Wednesday, April 17, 2013

Unprovoked seizures may happen even though the recommended seizure medications are taken without missed doses and possible triggers are avoided. Parents are often most worried about convulsive seizures. Most convulsive seizures last between 2 and 3 minutes and stop on their own. However, longer convulsive seizures lasting more than 5 minutes are less likely to stop spontaneously and rescue medications should be considered for these. More prolonged seizures are more likely to stop with rescue medication if it is given within the first 30 minutes compared to treatment given later. Therefore, status epilepticus is defined as prolonged seizures greater than 5 minutes. In some patients, brief but recurrent seizures within a short period of time should also be treated as status epilepticus.

Should my child have a seizure rescue medication?

About a quarter of children with epilepsy will experience status epilepticus. Those children with history of status epilepticus are at higher risk for recurrent status epilepticus. Not all seizure types require rescue medication. Epileptic (infantile) spasms often occur in clusters, and the typical rescue medications are often not effective for these seizures in infants. Brief seizures such as absence, tonic, atonic (drop) seizures which last for a few second, with quick recovery and do not appear to affect your child's awareness can occur repeatedly in clusters. In these cases, giving rescue medication frequently may result in overuse of rescue medication. Contact your child's physician for a tailored seizure action plan. Your child's scheduled seizure medications may need to be adjusted. Frequent use of acute seizure medications may result in tolerance and make these rescue medications less effective for stopping subsequent seizures. Children with infrequent seizures, without history of long seizures more than 5 minutes usually do not need rescue medication. In some circumstances, rescue medications are prescribed to those families who live in remote regions, far from emergency medical attention.

What are the rescue medications?

Medications for treating ongoing seizures in the community setting belong to a class of medications called benzodiazepines. Benzodiazepines decrease duration of seizures and number of repeated seizures when used by emergency personnel and in the hospital. Different benzodiazepines are available for acute seizure management. These include diazepam, midazolam, clonazepam and lorazepam. Different ways of giving benzodiazepines are available. Examples include drops in the inner surfaces of the mouth (buccal cavity) without swallowing, ingesting a solution or dissolvable tablet by mouth, via a nasal spray adaptor, or as a gel given rectally. How quickly the medication reaches a good blood level and how long the drug works depend on which benzodiazepine is used and how it is given. Emergency medical services start an IV and give medications directly into the blood, which become effective quickly. However, the ideal seizure rescue medication for use outside the hospital is one that can be given quickly, easily, safely and without medical training. Commercially available rescue medications include Diastat which comes in a twin pack syringes at specific doses to be given rectally. Diazepam is available as a concentrated solution (diazepam intensol) which can be given in the inner surfaces of the mouth and does not require swallowing. Midazolam can be given nasally. Clonazepam wafers and lorazepam intensol are also available.

How are seizure rescue medications given?

Although administration of seizure rescue medication does not require advance medical training, knowing the correct way of administering the specific rescue medication can affect how much drug is delivered. The correct way to give diazepam intensol include placing your child on his or her side and drop the solution onto the inner surfaces of the cheek that is faced down. Correct administration for rectal diazepam requires place your child on his or her side. Gently bend the upper leg towards you and undress your child from the waist down so that the buttocks are exposed. Put the provided lubrication on the Diastat syringe tips and insert the tip slowly into the rectum. Count to three seconds for each of the following steps: (1) gently push plunger to administer medication into rectum; (2) leave syringe in rectum; (3) hold buttocks together to prevent leakage (adapted from diastat.com). An adaptor is attached to a syringe to give midazolam nasally.

What are the side effects of seizure rescue medications?

Parents, caretakers, and school nurses who are the first responders during breakthrough seizures should understand the possible side effects of seizure rescue medications. Side effects of benzodiazepines include sedation and respiratory suppression. For those medications administered by mouth, there is a small risk of aspiration. Families using acute seizure medications for the first time are usually instructed to seek emergency help because it is not known whether the medication will be effective or is going to cause significant side effect. If rescue medications worked to stop seizures in the past without side effects, acute seizure management given at home or school may eliminate the need for emergency room visit. The current seizure should stop and your child is back to baseline. However, medical attention is still needed if there is any concern regarding seizure triggers such as fever and illness or for evaluations for injury from the seizure. Those children with first status epilepticus should be seen in the emergency room to evaluate for possible triggers for new prolonged seizure.

Are there other differences among the rescue seizure medications?

There are some practical issues with each of the commonly prescribed seizure rescue medications. Rectal diazepam (Diastat) is available in syringes of pre-packaged doses appropriate for the individual patient. There is no need to measure the amount needed. Rectal diazepam can be easily given in young children. In school age school and older, privacy and concerns with dignity may become an issue. Positioning for rectal administration maybe challenging in patients who are wheelchair bound, overweight, or have ongoing convulsive seizures. Whether to be ingested or to be dropped in the inner surfaces of the mouth without swallowing, solution and dissolvable tablets have possible risk of aspiration risk. However, the typical amount is small so that aspiration risk is small. Diazepam intensol does not require refrigeration but lorazepam intensol does. Each medication has different expiration times. Check with your pharmacist regarding the expiration dates. Diazepam intensol should be discarded 90-days after breaking the manufacturer's seal. Individual vials should be requested to be used at school and at home. There is no commercially available midazolam nasal spray. Midazolam solution would need to be drawn up using a needle and syringe, then the needle replaced by an adaptor to produce the nasal spray given into the nostrils.

Are there other steps for 'Seizure Action Plan'?

Always observe seizure safety. During the seizure, make sure that your child is safe, removing dangerous objects around him or her. Lay the child on the side. Look at the watch and start timing the seizure. Vagus nerve stimulators are battery-powered devices which send programmed pulses of electricity to the left vagus nerve. Patients with vagus nerve stimulator may use a magnet to give additional electric pulses to stop a generalized convulsive seizure during their typical warning. For some patients, a single repeated dose may be directed by your neurologist. If seizures do not stop within 5 minutes of giving rescue medication, then you should call 911.

Authored by: Lily Wong-Kisiel MD on 4/2013