Managementofconvulsionsafter

theneonatalperiod
Objectives Objectives
To review the properties of commonly Toreviewthepropertiesofcommonly
availabledrugsandtheirsafety
Diazepam p
Phenobarbitone
Toconsiderarationalapproachtotheirusein pp
theconvulsingchild
Tounderstandtheneedforappropriate pp p
supportivecare.
Diazepam Diazepam
Halflife,1020hours,longerinnewborns.
Danger of accumulation Dangerofaccumulation
Predominantlyinactivatedintheliver
C b i b i d l Canbegivenbyivandrectalroutes
Diazepam (2) Diazepam(2)
i
o
n
n
c
e
n
t
r
a
t
i
Level required
o
o
d

c
o
n
to control
seizures
p
a
m

b
l
o
D
i
a
z
e
p
Time after giving diazepam
Diazepam (2 iv) Diazepam(2iv)
i
o
n
n
c
e
n
t
r
a
t
i
After iv administration adequate
levels are reliably achieved
within 5 minutes with 0 3mg/kg
Level required
o
o
d

c
o
n
within 5 minutes with 0.3mg/kg
to control
seizures
p
a
m

b
l
o
D
i
a
z
e
p
Time after giving diazepam
Diazepam (2 pr) Diazepam(2pr)
i
o
n
n
c
e
n
t
r
a
t
i
After pr administration adequate
levels are usually achieved within
5 minutes with 0 5mg/kg
Level required
o
o
d

c
o
n
5 minutes with 0.5mg/kg
to control
seizures
p
a
m

b
l
o
D
i
a
z
e
p
Time after giving diazepam
Diazepam (2 im) Diazepam(2im)
i
o
n
After imadministration
n
c
e
n
t
r
a
t
i
After im administration
diazepam levels can rise
very slowly and are
di bl
Level required
o
o
d

c
o
n
unpredictable
to control
seizures
p
a
m

b
l
o
D
i
a
z
e
p
Time after giving diazepam
Diazepam (2 clinical implications) Diazepam(2clinicalimplications)
i
o
n
To terminate a convulsion iv
n
c
e
n
t
r
a
t
i
is preferred, rectal is OK and
im should not be used
Level required
o
o
d

c
o
n
to control
seizures
p
a
m

b
l
o
D
i
a
z
e
p
Time after giving diazepam
Diazepam (2 clinical implications) Diazepam(2clinicalimplications)
i
o
n
Levels stay moderately high for
n
c
e
n
t
r
a
t
i
many hours multiple doses can
result in very high, potentially
dangerous levels
Level required
o
o
d

c
o
n
dangerous levels
to control
seizures
p
a
m

b
l
o
D
i
a
z
e
p
Time after giving diazepam
Diazepam (2 clinical implications) Diazepam(2clinicalimplications)
i
o
n
Give the right dose iv / pr
d idl lt i
n
c
e
n
t
r
a
t
i
overdoses can rapidly result in
very high levels that have
serious side effects
Level required
o
o
d

c
o
n
to control
seizures
p
a
m

b
l
o
D
i
a
z
e
p
Time after giving diazepam
Diazepam side effects Diazepam sideeffects
Respiratory depression Respiratorydepression
pCO
2
,worsensacidosisandcancausean
increaseinintracranialpressure(ICP)possibly p ( ) p y
precipitatingconingandrespiratoryarrest.
pO
2
,worseningoxygendeliverytothe
b tissuesandbrain
Afterasingle(correct)doseofdiazepamup
t 10% f hild h di bl to10%ofchildrenhavediscernable
respiratorydepression
Giving rectal diazepam Givingrectaldiazepam
4 5 cm
inside the inside the
anal margin
All of the
barrel of a
2mls syringe
and nearly and nearly
all of a 1ml
syringe
Phenobarbitone Phenobarbitone
Half life, 2 days Halflife,2days
Dangerofaccumulation
Eliminated by the liver Eliminatedbytheliver
Canbegiven:
Deep im injection Deepiminjection
Slowivinfusion(max1mg/kg/min 15minfor
loadingdose!) g )
ivbolusdosesarecontraindicated.
Phenobarbitone (2) Phenobarbitone(2)
i
o
n
o
n
c
e
n
t
r
a
t
After 10 minutes adequate
levels are reliably achieved with
a loading dose of 15mg/kg im
Level required

b
l
o
o
d

c
o
a loading dose of 15mg/kg im
to control
seizures
b
a
r
b
i
t
o
n
e
P
h
e
n
o
b
Time after giving Phenobarbitone
Phenobarbitone (2 clinical implications) Phenobarbitone(2clinicalimplications)
i
o
n
Failure to use a loading dose
o
n
c
e
n
t
r
a
t
Failure to use a loading dose
will result in inadequate levels
and fail to control seizures
Level required

b
l
o
o
d

c
o
to control
seizures
b
a
r
b
i
t
o
n
e
P
h
e
n
o
b
Time after giving Phenobarbitone
Phenobarbitone (2 clinical implications) Phenobarbitone(2clinicalimplications)
i
o
n
The very long half life means that 2.5mg/kg
o
n
c
e
n
t
r
a
t
y g g g
once a day (max 5 mg/kg/day) is enough to
maintain effective levels in the acute phase
Level required

b
l
o
o
d

c
o
to control
seizures
b
a
r
b
i
t
o
n
e
P
h
e
n
o
b
Time after giving Phenobarbitone
Phenobarbitone side effects Phenobarbitone sideeffects
Respiratory depression Respiratorydepression
pCO
2
,worsensacidosisandcancausean
increase in intra cranial pressure (ICP) possibly increaseinintracranialpressure(ICP)possibly
precipitatingconingandrespiratoryarrest.
pO worsening oxygen delivery to the pO
2
,worseningoxygendeliverytothe
tissuesandbrain
In overdose coma and hypotension Inoverdose comaandhypotension.
A rational approach age >1m Arationalapproach age>1m.
Diazepam0 3mg/kg
1
Diazepam 0.3mg/kg
iv, or, 0.5mg/kg pr
1
Wait 5 minutes
to see if effective
Diazepam 0.3mg/kg
iv or 0 5mg/kg pr
2
to see if effective
Consider
glucose
iv, or, 0.5mg/kg pr
Wait 5 minutes
to see if effective
Phenobarbitone 15mg/kg im
(no previous phenobarbitone)
3
Maximumsafedoseswithin24hoursappeartobeDZx2plus
PBloadingx1.
Clinical dilemma? Clinicaldilemma?
Will treatment make things better or worse? Will treatment make things better or worse?
Managingtherisksofseizuresandtheir
treatment
Airway
Positioning
Suction
Supportafterseizure
Breathing
Oxygen
Checkafterseizure f
Circulation
Temperaturegradient?
Severe Pallor? SeverePallor?
Disability
Whatdrugshavebeen
used? used?
Glucose?
Questions? Questions?
Summary Summary
Diazepam and phenobarbitone when used Diazepamandphenobarbitone whenused
appropriatelyaresafeandusuallyeffective.
Overdosing(the2.5/5/10mgapproach)orim g ( / / g pp )
DZcanbedangerous
Whenseizurescontinuedespitebasictreatment
the dr gs can become as dangero s as the thedrugscanbecomeasdangerousasthe
convulsions
Insufficient attention is paid to basic airway and Insufficientattentionispaidtobasicairwayand
respiratorysupportthatmaypreventdeathand
braindamage.