Andy Lockey wrote:

It rather depends upon whether or not they have already had pre-hospital benzos. With the best will in the world, phenytoin takes time to work. It would probably be good practice in the prolonged "fitters" to get that going as soon as possible, but swift management with the benzo of your choice (see the discussion we had on the list of lorazepam vs. diazemuls vs. midazolam on the Acad-AE-Med website). Phenobarbitone can have depressent effects on blood pressure, respiratory drive and level of consciousness and it is probably safer to go the full whack and give them a controlled thio GA.

A small point Andy, but worrying about respiratory drive and level of consciousness is rather academic in prolonged fitters. Their GCS is 3 and their respiratory efforts are ineffectual. Besides there's nothing like a thio GA for depressing your resps, BP and GCS! (thio is after all a barbiturate,isn't it?). Prolonged seizures is one area, I feel, where ABCD should be "turned on its head", i.e. you can't sort out ABC until you stop the fitting first. I've no strong feelings about what agent you should use and the agents you describe sound sensible but I've got nothing against phenobarb in this situation. Involving intensivists is often too slow, and we should be able to initially sort out such cases ourselves (which may or may not include a GA).

Regards

Adrian Fogarty