Seizures – Emergency treatment

 

Status epilepticus

Step 1: Stop the seizure & begin medications

  • STOP THE SEIZURE! This is the most important thing to do.
    • Diazepam 0.5-1.0 mg/kg IV, or
    • Diazepam 1-2 mg/kg per rectum, or
    • Intranasal diazepam (0.5 mg/kg) or midazolam (0.2-0.5 mg/kg)
  • Draw labs for STAT PCV/TS, BG, Ca, electrolytes; also for submission of CBC/biochemical profile
  • Place an IV catheter ASAP & begin IV fluids
  • If seizure recurs, 2 more doses of diazepam can be given at 5 minute intervals
  • If the seizures respond to diazepam, start a diazepam CRI at 0.5mg/kg/hr for at least 12-24 hours seizure-free, then wean off diazepam over 12-24 hours and then discharge once seizure-free for 12-24 hours off diazepam.
  • If the seizure doesn’t stop within 5-10 minutes, give phenobarbital or levetiracetam intravenously (phenobarbital 4 mg/kg IV OR levetiracetam 30-60 mg/kg IV bolus once then standard dose 20-30 mg/kg q8hr)
    • It can take 20-25 minutes for phenobarbital to take effect
    • May need to fully load with phenobarbital (16-20 mg/kg total dose divided); Note: giving the entire dose all at once can be done, but there is a moderate to high risk of causing severe sedation – This author typically gives 4 mg/kg IV q4hr for 4 doses (4/4/4), but adjusts the dose/frequency of adminsistation if the patient is becoming too sedate.
  • Seizure not responsive to Valium and phenobarbital – give propofol or pentobarbital
    • Propofol 2 mg/kg IV to effect, then CRI 0.1-0.2 mg/kg/min
    • Pentobarbital 3-15 mg/kg IV slowly to effect
  • Propofol doesn’t stop the seizure? Intubate and begin general anesthesia
  • Consider vagal maneuvers (ocular compression) at any time

Step 2: Systemic monitoring

  • Monitor rectal temperature
    • Some patients are hyperthermic and may need cooling
  • Monitor BG & electrolytes
    • Hypoglycemia
      • BG < 40-60 before seizures occur
      • Give 50% dextrose 0.5-1.0 ml/kg IV diluted 1:1 with saline
      • Give thiamine (Vitamin B1) 25-50 mg/patient
    • Hyperglycemia
      • Hyperglycemia promotes anaerobic glycolysis, intracellular acidosis, free radical production, and neuronal cell death
      • BG > 250?  Consider giving regular insulin 0.1 units/kg
    • Hypocalcemia (ionized Ca < 0.7-0.8)
      • 10% calcium gluconate 1-4 ml/kg IV slowly to effect while monitoring ECG
  • Monitor ECG, blood gases & blood pressure

Step 3: Monitor neurological status

  • Serial neurological exams – looks for asymmetry
  • Monitor for signs of increased ICP
    • Signs: anisocoria, mydriasis, absent PLR, spontaneous nystagmus, apnea or tachypnea, positional strabismus
    • Cushing Reflex: hypertension with bradycardia
    • Treatment: treat early & aggressively!
      • Mannitol 0.5 – 1.0 gram/kg IV over 15-20 minutes
        • Can be repeated 2 more times at 2-4 hours
        • Monitor electrolytes, PCT/TS, urine ins/outs
      • Furosemide 0.2-0.4 mg/kg IV
      • Use of these medications REQUIRES normovolemic patient
        • Give bolus of IV fluids if dehydrated
        • If hydrated, give 2x maintenance rate IV fluids

In-hospital treatment of cluster seizures

Give diazepam if the patient is actively having a seizure.
Dose: 0.5 mg/kg IV or 1-2 mg/kg PR

If patient responds to valium, start a diazepam CRI 0.25-0.5mg/kg/hr.

If doesn’t respond to diazepam or has breakthrough seizures, give propofol to effect and then start a propofol CRI 0.1-0.2 mg/kg/min


At-home treatment options for cluster seizures

Rectal diazepam

  • Dose: 1-2 mg/kg per rectum
  • Can give up to 3 doses in 1 day, as close together as every 5 minutes if seizure doesn’t stop.
  • NOTES:
    • DO NOT pre-load syringes!
      • Diazepam is light-sensitive so it must be kept in the dark.
      • Diazepam adsorbs to plastic leading to a less-than-desired dose being given if stored in syringes
  • Diazepam suppositories prepared by a compounding pharmacy (NOTE: A recent study found that diazepam is poorly absorbed, if at all, from suppositories so this route is no longer recommended
  • Diastat rectal gel (VERY expensive)

Intranasal midazolam or diazepam

  • Midazolam: 0.25-0.5 mg/kg IN
  • Diazepam: 0.5 mg/kg IN

Oral medication pulse protocol options – Reserved for dogs with recurrent cluster episodes

  • Clorazepate: 0.5-1.5 mg/kg PO q8hr or 1-2 mg/kg PO q12hr
  • Gabapentin:  50 mg/kg divided PO q8hr x 3 days
Last updated by NeuroPetVet on December 17, 2017.