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