. |
| Midazolam IV/IM/IN | Commonly 1 mg/mL or 5 mg/mL | Usually no dilution is needed for IV seizure bolus. | Give the calculated IV dose slowly. For IN use, use the concentrated preparation, commonly 5 mg/mL, to keep nasal volume low. Do not use a large-volume dilute solution intranasally. |
| Diazepam IV | Commonly 5 mg/mL | Do not routinely dilute. Diazepam may precipitate in IV fluids. | Give slowly through a large vein, preferably directly into a running compatible IV line if local protocol permits. Flush line before and after. |
| Clonazepam IV | Often 1 mg/mL, may come with diluent depending on country/product | Product-dependent. Some preparations require reconstitution or dilution immediately before use. | Follow the specific ampoule label. Give slowly. Avoid mixing with other drugs in the same syringe. |
Levetiracetam calculation examples
| Patient weight | Status dose: 60 mg/kg | Maximum rule | Volume if vial is 100 mg/mL | Easy dilution |
|---|---|---|---|---|
| 15 kg | 900 mg | Below maximum | 9 mL | Add 9 mL to compatible IV fluid, often a 100 mL bag, infuse 10 to 15 min |
| 30 kg | 1,800 mg | Below maximum | 18 mL | Add 18 mL to compatible IV fluid, infuse 10 to 15 min |
| 50 kg | 3,000 mg | Below maximum | 30 mL | Add 30 mL to compatible IV fluid, infuse 10 to 15 min |
| 80 kg | 4,800 mg | Cap at 4,500 mg | 45 mL | Add 45 mL to compatible IV fluid, infuse 10 to 15 min |
Formula:
Levetiracetam volume in mL = prescribed dose in mg ÷ vial concentration in mg/mLFor a 100 mg/mL vial:
- 500 mg = 5 mL
- 1,000 mg = 10 mL
- 1,500 mg = 15 mL
- 3,000 mg = 30 mL
- 4,500 mg = 45 mL
3. Indications
| Drug | Common emergency indications | Other common uses |
|---|---|---|
| Midazolam | Ongoing convulsive seizure, status epilepticus, seizure cluster, especially when no IV access | Procedural sedation, induction of anesthesia, ICU sedation |
| Diazepam | Ongoing seizure/status epilepticus, seizure clusters, rectal rescue treatment | Muscle spasm, alcohol withdrawal, acute anxiety in selected settings |
| Clonazepam | Status epilepticus where IV clonazepam is part of local protocol | Adjunct treatment of absence, myoclonic, atonic, and other difficult-to-control seizures |
| Levetiracetam | Second-line medicine for convulsive status epilepticus after benzodiazepines | Focal seizures, generalized tonic-clonic seizures, myoclonic seizures |
4. Contraindications and major cautions
In a life-threatening seizure, there are few absolute reasons to withhold a benzodiazepine. Instead, administer it while preparing airway support.
| Drug | Do not give / major caution | Practical meaning |
|---|---|---|
| Midazolam | Known allergy to benzodiazepines; severe respiratory depression without airway support; shock/coma; acute narrow-angle glaucoma | Seizure may still require treatment, but have oxygen, suction, bag-mask, and advanced airway support ready. |
| Diazepam | Benzodiazepine allergy; severe respiratory insufficiency, sleep apnea, myasthenia gravis, severe hepatic impairment, acute narrow-angle glaucoma | Use great caution with opioids, alcohol, or other sedatives because respiratory arrest risk rises. |
| Clonazepam | Benzodiazepine allergy; severe liver disease; significant respiratory depression; acute narrow-angle glaucoma | Same major sedation and respiratory risks as other benzodiazepines. |
| Levetiracetam | Known levetiracetam allergy | Reduce maintenance dose in renal impairment. IV loading is often still used in emergency status epilepticus, but discuss with senior clinician/pharmacy in severe renal failure. Watch for behavioral adverse effects. |
5. Side effects to watch for immediately
| Drug | Common effects | Dangerous effects: act now |
|---|---|---|
| Midazolam | Drowsiness, confusion, poor coordination, low BP | Slow or stopped breathing, low oxygen, apnea, hypotension, paradoxical agitation |
| Diazepam | Drowsiness, confusion, ataxia, fatigue | Respiratory depression/apnea, hypotension, injection-site phlebitis, especially with rapid IV use |
| Clonazepam | Drowsiness, dizziness, ataxia, excessive secretions | Respiratory depression, hypotension, prolonged sedation |
| Levetiracetam | Sleepiness, dizziness, weakness, headache | Agitation, irritability, aggression, mood change, hallucinations or psychosis rarely; allergy/anaphylaxis very rarely |
6. Simple emergency sequence
| Time | What to do |
|---|---|
| 0 to 5 min | ABCDE. Position patient safely, oxygen, suction, monitor, bedside glucose, call for help. Do not restrain and do not place objects in mouth. |
| At 5 min or ongoing convulsion | Give one adequate benzodiazepine dose: IM/IN midazolam if no IV, or slow IV diazepam/midazolam if IV available. |
| 5 to 10 min later | If still convulsing, give a second adequate benzodiazepine dose as per local protocol. |
| After 2 benzodiazepine doses | Give levetiracetam 60 mg/kg IV, maximum 4,500 mg, over 10 to 15 min. Consider alternatives per protocol: fosphenytoin or sodium valproate. |
| Persistent seizure | Refractory status epilepticus: ICU/anaesthesia/neurology urgently, continuous EEG if available, airway control and anesthetic infusion protocol. |
High-yield memory aid
- Midazolam / diazepam / clonazepam = fast seizure stopper
- Levetiracetam = longer-acting seizure controller
- Benzodiazepines can stop breathing, so monitor airway continuously.
