Revamp how you address seizures — 4 new treatments

There are several new treatments for seizures that ED nurses should be aware of. Here are four:

Phosphenytoin.

Andy Jagoda, MD, FACEP, associate professor at the department of emergency medicine at Mount Sinai School of Medicine in New York City, says, "The biggest concern is that a loading dose of a gram of phosphenytoin is a total volume of 20 ccs, and most nursing protocols don’t allow nurses to administer more than 2 ccs IM. That has created a tremendous amount of concern for the nursing community."

Nursing protocols should be adapted to accommodate the recommended dosing, Jagoda says. "It can be given in a split dose, but can also be given in one site," he explains. "Other than a little bit of local irritation, most patients tolerate it very well."

Rectal diazepam.

This is new on the market and is particularly valuable in children with recurrent seizures or clusters of seizures, says Jagoda.

"There have been some studies published in the last year showing that an IM dose of diazepam — because it’s slowly released — can keep therapeutic levels for a prolonged period of time and minimize the recurrence of clusters."

If seizure disorders are treated at home, rectal dosing will allow parents to begin therapy before EMS even arrives, notes Jagoda. "In addition, when IV access needs to be established and the patient needs to be given an anticonvulsant, diazepam can be given rectally which makes it easier to administer. This is an option for someone not comfortable with IM dosing," he explains. "Another role for this may be in pre-hospital care, where providers may not be allowed to give IM dosing."

Intravenous valproic acid.

"Valproic acid is a common antiepoleptic drug; but up until now, we’ve had no way of increasing patient’s serum levels, short of slowly increasing their oral dose," Jagoda says.

Valproic acid can’t be loaded orally because it causes a significant amount of GI upset, he explains.

"The IV route will allow us to manage these patients and give larger doses than we could give orally," Jagoda says. "It will enable us to increase serum blood levels in patients who are subtherapeutic and seize. This is being used in Europe to treat status epilepticus, but that is not a defined role for it in the states yet."

Prolonged post ictal period.

When a patient who has had a seizure and has been given benzodiazene, the seizures will usually stop.

"Now, you have a patient who is lethargic, and you’re faced with the question of why. Is it because of the drug — because the body has shut down after the seizure — or is there an infection we haven’t recognized, such as meningitis?" he asks. "After most patients have seized, they have a period of being less responsive called the post ictal period, which can last from a few minutes to a few hours."

The patient may not be waking up because they are still seizing, says Jagoda.

"There is some evidence to suggest this isn’t as infrequent as we once thought it was," he explains. "Nonconvulsive seizures just give the patient altered behavior symptoms, but the patient is still having a seizure."

New evidence suggests that 10% to 20% of patients treated for status epilepticus who stop having motor activity are actually still having seizure discharges in their brain, Jagoda notes.

"Nobody knows if this untreated seizure activity increased morbidity or mortality, but it’s a very exciting area of future research."

In patients who have stopped seizing and are not waking up, among all the things that practitioners normally consider, also consider that they might still be seizing, says Jagoda. "Therefore, to make the diagnosis, you should probably get a bedside EEG," he advises. "Early consultation with an expert in seizure management is probably indicated."

Source

For more information on new developments in seizure management, contact:

Andy Jagoda, MD, FACEP, Department of Emergency Medicine, Mount Sinai School of Medicine, One Gustave Levy Place, P. O. Box 1149, New York, NY 10029. Telephone: (212) 241-3870. E-mail: andy_jagoda@smtplink.mssm.edu.