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  • 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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