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

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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. Case Presentation.
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First Line Therapy in Acute Seizure Management: Focusing on the Pediatric PatientWilliam C. Dalsey, MD, FACEP, MBADepartment of Emergency MedicineRobert Wood Johnson University HospitalNew JerseyCase 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 can’t be obtained.
  • Critical Questions
  • How do you evaluate and treat a pediatric patient with a seizure?
  • What is this best first-line treatment?
  • What if I can’t obtain IV access?
  • Complicating Factors: Status Epilepticus? Hypoxia, Hypoglycemia, Febrile SeizuresWhat 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; 339:792-798What 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 suppressionTreiman. Epilepsia 1989:30;4-10Prensky. NEJPM 1967; 276:779-784Leppik. JAMA 1983; 249:1452-1454Class B Evidence:
  • Phenobarbital is an effective alternative to the use of phenytoins in status epilepticus.
  • Treiman. NEJM 1998; 339:792-798Class 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
  • Do the Clinical Guidelines Address Our Patient?
  • What do they say?
  • What don’t they tell us?
  • 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)
  • 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; 23:216-224Cereghino. Neurology 1998;51:1274-1282Remy. Epilepsia 1992;22(2):3530358Rectal Diazepam
  • Dosing is age dependent:
  • 2 -5 years: .5 mg / kg
  • 6 - 11 years: .3 mg / kg
  • > 11 years: .2 mg /kg
  • Prepackaged commercial syringes available in 2.5, 5, 10, 20 mg
  • 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 1999;353:623-62.Fisgin, Tunc. Child Neur 17;2; Feb 2002, p.123-126.Intramuscular Midazolam
  • Water soluble; well absorbed
  • Adult dose 10 - 15 mg
  • Case reports
  • Jawad. J Neurol Neurosurg Psych 1986; 49:1050-1054Chamberlain. Pediatr Emerg Care 1997; 13:92-94Intramuscular 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; supplement:26-31Conclusions
  • 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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