8 convulsions etat+

8/12/2019 8 Convulsions ETAT+

1/22

Management of convulsions after

the neonatal period

Dr Ngugi


2/22

Objectives

To review the properties of commonlyavailable drugs and their safety

DiazepamPhenobarbitone

To consider a rational approach to their usein the convulsing child

To understand the need for appropriatesupportive care.


3/22

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


4/22

Diazepam (2)

Level required

to control

seizures

Time after giving diazepam

Diazep

amb

loodco

ncentration


5/22

Diazepam (2 iv)

Level required

to control

seizures


Diazep

amb

loodco

ncentration

After iv administration adequate

levels are reliably achieved

within 5 minutes with 0.3mg/kg


6/22

Diazepam (2 pr)

Level required

to control

seizures


Diazep

amb

loodco

ncentration

After pr administration adequate

levels are usually achieved within

5 minutes with 0.5mg/kg


7/22

Diazepam (2 im)

Level required

to control

seizures


Diazep

amb

loodco

ncentration

After im administration

diazepam levels can rise

very slowly and are

unpredictable


8/22

Diazepam (2 clinical implications)

Level required

to control

seizures


Diazep

amb

loodco

ncentration To terminate a convulsion iv

is preferred, rectal is OK and

im should not be used


9/22


Level required

to control

seizures


Diazep

amb

loodco

ncentration Levels stay moderately high for

many hoursmultiple doses

can result in very high,

potentially dangerous levels


10/22


Level required

to control

seizures


Diazep

amb

loodco

ncentration Give the right doseiv / pr

overdoses can rapidly result in

very high levels that have

serious side effects


11/22

Diazepamside effects

Respiratory depression

pCO2, worsens acidosis and can cause anincrease 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 upto 10% of children have discernablerespiratory depression


12/22

Giving rectal diazepam

45 cm

inside the

anal marginAll of the

barrel of a

2mls syringe

and nearlyall of a 1ml

syringe


13/22

Phenobarbitone

Half life, 2 days

Danger of accumulation

Eliminated by the liver Can be given:

Deep im injection

Slow iv infusion (max 1mg/kg/min15min forloading dose!)

iv bolus doses are contraindicated.


14/22

Phenobarbitone (2)

Level required

to control

seizures

Time after giving Phenobarbitone

Phenobarbitoneblood

concentration

After 10 minutes adequate

levels are reliably achieved with

a loading dose of 15mg/kg im


15/22

Phenobarbitone (2 clinical implications)

Level required

to control

seizures


Phenobarbitoneblood

concentration

Failure to use a loading dose

will result in inadequate levels

and fail to control seizures


16/22

Phenobarbitone (2 clinical implications)

Level required

to control

seizures


Phenobarbitoneblood

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


17/22

Phenobarbitoneside 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 overdosecoma and hypotension.


18/22

A rational approach.

Diazepam 0.3mg/kg

iv, or, 0.5mg/kg pr

Diazepam 0.3mg/kg

iv, or, 0.5mg/kg pr

Phenobarbitone 15mg/kg im(no previous phenobarbitone)

1

3

2

Wait 5 minutes

to see if effective

Wait 5 minutes

to see if effective

Considerglucose

Maximum safe doses within 24 hours appear to be DZ x 2

plus PB loading x 1.


19/22

Clinical dilemma?

Wil l treatment make th ing s better or w orse?


20/22

Managing the risks of seizures and

their treatment

Positioning

Observation

Airway support

Oxygen

Bag & mask

ventilation


21/22

Questions?


22/22

Summary

Diazepam and phenobarbitone when usedappropriately 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 theconvulsions

Insufficient attention is paid to basic airway andrespiratory support that may prevent death and

brain damage.

8 convulsions etat+

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