Title: First Line Therapy in Acute Seizure Management: Focusing on the Pediatric Patient
1First 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
2Case 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.
3Critical 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
4What 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
5What 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
6Class B Evidence
- Phenobarbital is an effective alternative to the
use of phenytoins in status epilepticus. -
Treiman. NEJM 1998 339792-798
7Class C Evidence
- Fosphenytoin is water soluble and may be
preferred over phenytoin when safety concerns or
speed of administration are concerns - High dose phenytoins to 30 mgt/kg may be more
effective in treating status than standard doses - IV propofol or barbituates may be considered in
refractory status
8Do the Clinical Guidelines Address Our Patient?
- What do they say?
- What dont they tell us?
9If you have no IV access, are there alternatives
routes for benzodiazepines administration?
- Intranasal (Midazolam)
- Buccal (Midazolam)
- IM (Lorazepam, Midazolam)
- Rectal (Diazepam, Midazolam)
- ET (Diazepam)
10Rectal 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
11Rectal 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
12Intranasal 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.
13Intramuscular 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
14Intramuscular 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
15Conclusions
- 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