For patients with no IV access, other options are available Midazolam is reliably and rapidly absorbed intramuscularly at the above dosing Diazepam can also be given as a rectal gel PR at a dose of 0.2 to 0.5 mg/kg/dose with a maximum dose of 20 mg/dose Both intranasal and buccal routes of midazolam have been described with successful cessation of seizures, often in prehospital settings These modes of administration should be reserved for providers who have administered intranasal or buccal medication in the past, rather than have their first attempt of using these routes on an actively seizing child (Fig 72.2 ) Diazepam has an advantage in that it can be given rectally, which is useful when a patient does not have IV access A rectal gel is available in fixed doses of 5, 7.5, 10, 12.5, 15, 17.5, or 20 mg The IV preparation of the drug may be used alternatively Recommended rectal dosing for children up to years of age is 0.5 mg/kg Midazolam can be given intramuscularly (0.2 mg/kg/dose; not to exceed a cumulative dose of 10 mg) and should be considered if there is delay in IV access Midazolam has a theoretical advantage in that patients will return to baseline more quickly than with lorazepam or diazepam, thus allowing for better assessment of mental status and the need for CT scan and/or LP Phenytoin (Dilantin) is a second-line agent for the treatment of seizures Phenytoin blocks sodium channels and thus acts by a different mechanism than the benzodiazepines The dose is 15 to 20 mg/kg as an initial load It has several limitations as compared with the benzodiazepines First, peak CNS concentrations may not be reached until 10 to 30 minutes after its infusion is completed and, thus, it is much slower in onset Furthermore, it must be administered slowly (no faster than mg/kg/min, or 20 minutes for a dose of 20 mg/kg) because of concerns of cardiac conduction disturbances It cannot be given in dextrose-containing solutions As a result of the limitations in the administration of phenytoin, fosphenytoin (Cerebyx) was created It is a prodrug whose active metabolite is phenytoin The drug is dosed as phenytoin equivalents (PEs), and the loading dose is 15 to 20 mg PE/kg The advantages are that it can be given much more rapidly (up to mg PE/kg/min, or minutes for a dose of 20 mg PE/kg) and that it may be given in either normal saline or a 5% dextrose-containing solution or intramuscularly Phenobarbital (Luminal) is another second-line agent for the treatment of seizures The loading dose is 10 to 20 mg/kg Its advantage over phenytoin is that it can be given more rapidly (2 mg/kg/min, or 10 minutes for a dose of 20 mg/kg) However, it has an extremely long half-life (up to 120 hours) and a pronounced