India · Acute Seizure · Status Epilepticus · Febrile Seizure · Anxiety · Muscle Spasm · Procedural Sedation · Calmpose · Valium
⛔ Respiratory depression — have BVM ready
⛔ Max IV rate: 2 mg/min (adults); 1 mg/min (children)
⚠️ Dependence with prolonged use (>4 weeks)
⚠️ Elderly: halve all doses — prolonged sedation
⚠️ Avoid with alcohol, opioids, other CNS depressants
⚠️ Pregnancy (1st trim): cleft palate risk; 3rd trim: neonatal withdrawal
| Indication | Paediatric dose | Adult dose | Route | Max |
|---|---|---|---|---|
| Acute seizure / febrile seizure | 0.25–0.5 mg/kg | 10 mg | IV or rectal | 10 mg/dose child; 20 mg adult |
| Status epilepticus (1st line) | 0.3–0.5 mg/kg IV | 10–20 mg IV | IV (preferred) | May repeat once after 10 min |
| Rectal (no IV access) | 0.5 mg/kg rectal | 10–20 mg rectal | Rectal tube | 20 mg total |
| Eclampsia seizure | — | 10 mg IV slowly | IV | Repeat once; MgSO4 preferred |
| Anxiety (short-term, adult) | — | 2–10 mg BD–QDS | Oral | 30 mg/day; max 4 weeks |
| Muscle spasm | — | 5–10 mg TDS–QDS | Oral | 30 mg/day |
| Alcohol withdrawal | — | 10–20 mg oral/IV reducing over 5–7 days | Oral or IV | As per CIWA protocol |
| Procedural sedation (adult) | 0.1–0.2 mg/kg IV | 5–10 mg IV titrated | IV slow | 20 mg total |
| Tetanus spasm control | 0.1–0.3 mg/kg IV PRN | 5–15 mg IV PRN | IV or oral | ICU titrated — specialist |
Diazepam (Calmpose, Valium) remains one of the most widely used benzodiazepines in Indian emergency medicine, neurology, and psychiatry. It is first-line for acute seizures and status epilepticus in pre-hospital and emergency settings where IV lorazepam is unavailable — which is the case in most Indian districts. Its anticonvulsant effect is rapid (onset 1–3 minutes IV) but its long half-life (20–100 hours) and active metabolites mean sedation can persist for many hours after an acute dose, particularly in children and the elderly.
In a child actively seizing in the community or on arrival to hospital without IV access, rectal diazepam is the most practical and effective route. Stesolid rectal tubes (5mg and 10mg) allow rapid administration without IV insertion in a convulsing child. The rectal dose is 0.5 mg/kg (maximum 10 mg in children under 5, 20 mg in older children). Insert the tube into the rectum and hold the buttocks together for 2–3 minutes to ensure absorption. When IV access is established, IV diazepam 0.25–0.5 mg/kg should be the route of choice. IM diazepam has erratic absorption and is less preferred — midazolam IM is a better alternative where available.
Diazepam is first-line for status epilepticus (seizure lasting >5 minutes or two seizures without recovery) per IAP guidelines. After one IV dose of 0.3–0.5 mg/kg, if seizure continues after 5–10 minutes, repeat once. If seizure persists after two diazepam doses (total ~30 minutes of seizure): add IV phenytoin or IV valproate as the second-line agent. Diazepam does not maintain seizure control long-term (effect wanes as drug redistributes out of the CNS) — phenytoin provides sustained coverage after the acute phase. Always have bag-mask ventilation immediately available and monitor SpO2 throughout.
Diazepam should be used for anxiety only for the shortest possible period. Tolerance develops within 2–4 weeks, after which the same dose provides less anxiolytic benefit. Physical dependence develops, and abrupt discontinuation after more than 4–6 weeks of regular use causes a severe withdrawal syndrome (anxiety, insomnia, tremor, and in severe cases, seizures). In India, long-term benzodiazepine use for anxiety is extremely common and represents a significant public health problem. SSRIs (sertraline, escitalopram) are the appropriate long-term treatment for anxiety disorders.