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Seizure Drugs                                                  
See also Epilepsy/Seizures

Status Epilepticus Rx Protocol    7-18-96

0-5 Min:
Airway, check for trauma/CNS lesions, herniation signs. IV saline, 50mL 50% glucose. Cardiac monitor. Check bl. glucose,lytes,Ca, Creat,BUN, toxic.screen, anticonvulsant levels.

10 minutes:
*IV Ativan 0.1mg/kg at <2mg/min, then IV Dilantin 20mg/kg at <50mg/min
Watch for arrythmia & hypotension.

30-40 minutes:
ICU & Stat Neuro consult if no response to Dilantin Rx.
*IV phenobarbital 20 mg/kg at <100mg/min. Pt may need respirator support.
If no response, give additional Phenobarbital 10mg/kg at <100mg/min.

50-60 minutes:
If no response to phenobarbital, give Versed/Midazolam infusion, load 0.2mg/kg, then 0.05 - 0.3 mg/kg/hr.

120 minutes:
If no response to Versed after 60 min,Consider barbiturate anesthesia using Pentobarbital 5mg/kg followed by 1-3 mg/kg/hr until burst suppression pattern is seen on EEG. Use only in consultation with Neurologist.

REF:
NEJM 1982, 306:1337 & Advances in Neurology by Delgado-Escueta: 'Gen.Principles of Rx'   

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General Rx Approach to seizures:

Give oxygen + keep optimal airway + check vital signs + IV line.

Stat bl.glucose,lytes,CBC,ABG,EKG?, anticonvulsant level, toxicology ? check oxymetry.

Identify & correct precipitating cause

If suspect hypoglycemia, Thiamine 100mg IV, then 50ml D50W IV prn

Ativan (lorezepam) 0.1mg/kg at 2mg/min or Valium (diazepam) 0.2 mg/kg at 5mg/min IV until seizure stops (or max of 20 mg.) It is short-acting 15-20 min.
Long acting Dilantin should be given to prevent recurrent status seizure.

Dilantin (phenytoin) 15-20mg/kg IV loading at rate <50mg/min. Monitor ECG & BP. If status still does not stop, may give additional 5mg/kg to a max of 30mg/kg.
(Cerebyx/Fosphenytoin 50 PE/ml is rapidly & completely converted to phenytoin/Dilantin after IV injection - it can be infused in 1/3 the time of IV Dilantin with max.rate of 150 mg PE/min.)
Daily 300-500 mg/day PO or IV.   Watch for prolongation of QT >1/2 cycle

Phenobarbital if status epilepticus persists, give 20mg/kg at<100mg/min IVuntil seizure stops or max. dose of 20mg/kg.  Usual initial loading 300-800mg.  Maintenance: 90-120mg/day PO or IV.  **When give phenobarb after Valium, risk of apnea or hypopnea is great & assisted ventilation is usually required.

Intubation & general anesthesia Rx.

Paraldehyde soln IV at 5 ml/500 ml D5W at 50ml/h till seizure is controlled.

Lidocaine 50-100 mg IV push, followed by 1-2 mg/min infusion.

Neurontin (Gabapentin) 100,300,400mg capsule.  Usual dose: 300-600mg tid PO as adjunctive Rx for partial-seizures.

Lamictal/Lamotrigine tab as adjunctiveRx for partial seizures in adults. Warning: potential Stevens-Johnson synd, toxic epidermal necrosis.

REF: JAMA 8-18-93 Recommendations of the Epilepsy Foundation of America.

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Drugs of Choice for major epilepsy:
Symptomatic partial epilepsy
-complex partial seizures: carbamazepine (Tegretol), phenytoin (Dilantin), phenobarbital.
-generalized tonic-clonic seizures: as above.

Idiopathic generalized epilepsy
-absence (petit mal) seizure: ethosuximide(Zarontin), clorazepate (Tranxene), valproic cid (Depakote -use in assoc.with other seizure type)
-myoclonic seizures: valproic acid, clonazepate
-generalized tonic-clonic seizures: valproic acid (Depakote), carbamazepine (Tegretol), phenytoin (Dilantin), phenobarbital.

(AIM 3-1-94. p 413)