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Managing Seizure Patients in the Emergency Department

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

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Managing Seizure Patients in the Emergency Department

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  1. Managing Seizure Patients in the Emergency Department James Wheless, MD Director, Texas Comprehensive Epilepsy Program University of Texas - Houston

  2. Question #1: When is an antiepileptic drug (AED) loading dose necessary?

  3. 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

  4. 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

  5. Acute Seizures That MayNot 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)

  6. Question #2: What medications are best for an AED loading dose?

  7. Question #3: What is the empirical therapy for acute seizures?

  8. Question #4: What antiepileptic drugs are useful for nonconvulsive status epilepticus (SE) (altered mental status presenting as SE)?

  9. Question #5: • When do we use: • Fosphenytoin? • Phenobarbital? • IV Valproate?

  10. Question #6: What parenteral medications can be given if no IV access is available?

  11. Development of a Rapid-Onset Intranasal Deliveryof Diazepam • Effective nasal delivery volume < 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

  12. Pediatric Status Epilepticus:IM Midazolam • Children (N = 48) 4 mo.- 14 yrs. (69 episodes) • Midazolam 0.2 mg/Kg IM in ER • 35 seizures 10-20 min., 34 > 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

  13. Chaimberlain JM, Pediatric Emerg. Care, 1997;13, 92

  14. 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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