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    PowerPoint Presentation PowerPoint Presentation Presentation Transcript

    • 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
      • Seizures secondary to partial compliance
      • Dose (mg) = weight (Kg) x V D (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
    • Acute Seizures That Need a Loading Dose
      • Progressive neurologic disease
      • Acute symptomatic seizures
      • New onset adult seizures
      • Status epilepticus – depends on etiology
      • ( febrile status epilepticus- probably not)
      • Neonatal seizures
    • 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)
    • 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 Delivery of 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
    • 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
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    • Chaimberlain JM, Pediatric Emerg. Care, 1997;13, 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 to Avoid 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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