Managing Seizure Patients in the  Emergency Department James Wheless, MD Director, Texas Comprehensive Epilepsy Program Un...
Question #1: When is an antiepileptic drug (AED) loading dose necessary?
Acute Seizures That Need a Loading Dose <ul><li>Seizures secondary to partial compliance </li></ul><ul><li>Dose (mg) = wei...
Acute Seizures That Need a Loading Dose <ul><li>Progressive neurologic disease </li></ul><ul><li>Acute symptomatic seizure...
Acute Seizures That  May   Not  Need a Loading Dose <ul><li>New onset pediatric complex partial,  </li></ul><ul><li>genera...
Question #2: What medications are best for an AED loading dose?
 
Question #3: What is the empirical therapy for acute seizures?
 
 
 
 
 
 
 
 
 
Question #4: What antiepileptic drugs are  useful for nonconvulsive  status epilepticus (SE) (altered mental status presen...
 
 
 
 
 
<ul><li>Question #5: </li></ul><ul><li>When do we use: </li></ul><ul><li>Fosphenytoin? </li></ul><ul><li>Phenobarbital? </...
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Question #6: What parenteral medications can be given if no IV  access is available?
 
 
 
Development of a Rapid- Onset Intranasal Delivery of Diazepam <ul><li>Effective nasal delivery volume  <  300ml (150ml/nos...
Pediatric Status Epilepticus: IM Midazolam <ul><li>Children (N = 48) 4 mo.- 14 yrs. (69 episodes) </li></ul><ul><li>Midazo...
 
Chaimberlain JM, Pediatric Emerg. Care, 1997;13, 92
 
 
 
Pharmacokinetics of  Midazolam by Intranasal (IN) Administration <ul><li>Subjects (6) had irritation, general discomfort <...
 
 
 
 
 
Parenteral Formulation to Avoid for IM Use <ul><li>Depacon (IV Valproate) </li></ul><ul><li>IM – muscle necrosis </li></ul...
 
Question #7: How do pediatric and adult cases of acute seizures and status epilepticus differ?
 
 
 
 
 
 
 
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  1. 1. Managing Seizure Patients in the Emergency Department James Wheless, MD Director, Texas Comprehensive Epilepsy Program University of Texas - Houston
  2. 2. Question #1: When is an antiepileptic drug (AED) loading dose necessary?
  3. 3. Acute Seizures That Need a Loading Dose <ul><li>Seizures secondary to partial compliance </li></ul><ul><li>Dose (mg) = weight (Kg) x V D (L/Kg) x D Cp (mg/dL) </li></ul><ul><li>Seizures with a high rate of recurrence </li></ul><ul><li> (Some seizures are like potato chips: </li></ul><ul><li> you can never have just one!!) </li></ul>Myoclonic, tonic, absence, atonic
  4. 4. Acute Seizures That Need a Loading Dose <ul><li>Progressive neurologic disease </li></ul><ul><li>Acute symptomatic seizures </li></ul><ul><li>New onset adult seizures </li></ul><ul><li>Status epilepticus – depends on etiology </li></ul><ul><li>( febrile status epilepticus- probably not) </li></ul><ul><li>Neonatal seizures </li></ul>
  5. 5. Acute Seizures That May Not Need a Loading Dose <ul><li>New onset pediatric complex partial, </li></ul><ul><li>generalized tonic-clonic seizures </li></ul><ul><li>( not status epilepticus) </li></ul><ul><li>Febrile seizures </li></ul><ul><li>Some acute symptomatic seizures </li></ul><ul><li>(i.e., decreased blood sugar) </li></ul>
  6. 6. Question #2: What medications are best for an AED loading dose?
  7. 8. Question #3: What is the empirical therapy for acute seizures?
  8. 18. Question #4: What antiepileptic drugs are useful for nonconvulsive status epilepticus (SE) (altered mental status presenting as SE)?
  9. 24. <ul><li>Question #5: </li></ul><ul><li>When do we use: </li></ul><ul><li>Fosphenytoin? </li></ul><ul><li>Phenobarbital? </li></ul><ul><li>IV Valproate? </li></ul>
  10. 39. Question #6: What parenteral medications can be given if no IV access is available?
  11. 43. Development of a Rapid- Onset Intranasal Delivery of Diazepam <ul><li>Effective nasal delivery volume < 300ml (150ml/nostril) </li></ul><ul><li>Ethyl laurate-based microemulsion developed </li></ul><ul><li>Diazepam solubility in microemulsion is 41 mg/ml </li></ul><ul><li>Bioavailability = ½ of IV diazepam </li></ul><ul><li>Maximum plasma concentration reached in 2-3 min. </li></ul><ul><li>Li L et al (B M Squibb), Int. J. Pharm., 2002, 237 (1-2): 77-85 </li></ul>
  12. 44. Pediatric Status Epilepticus: IM Midazolam <ul><li>Children (N = 48) 4 mo.- 14 yrs. (69 episodes) </li></ul><ul><li>Midazolam 0.2 mg/Kg IM in ER </li></ul><ul><li>35 seizures 10-20 min., 34 > 20 min. duration at </li></ul><ul><li>presentation in ER </li></ul><ul><li>Results: </li></ul><ul><ul><li>57 episodes (83%) stopped in 1-5 min. </li></ul></ul><ul><ul><li>7 episodes (10%) stopped in 5-10 min. </li></ul></ul><ul><ul><li>Lahat E et al, Pediatric Neurology, 1992; 8: 215-216 </li></ul></ul>
  13. 46. Chaimberlain JM, Pediatric Emerg. Care, 1997;13, 92
  14. 50. Pharmacokinetics of Midazolam by Intranasal (IN) Administration <ul><li>Subjects (6) had irritation, general discomfort </li></ul><ul><li>Suggested doses for status epilepticus: </li></ul><ul><li>- children 0.2 mg/Kg IN </li></ul><ul><li>- adults 5-10 mg IN </li></ul><ul><li>Parenteral midazolam 5 mg/ml </li></ul><ul><li>Mean peak plasma conc. reached 14 min. ( + 5) </li></ul><ul><li>Mean bioavailability 0.83 ( + 0.19) IN </li></ul><ul><li>Knoester PD et al, Br. J. Clin. Pharmacol., 2002; 53(5): 501-507 </li></ul>
  15. 56. Parenteral Formulation to Avoid for IM Use <ul><li>Depacon (IV Valproate) </li></ul><ul><li>IM – muscle necrosis </li></ul><ul><li>Phenytoin </li></ul><ul><li>IM – muscle necrosis </li></ul><ul><li>Phenobarbital </li></ul><ul><li>slow onset </li></ul>
  16. 58. Question #7: How do pediatric and adult cases of acute seizures and status epilepticus differ?
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