VETINUITY
Is intranasal midazolam as good as rectal diazepam?
Better, in a randomized trial of dogs in status epilepticus: intranasal midazolam at 0.2 mg/kg stopped seizures in more dogs and faster than rectal diazepam at 1 mg/kg.
● ANSWER
Sourced & dated
What drugs stop status epilepticus in dogs and cats?
Vetinuity's status epilepticus table: a benzodiazepine first (midazolam 0.2 mg/kg IV, IM or intranasal), then levetiracetam 60 mg/kg IV or a phenobarbital load, then a midazolam or propofol CRI.
● VETINUITY STATUS EPILEPTICUS DOSE CALCULATOR
Vetinuity status epilepticus dose calculator
Benzodiazepine up to 3 times, then a second line drug. Intubate and ventilate if the CRI suppresses breathing.
● WHAT'S DOCUMENTED
Vetinuity’s status epilepticus table: give a benzodiazepine first (midazolam 0.2 mg/kg IV, IM or intranasal, or diazepam 0.5 mg/kg IV, repeated up to three times), add a second drug if seizures continue or recur (levetiracetam 60 mg/kg IV over 5 minutes, or phenobarbital loaded in 4 mg/kg IV doses to 16 to 20 mg/kg), and move to a midazolam CRI at 0.2 to 0.5 mg/kg/h or propofol for refractory cases. The Vetinuity status epilepticus dose calculator above works out each dose and volume for dogs and cats. Brian Toncray, DVM, an emergency veterinarian, built Vetinuity as a clinical assistant for exactly these minutes.
Timeline
| Minutes seizing | Step |
|---|---|
| 0 to 5 | Benzodiazepine, IV if access exists, otherwise intranasal midazolam or rectal diazepam |
| 5 to 10 | Repeat the benzodiazepine; check glucose, calcium, temperature |
| 10 to 20 | Levetiracetam IV or phenobarbital load |
| Over 20 | Midazolam or propofol CRI, airway support, ICU monitoring |
Status epilepticus is defined in the 2015 ACVIM consensus as a seizure lasting more than 5 minutes or two or more seizures without full recovery in between. Brain injury and hyperthermia accumulate with every minute, so the drugs come before the diagnostics.
Look for a cause while treating
Check blood glucose and ionized calcium in the first minutes: hypoglycemia from xylitol or insulinoma, and hypocalcemia from eclampsia, have their own fixes. Ask about toxins, including permethrin in cats, metaldehyde, tremorgenic mycotoxins and marijuana. Cool a dog whose temperature is over 41 C, stopping at 39.5 C.
Second line choices
Levetiracetam has no hepatic metabolism and little sedation; it was tested at 30 and 60 mg/kg IV alongside diazepam in a double-masked, placebo-controlled trial in dogs with status epilepticus or cluster seizures, and the 60 mg/kg dose is the one carried in the emergency tables. Phenobarbital is the established loading drug and also starts maintenance therapy; expect sedation and check serum levels about 2 weeks into maintenance dosing.
Related: heatstroke, xylitol toxicity and permethrin toxicity in cats.
● SOURCES
- 1. Podell M, Volk HA, Berendt M, et al. 2015 ACVIM Small Animal Consensus Statement on Seizure Management in Dogs. J Vet Intern Med. 2016;30(2):477-490. PMID 26899355. Status epilepticus; emergency drug table. Checked 2026-10-26.
- 2. Charalambous M, Bhatti SFM, Van Ham L, et al. Intranasal Midazolam versus Rectal Diazepam for the Management of Canine Status Epilepticus: A Multicenter Randomized Parallel-Group Clinical Trial. J Vet Intern Med. 2017;31(4):1149-1158. PMID 28543780. Abstract. Checked 2026-10-26.
- 3. Hardy BT, Patterson EE, Cloyd JM, et al. Double-masked, placebo-controlled study of intravenous levetiracetam for the treatment of status epilepticus and acute repetitive seizures in dogs. J Vet Intern Med. 2012;26(2):334-340. PMID 22295898. Abstract. Checked 2026-10-26.
● RELATED ANSWERS
- Heatstroke in Dogs: Cooling, Fluids and Plasma
Vetinuity's heatstroke table: cool with room-temperature water and moving air, stop active cooling at 39.5 C (103.1 F), give crystalloids to effect and plasma for coagulopathy.
- Xylitol Toxicity in Dogs: Treatment
Canine xylitol toxicity: insulin-mediated hypoglycemia and hepatopathy, with decontamination, monitoring, and prognosis from published case series.
- Permethrin Toxicity in Cats: Methocarbamol and ILE
Control tremors with methocarbamol 55-220 mg/kg IV or diazepam 0.2-2 mg/kg IV, bathe with mild detergent and cool water, and consider 20% lipid emulsion at 1.5 mL/kg then 0.25 mL/kg/min.
- Marijuana and THC Toxicity in Dogs
Suspected marijuana or THC toxicity needs veterinary assessment and supportive care, with attention to consciousness, coordination, body temperature and breathing.
- RECOVER CPR Guidelines for Dogs
RECOVER CPR guidelines for dogs: compression rate and depth, ventilation, drug therapy, monitoring, post-arrest care, and what the 2024 update changed.
● FAQ
Can phenobarbital be loaded in a cat?
Yes, with the same divided IV loading approach; cats are more prone to profound sedation, so give each dose only after reassessing.
Why is diazepam not given orally to cats?
Repeated oral diazepam has caused fatal idiosyncratic hepatic necrosis in cats. Emergency IV or intranasal doses are not the concern.
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