Only one point to add; Midazolam can be given i.m. as well as i.n. and i.v. I believe it's better absorbed via the i.m. route compared to Lorazepam.
Ray McGlone
A&E Consultant
Lancaster
----- Original Message -----
From: A S Lockey
To: [log in to unmask]
Sent: Saturday, March 10, 2001 11:10 PM
Subject: Re: refractory seizures
David,
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.
My personal management for the genuine prolonged fitter (ie no history of pseudo fitting) would be:
a.. ABC + Oxygen + rapid bedside glucose test and glucose if needed
b.. Lorazepam 4mg IV for adults (repeat once as necessary) (or rectal diazepam/buccal midazolam/nasal midazolam if no IV access)
c.. Phenytoin IV concurrently
d.. Rapid involvement of intensivists for consideration of thiopentone induction +/- CT head
I would suggest that if the patient has been genuinely convulsing for the periods of time that you mention, we cannot afford to waste time titrating in various infusions and that we should probably head for swift GA as the safest and most accurately controlled situation. That is only an opinion.....
Andy
-----Original Message-----
From: The list will be of relevance to all trainees including undergraduates and [mailto:[log in to unmask]]On Behalf Of david vickery
Sent: 10 March 2001 12:19
To: [log in to unmask]
Subject: refractory seizures
What are peoples opinions about the management of refractory seizures in the emergency department? That is seizures unresponsive to treatment or lasting longer than 60 minutes.
If we accept the APLS algorithm as a standard for status in children, then how do we best manage those few that present late, and hence may commence the treatment algorithm 45 minutes + down the line. Late presentation may be multifactorial - due to transport delays, home treatment of recurrent "fitters", subsequent vascular access difficulties, etc. It is likely that some of these will be refractory and become increasingly acidotic +/- hypoxic.
Options include:
a.. loading with phenytoin as second (?first) line treatment
b.. low threshold for loading with phenobarbitone
c.. midazolam infusion titrated to effect.
Airway protection and assisted ventilation taken as read.
David Vickery
Consultant in Emergency Medicine
Gloucestershire Royal NHS Trust
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