Epileptic Emergency Treatment

1.    Ask the Owner 2 questions

Is the patient a known epilepticer who’s getting KBr or Phenobarbital (PB)?

Does the patient have diabetes and is taking insulin?

Why is that relevant?

If he isn’t getting KBr —> i.v. full electrolyte infusion

If he is already getting KBr —> i.v. 0,9% NaCl + 5% Glucose (1:1)

If he has diabetes he’s probably hyperglycemic

2.    First Step in Treatment is Diazepam (0,5 mg/kg i.v.)

Onset of action: 1-2 Minutes

If the first dose isn’t working the treatment can be repeated 2-3 times

If an i.v.- access isn’t possible try Diazepam rectal tubes

If he isn’t getting PB already: 1 mg/kg

If he is getting PB: 2 mg/kg

Onset of action: 15-20 Minutes

OR

Midazolam intranasal with an atomizer (0,2 mg/kg)

Onset of action: 1-5 Minutes

3.    Next Step: Phenobarbital (10 mg/kg i.v.)

Give PB even if Diazepam worked, because the effect of Diazepam will only last for 20-30 minutes

Can be repeated once if the patient isn’t already getting PB

Onset of action: 15-20 Minutes

CAVE: If the Patient is already getting PB always check the blood level before treating him with PB!

4.    If the seizures persist or occure again within the next 2 hours: Levetiracetam (20 mg/kg slowly i.v.)

Can be repeated 2 times

5.    Start Diagnostics

Hypoglycemia: 3-5 ml/kg 20% Glucose i.v.

Hypocalcemia: 0,5 – 1 ml/kg 10% Ca-Carbonat slowly i.v. (CAVE: Bradycardia)

Temperature: > 40 degree Celcius —> cool him down

    < 39,5 degree Celcius —> stop or will cool down too much

6.    If the Seizures persist or occur again ask yourself if Diazepam worked the first time

If YES:

Diazepam

0,5 mg/kg i.v. Bolus followed by…

0,1 – 0,5 mg/kg/h  (continous infusion), 30 mg Diazepam in 250 ml 5% Glucose

If it works reduce Diazepam in 6-8 hours

If it doesn’t work put him under anaesthesia

If NO:

Pentobarbital

1-2 mg/kg i.v. Bolus followed by…

1-5 mg/kg/h continous infusion

Propofol

4-8 mg/kg i.v. Bolus followed by…

4-8 mg/kg/h continous infusion

Cave: Both those drugs can cause depression of breathing, so the patient has to be under surveillance all the time!

Inhalation anaesthesia

Simultaneous to all 3 of them: PB on maintenance dose of 2,5 mg/kg i.m. (2x/day)

Wake the patient up after 6-8 hours