Managing Seizure Patients

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Managing Seizure Patients in the Emergency
Department
James Wheless, MD Director, Texas Comprehensive
Epilepsy Program University of Texas -
Houston
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Question 1 When is an antiepileptic drug (AED)
loading dose necessary?
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Acute Seizures That Needa Loading Dose

• Seizures secondary to partial compliance
• Dose (mg) weight (Kg) x VD (L/Kg) x D Cp
  (mg/dL)
• Seizures with a high rate of recurrence
• (Some seizures are like potato chips
• you can never have just one!!)

Myoclonic, tonic, absence, atonic
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Acute Seizures That Needa Loading Dose

• Progressive neurologic disease
• Acute symptomatic seizures
• New onset adult seizures
• Status epilepticus depends on etiology
• (febrile status epilepticus- probably not)
• Neonatal seizures

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Acute Seizures That May Not Need a Loading Dose

• New onset pediatric complex partial,
• generalized tonic-clonic seizures
• (not status epilepticus)
• Febrile seizures
• Some acute symptomatic seizures
• (i.e., decreased blood sugar)

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Question 2 What medications are best for an
AED loading dose?
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Question 3 What is the empirical therapy for
acute seizures?
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Question 4 What antiepileptic drugs are
useful for nonconvulsive status epilepticus
(SE) (altered mental status presenting as SE)?
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• Question 5
• When do we use
• Fosphenytoin?
• Phenobarbital?
• IV Valproate?

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Question 6 What parenteral medications can be
given if no IV access is available?
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Development of a Rapid-Onset Intranasal
Deliveryof Diazepam

• Effective nasal delivery volume lt 300ml
  (150ml/nostril)
• Ethyl laurate-based microemulsion developed
• Diazepam solubility in microemulsion is 41
  mg/ml
• Bioavailability ½ of IV diazepam
• Maximum plasma concentration reached in 2-3
  min.
• Li L et al (B M Squibb), Int. J. Pharm., 2002,
  237 (1-2) 77-85

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Pediatric Status EpilepticusIM Midazolam

• Children (N 48) 4 mo.- 14 yrs. (69 episodes)
• Midazolam 0.2 mg/Kg IM in ER
• 35 seizures 10-20 min., 34 gt 20 min. duration
  at
• presentation in ER
• Results
• 57 episodes (83) stopped in 1-5 min.
• 7 episodes (10) stopped in 5-10 min.
• Lahat E et al, Pediatric Neurology, 1992 8
  215-216

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Chaimberlain JM, Pediatric Emerg. Care, 199713,
92
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Pharmacokinetics of Midazolam by Intranasal (IN)
Administration

• Subjects (6) had irritation, general discomfort
• Suggested doses for status epilepticus
• - children 0.2 mg/Kg IN
• - adults 5-10 mg IN
• Parenteral midazolam 5 mg/ml
• Mean peak plasma conc. reached 14 min. (5)
• Mean bioavailability 0.83 (0.19) IN
• Knoester PD et al, Br. J. Clin.
  Pharmacol., 2002 53(5) 501-507

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Parenteral Formulation toAvoid for IM Use

• Depacon (IV Valproate)
• IM muscle necrosis
• Phenytoin
• IM muscle necrosis
• Phenobarbital
• slow onset

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Question 7 How do pediatric and adult cases of
acute seizures and status epilepticus differ?
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