Management of convulsions after the neonatal period

Dr Ngugi

Objectives
To review the properties of commonly available drugs and their safety
Diazepam Phenobarbitone

To consider a rational approach to their use in the convulsing child To understand the need for appropriate supportive care.

Diazepam
Half-life, 10-20 hours, longer in newborns.
Danger of accumulation

Predominantly inactivated in the liver Can be given by iv and rectal routes

Diazepam (2)
Diazepam blood concentration

Level required to control seizures

Time after giving diazepam

Diazepam (2 iv)
Diazepam blood concentration After iv administration adequate levels are reliably achieved within 5 minutes with 0.3mg/kg Level required to control seizures

Time after giving diazepam

Diazepam (2 pr)
Diazepam blood concentration After pr administration adequate levels are usually achieved within 5 minutes with 0.5mg/kg Level required to control seizures

Time after giving diazepam

Diazepam (2 im)
Diazepam blood concentration After im administration diazepam levels can rise very slowly and are unpredictable Level required to control seizures

Time after giving diazepam

Diazepam (2 clinical implications)

Diazepam blood concentration
To terminate a convulsion iv is preferred, rectal is OK and im should not be used

Level required to control seizures

Time after giving diazepam

Diazepam (2 clinical implications)

Diazepam blood concentration
Levels stay moderately high for many hours multiple doses can result in very high, potentially dangerous levels

Level required to control seizures

Time after giving diazepam

Diazepam (2 clinical implications)

Diazepam blood concentration
Give the right dose iv / pr overdoses can rapidly result in very high levels that have serious side effects

Level required to control seizures

Time after giving diazepam

Diazepam side effects

Respiratory depression
pCO2, worsens acidosis and can cause an increase in intra-cranial pressure (ICP) possibly precipitating coning and respiratory arrest. pO2, worsening oxygen delivery to the tissues and brain

After a single (correct) dose of diazepam up to 10% of children have discernable respiratory depression

Giving rectal diazepam

4 5 cm inside the anal margin All of the barrel of a 2mls syringe and nearly all of a 1ml syringe

Phenobarbitone
Half life, 2 days
Danger of accumulation

Eliminated by the liver Can be given:

Deep im injection Slow iv infusion (max 1mg/kg/min 15min for loading dose!) iv bolus doses are contraindicated.

Phenobarbitone (2)
Phenobarbitone blood concentration

After 10 minutes adequate levels are reliably achieved with a loading dose of 15mg/kg im Level required to control seizures

Time after giving Phenobarbitone

Phenobarbitone (2 clinical implications)

Phenobarbitone blood concentration

Failure to use a loading dose will result in inadequate levels and fail to control seizures

Level required to control seizures

Time after giving Phenobarbitone

Phenobarbitone (2 clinical implications)

Phenobarbitone blood concentration

The very long half life means that 2.5mg/kg once a day (max 5 mg/kg/day) is enough to maintain effective levels in the acute phase

Level required to control seizures

Time after giving Phenobarbitone

Phenobarbitone side effects

Respiratory depression
pCO2, worsens acidosis and can cause an increase in intra-cranial pressure (ICP) possibly precipitating coning and respiratory arrest. pO2, worsening oxygen delivery to the tissues and brain

In overdose coma and hypotension.

A rational approach.
1
Diazepam 0.3mg/kg iv, or, 0.5mg/kg pr Wait 5 minutes to see if effective Consider glucose

Diazepam 0.3mg/kg iv, or, 0.5mg/kg pr

Wait 5 minutes to see if effective 3 Phenobarbitone 15mg/kg im
(no previous phenobarbitone)

Maximum safe doses within 24 hours appear to be DZ x 2 plus PB loading x 1.

Clinical dilemma?

Will treatment make things better or worse?

Managing the risks of seizures and their treatment

Positioning Observation Airway support Oxygen Bag & mask ventilation

Questions?

Summary
Diazepam and phenobarbitone when used appropriately are safe and usually effective. Overdosing (the 2.5 / 5 / 10 mg approach) or im DZ can be dangerous When seizures continue despite basic treatment the drugs can become as dangerous as the convulsions Insufficient attention is paid to basic airway and respiratory support that may prevent death and brain damage.