Diazepam and cluster seizures

[Veneficus]

Here's a good bit of loosely related trivia: why does the Harriet lane handbook (bible for peds) discourage RSI for status epilepticus in children ?

If I am not mistaken, Nelson Textbook of Pediatrics is the bible for peds?

 

[Dwindlin]

If I am not mistaken, Nelson Textbook of Pediatrics is the bible for peds?

For text books maybe, but no one carries one around in their coat pocket like they do Harriet Lane.

 

[Veneficus]

For text books maybe, but no one carries one around in their coat pocket like they do Harriet Lane.

Gave up on those books, they make the coat too heavy and lopsided.

(though I was rather fond of the oxford guides a while back)

 

[medicsb]

The anti-seizure duration of activity of diazepam is short (~20 minutes) as compared to the duration of the sedation.

Would you happen to have a source for the anti-SZ duration of action vs. sedation? Basic & Clinical Pharmacology, 12e (Katzung, et al.) doesn't mention there being a difference. Pretty much all I can find on the preference of non-benzos is the side-effect profile and development of tolerance.

 

[mycrofft]

Speaking from experience, once you have an effective blood level established, Valium's effective life to prevent irritability/excitement (and hence delirium tremens and seizures) from ETO detox is much longer than 20 min.The protocol was a three-dose loader (10 mg po Q 2 hrs times three), then three ays at 10 mg po TID, three at BID, three at 5 mg BID, then qd of 5 mg for two days. Later they dropped the last step and it was just as good.
Ativan...rollercoastering vital signs and some tremors.

 

[Doczilla]

Hmm, I gotta dig it up. There's a comment that says " avoid paralytics". I can understand why RSI isn't definitive for status epilepticus, but I can't get a clear answer on why its frowned upon.

 

[Melclin]

Hmm, I gotta dig it up. There's a comment that says " avoid paralytics". I can understand why RSI isn't definitive for status epilepticus, but I can't get a clear answer on why its frowned upon.

Is it an issue of lasting paralysis obscuring further seizure activity perhaps?

 

[Smash]

Long term neuromuscular blockade would obviously be problematic in that you could obviously not monitor seizure activity, so would have no idea if therapy is effective or not (pre-hospital of course, with no EEG capability)

However in terms of straight RSI, I can't see any issue with a short term NMB. It is not an uncommon thing to intubate a status epilepticus patient so airway, ventilation and oxygenation cease to be an issue whilst giving large doses of first and/or second line anticonvulsants.

For the OP, did the patient ever regain consciousness between seizures?

 

[Smash]

Obviously I need to not post when I am hungry and tired. Obviously.

 

[STXmedic]

Smash: No, the patient never regained consciousness. The best response we ever got was appropriate withdrawal from pain.

 

[mycrofft]

Status epileptics or this close analogue are sometime unrecoverable. The seizure is not only a problem itself but a symptom, in tho case most likely of a fatal insult like a CVA or neoplastic body or ???.

I'm curious also about paralyzing people undergoing seizures then taking over their respirator functions. On the surface it sounds reasonable. Frag em, gag em, bag em and start a benzo drip.

 

[Doczilla]

I hope you don't have that patented, because I'm going to use that expression

I'm thinking that maybe they don't want providers to "forget" that the parylized child is still seizing neurologically. I'm guessing that the harriet lane handbook assumes EEG capability, but maybe not.

I've RSI's seizing kids before, but the seizures were always secondary to head trauma, or in the case of last year, a little girl caught frag to her c-cpine, and the RSI was to prevent further movement.

 

[Aidey]

Hmm, I gotta dig it up. There's a comment that says " avoid paralytics". I can understand why RSI isn't definitive for status epilepticus, but I can't get a clear answer on why its frowned upon.

Yup, it is in the acute seizure management table in chapter 3 I think, 18th edition. It isn't in the 16th edition.

 

[RocketMedic]

I'd reckon it's a multi-part thing.

1. RSI in children (even moreso than adults) is a situation where you need the tube, because most supralingual airways won't fit, the airway is smaller, and we don't really have a good alternate for ETI except for BLS airway management.

2. Accidental overdoses leading to respiratory arrest may be more common in children? -medication error. 2a- medication reactions stemming from sedation/continued sedation, as the peak affect would occur later with benzodiazepenes than is workable in RSI.

2b. Paradoxical reactions?

3. The aforementioned masking characteristics of benzodiazepenes may make it more difficult to assess therapies and/or the root cause of the seizure, particularly with trauma patients (did the seizure cause trauma, or is trauma the result of the seizure?)

4. Amidate may worsen seizure conditions.
EDIT- I found a research paper that trialed amidate in 105 patients under 10- none seized or experienced a myoclonic reaction.

I'm not sure why, to be honest. RSIing a kid seems like something to do to protect the airway in the context of refractory seizures.

 

[Murphy]

About the ~20 minute efficacy of valium for seizures - I can't say that I've seen it in a drug reference manual, but I have heard it repeatedly in neurology classes and texts and in other reference books on seizure treatment. I don't have accesses to manuals right now... the best that I can do with a web search is:

Oops, I wasn't allowed to post the links without a higher post count. I found an article on professionals dot epilepsy dot com about diazepam that mentions it, and I had a link to a training article by the Foundation for Education and Research for Neurological Emergencies.

I know there are better references on line, but I keep finding research papers about longer acting or newer benzos instead... several reference the short seizure control timeframe for valium but none of those gave an actual duration. I'm giving up on the web search.

Neither of the links are medical texts, but both reference the duration of valium. The reason is because it is highly lipid soluble and rapidly redistributes. Hope this helps.

 

[mycrofft]

Murph, send one of us the links as a message and we can post them