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First Line Therapy in Acute Seizure Management: Focusing on the Pediatric Patient

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Title: First Line Therapy in Acute Seizure Management: Focusing on the Pediatric Patient


1
First Line Therapy in Acute Seizure Management
Focusing on the Pediatric Patient
  • William C. Dalsey, MD, FACEP, MBA
  • Department of Emergency Medicine
  • Robert Wood Johnson University Hospital
  • New Jersey

2
Case Presentation
  • A seven year old with spina bifida and arnold
    chiari fell and hit her head. She has
    intermittent generalized tonic clonic seizures
    without return to baseline. IV access cant be
    obtained.

3
Critical Questions
  • How do you evaluate and treat a pediatric patient
    with a seizure?
  • What is this best first-line treatment?
  • What if I cant obtain IV access?
  • Complicating Factors Status Epilepticus?
    Hypoxia, Hypoglycemia, Febrile Seizures

4
What does the literature support?
  • Class A recommendation both diazepam followed
    by phenytoin or the use of lorazepam are
    acceptable acute treatment strategies
  • Is lorazepam better?

Treiman. NEJM 1998 339792-798
5
What else does the literature show?
  • Class B Recommendations
  • 1. All benzodiazepines are highly effective. In
    pediatric patients lorazepam may be preferred due
    to less risk of respiratory suppression


Treiman. Epilepsia 1989304-10 Prensky. NEJPM
1967 276779-784 Leppik. JAMA 1983 2491452-1454
6
Class B Evidence
  • Phenobarbital is an effective alternative to the
    use of phenytoins in status epilepticus.

Treiman. NEJM 1998 339792-798
7
Class C Evidence
  1. Fosphenytoin is water soluble and may be
    preferred over phenytoin when safety concerns or
    speed of administration are concerns
  2. High dose phenytoins to 30 mgt/kg may be more
    effective in treating status than standard doses
  3. IV propofol or barbituates may be considered in
    refractory status

8
Do the Clinical Guidelines Address Our Patient?
  • What do they say?
  • What dont they tell us?

9
If you have no IV access, are there alternatives
routes for benzodiazepines administration?
  • Intranasal (Midazolam)
  • Buccal (Midazolam)
  • IM (Lorazepam, Midazolam)
  • Rectal (Diazepam, Midazolam)
  • ET (Diazepam)

10
Rectal Diazepam
  • Diazepam well absorbed rectally gel or solution
    better than suppositories
  • Tmax 17 minutes with therapeutic effect earlier
  • May provide longer acting anticonvulsant effect
    than intravenous administration due to slower
    absorption rate
  • Has been used effectively by EMS
  • Double blind placebo controlled studies have
    demonstrated its effectiveness

Dieckmann. Ann Emerg Med 1994 23216-224 Cereghin
o. Neurology 1998511274-1282 Remy. Epilepsia
199222(2)3530358
11
Rectal Diazepam
  • Dosing is age dependent
  • 2 -5 years .5 mg / kg
  • 6 - 11 years .3 mg / kg
  • gt 11 years .2 mg /kg
  • Prepackaged commercial syringes available in 2.5,
    5, 10, 20 mg

12
Intranasal Midazolam
  • Randomized controlled clinical trials support the
    effectiveness of treating status epilepticus in
    pediatric patients with dosages of .2mg/kg
  • Faster and perhaps more effective than rectal
    diazepam in RCTs

Lahat, Eli. British Medical Journal 32(7253) 8
July 2000 p 83-86. Scott RC. Lancet
1999353623-62. Fisgin, Tunc. Child Neur 172
Feb 2002, p.123-126.
13
Intramuscular Midazolam
  • Water soluble well absorbed
  • Adult dose 10 - 15 mg
  • Case reports

Jawad. J Neurol Neurosurg Psych 1986
491050-1054 Chamberlain. Pediatr Emerg Care
1997 1392-94
14
Intramuscular Fosphenytoin
  • 100 bioavailable
  • 20 PE /kg 20 cc intragluteal
  • Therapeutic levels at 1 hours
  • Pruritis and paresthesias most common side
    effects
  • Cardiac monitoring not necessary

DeToledo. Emerg Med 1996 supplement26-31
15
Conclusions
  • Lorazepam is the preferred first line agent for
    seizure control due to its long lasting
    anticonvulsant properties.
  • Diazepam is equally effective but requires that a
    concomitant, long acting AED be administered.
  • When the IV access is unavailable
  • IN or IM midazolam
  • Rectal diazepam
  • IM fosphenytoin
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