- Levetiracetam must be diluted for IV infusion.
- Diazepam usually should not be diluted because it can precipitate.
- Do not exceed two benzodiazepine doses before escalating.
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Simple emergency seizure drug table
Emergency seizure = seizure lasting 5 minutes or repeated seizures without waking up.
Call senior help, give oxygen, check blood sugar, monitor breathing, pulse and BP.
Call senior help, give oxygen, check blood sugar, monitor breathing, pulse and BP.
| Medicine | Easy job | How it works | Emergency dose | How to give / dilute | Main danger |
|---|---|---|---|---|---|
| Midazolam | First medicine to quickly stop seizure, especially if no IV line | Increases GABA, the brain’s natural “brake” | IM or IN: 0.2 mg/kg, max 10 mg. Adults >40 kg: often 10 mg IM | IM: inject into thigh. IN: divide between both nostrils. Usually no dilution for emergency dose. | Sleepiness, low BP, slow breathing/apnea |
| Diazepam | Fast seizure stopper when IV access is present, or rectally if no IV | Same as midazolam: increases GABA brain brake | IV: 0.15 to 0.2 mg/kg, max 10 mg. Rectal: usually 0.2 to 0.5 mg/kg depending on product/age | IV slowly, maximum about 5 mg/min. Do not routinely dilute because it can form crystals. | Respiratory depression, low BP, drowsiness |
| Clonazepam | Alternative seizure stopper in some hospitals/countries | Same GABA brain brake | Adult: 1 mg IV slow, often at 0.5 mg/min. Pediatric dose must follow local protocol. | Give slow IV. Dilution depends on the brand/ampoule, so check its label. | Slow breathing, low BP, prolonged sleepiness |
| Levetiracetam | Second medicine to prevent seizure returning after benzodiazepines | Reduces excessive electrical signaling in the brain by acting on SV2A | 60 mg/kg IV, maximum 4,500 mg | Usually vial is 100 mg/mL. Add calculated dose to compatible IV fluid, commonly 100 mL normal saline, and infuse over 10 to 15 min. | Sleepiness, dizziness, agitation/irritability, rare allergy |
Easy order to remember
- Midazolam or diazepam or clonazepam = fast seizure stopper
- If seizure continues after 5 to 10 minutes, a second benzodiazepine dose may be given according to local protocol.
- After 2 proper benzodiazepine doses, give levetiracetam IV.
- Do not keep giving benzodiazepines again and again because they can stop breathing.
This escalation is consistent with NICE seizure emergency guidance.
Levetiracetam easy calculation
If injection strength is 100 mg/mL:
| Dose needed | Take from vial |
|---|---|
| 500 mg | 5 mL |
| 1,000 mg | 10 mL |
| 1,500 mg | 15 mL |
| 3,000 mg | 30 mL |
| 4,500 mg maximum | 45 mL |
Formula:
Dose in mg ÷ 100 = volume in mLExample:
Patient weight = 50 kg
Dose = 50 × 60 = 3,000 mg
Volume = 3,000 ÷ 100 = 30 mL
Then dilute in compatible fluid and run over 10 to 15 minutes.
Patient weight = 50 kg
Dose = 50 × 60 = 3,000 mg
Volume = 3,000 ÷ 100 = 30 mL
Then dilute in compatible fluid and run over 10 to 15 minutes.
Important cautions
| Drug | Avoid / be very careful in |
|---|---|
| Midazolam, diazepam, clonazepam | Severe breathing problem, opioid/alcohol use, low consciousness, low BP, benzodiazepine allergy |
| Levetiracetam | Allergy to levetiracetam. Reduce regular maintenance dose in renal impairment. |
Most important: Benzodiazepines can cause apnea. Keep suction, oxygen, bag-mask ventilation, and airway help ready before or immediately after giving them. Local hospital protocol and the exact vial label always take priority.
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