Pediatric emergency medicine trisk 2616 2616
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The loading dose of valproate is 40 mg/kg, maximum 3,000 mg/dose. The
loading dose for levetiracetam is 60 mg/kg, maximum 4,500 mg/dose. VPA may
be particularly useful for patients with a known seizure disorder, who are
currently using VPA, and low serum concentrations are suspected.
IV phenobarbital is another option if none of previously described second-line
options are available. Phenobarbital, like other barbiturates, may cause significant
sedation, respiratory depression, and hypotension. The loading dose of
phenobarbital is 20 mg/kg, sometimes given in two divided doses. The total drug
dose is given over 5 to 10 minutes IV (maximum 30 mg/min in an adult), or IM in
the absence of IV access. Onset of action is usually within 15 to 20 minutes and
lasts more than 24 hours.
Patients with SE that lasts for more than 30 to 60 minutes present a special
problem. The best available evidence suggests that irreversible neuronal injury
occurs within this timeframe, so the clinician should be more aggressive at 30
minutes. Further management should be done, when possible, in conjunction with
a neurologist, an intensivist, and with continuous EEG monitoring. Options
include an additional second-line agent, continuous infusion of benzodiazepines,
barbiturate coma, or general anesthesia.
With prolonged seizures, the duration of postictal drowsiness and confusion
may also be protracted. However, the child who fails to arouse within 15 to 30
minutes after cessation of seizures should be evaluated carefully to rule out
nonconvulsive SE. Children with SE, even if successfully treated in the ED,
should be admitted to the hospital for monitoring and observation. Rarely, a child
may enter the ED in absence status. In this case, the child may be sitting in a
confused or dreamy state. Such attacks may last for hours or even days. The drug
of choice in the treatment of absence status is a benzodiazepine at the dosages
outlined above.
At times, a child may present with continual focal seizure activity (with or
without clouding of consciousness), a condition known as epilepsia partialis
continua. The treatment for partial seizures is less urgent than that for generalized
seizures, and such seizures are often intractable to anticonvulsant medication. In
such cases, fosphenytoin in a dose of 15 to 20 mg/kg can be infused slowly. All
such patients should be admitted to the hospital for further observation and
evaluation. Other pharmacologic attempts to control these focal seizures should
be performed in the hospital.
The decision to initiate long-term prophylactic therapy with anticonvulsant
medications is based on a consideration of a number of factors, including the
patient’s age, type of seizure, risk of recurrence, coexisting medical conditions,
