Pediatric emergency medicine trisk 1444 1444
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sedating effect. Furthermore, it can cause significant respiratory depression,
especially when given after a benzodiazepine. One must be prepared to intubate a
patient who has received both a benzodiazepine and a barbiturate for the
treatment of seizures. It is important to remember that if a patient needs to be
intubated, a muscle relaxant can mask the motor manifestation of seizure activity.
The side-effect profile of phenobarbital and the fact that it acts on GABA
receptors (similar to the first line of benzodiazepines), make phenobarbital an
inferior choice to the fast-administered/fast-acting fosphenytoin. Therefore,
phenobarbital is now considered a third-line agent.
Valproic acid (Depakene) is a commonly used antiepileptic agent and the IV
preparation had been used in the past to rapidly attain therapeutic levels.
Recently, there have been a few case series demonstrating its effectiveness in
treating seizures in children who have been refractory to the first-line agents. As
such, many now consider it a third-line agent for the treatment of status
epilepticus. It is given intravenously at a dose of 15 to 40 mg/kg over 10 minutes.
It is generally well tolerated and is less sedating than the barbiturates.
IV levetiracetam (Keppra) has also been used for pediatric status, with a
loading dose of 40 to 60 mg/kg given over 10 minutes. There is some evidence
that phenytoin/fosphenytoin, valproate, and levetiracetam are all equally
reasonable choices in this setting. Since levetiracetam has less immediate side
effects than fosphenytoin, it is now becoming increasingly common as a second
line of treatment. Furthermore, single doses of up to 60 mg/kg have been
endorsed by at least two guideline panels and these doses were well tolerated and
appear promising. A recent randomized controlled trial involving children and
adults with SE refractory to benzodiazepines demonstrated equal effectiveness of
approximately 50% of fosphenytoin, levetiracetam, and valproate. Two recent
large trials of phenytoin versus levetiracetam also failed to demonstrate a
difference in effectiveness.
Pyridoxine deficiency is an uncommon cause of seizures in newborns. One
should consider its use (50 to 100 mg IV) primarily in patients younger than 3
months whose seizure activity is refractory to the other therapies. Rarely,
pyridoxine-dependent epilepsy may present in older patients, so some guidelines
recommend its use in refractory status epilepticus in patients up to 18 months of
age. Pyridoxine is also used in the treatment of isoniazid overdose (usual initial
dose 70 mg/kg).
If all the described therapies fail, patients may require general anesthesia to
abort the seizures. A variety of agents can be used, including inhalational
anesthetics (e.g., halothane, isoflurane), large doses of short-acting barbiturates
