Review of the efficacy of rectal paraldehyde in the management of acute and prolonged tonic–clonic convulsions

Introduction: The aim of this prospective audit was to assess the effectiveness and safety of rectal paraldehyde in the management of acute, including prolonged, tonic-clonic convulsions. There are very limited published data on its effectiveness and safety and previous data have focused on its intramuscular route of administration. Methods: Four hospitals participated in the study. Information was collected on each dose of paraldehyde used for the treatment of a tonic-clonic convulsion over one year. Data were not included on patients treated with rectal paraldehyde for other seizure types or non-convulsive status epilepticus. Results: Data analysis was undertaken in 53 episodes in 30 patients. Patient’s ages ranged from 5 months to 16 years (mean 6.12 years and median 5.91 years). A pre-existing diagnosis of epilepsy was recorded in 35 episodes (66%). The mean dose of paraldehyde was 0.65ml/kg (standard deviation 0.22 ml/kg, 95% confidence interval +/- 0.06ml/kg) and median dose 0.79ml/kg. Rectal paraldehyde terminated the convulsion in 33 (62.3%) of the 53 episodes. In the 35 episodes where a pre-existing diagnosis of epilepsy was recorded, paraldehyde stopped the convulsion on 26 (74.3%) occasions. There was no difference in the dose of paraldehyde between the episodes where the convulsion was or was not terminated. There was no recorded respiratory depression in any episode. Conclusions: This study provides unique evidence that supports the belief that rectal paraldehyde is effective and safe in treating acute prolonged tonic-clonic convulsions. This would appear to confirm that paraldehyde should remain a treatment for the management of prolonged tonic-clonic convulsions, including convulsive status epilepticus.