Pharmacotherapy

Febrile Seizures

Emergency Management

• Lorazepam 0.1 mg/kg IV/IO (max 4 mg) or diazepam 0.2-0.5 mg/kg IV/IO/PR (max 10 mg)
  • Can repeat every 5-10 minutes until seizure controlled

• Midazolam 0.2 mg/kg IN/buccal (max 10 mg)
  • Easy to administer, absorbs quickly

• Supportive care:
  • Antipyretics: acetaminophen, ibuprofen
  • Cooling measures
  • Oxygenation, airway management
• Identify source of fever and treat infection

Prophylaxis

• Not routinely recommended
• Increased risk of recurrence if:
  • Age < 12 months
  • Seizure with low-grade fever
  • Brief time between fever onset and seizure
  • Strong family history
• Oral diazepam:
  • 0.33 mg/kg/dose every 8 hours during febrile illness
  • Reduces recurrence risk by ~40%
  • Risk of respiratory depression
  • Side effects: sedation, ataxia

• Chronic anticonvulsants generally not recommended
  • Phenobarbital, valproic acid, primidone lower recurrence risk
  • Toxicities outweigh benefits for most patients

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Status Epilepticus

Emergency management

• First-line: IV lorazepam 0.1 mg/kg (max 4 mg) OR IV diazepam 0.3-0.5 mg/kg (max 10 mg)
  • Repeat every 5 minutes until seizure controlled
  • Faster absorption with lorazepam, longer duration with diazepam

• Second-line: IV fosphenytoin 20 mg PE/kg; IV valproic acid 20-40 mg/kg; IV levetiracetam 20-60 mg/kg
  • Load fosphenytoin at maximum rate of 150 mg/min
  • Monitor valproic acid levels, avoid in liver impairment
  • Levetiracetam generally well tolerated

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Refractory status epilepticus

IV anesthetics:

• Propofol starting at 2-5 mcg/kg/min, titrate up to 5-10 mcg/kg/min
• Midazolam 0.2-2 mg/kg bolus, then 0.05-2 mg/kg/hr infusion
• Pentobarbital typical starting dose 5-15 mg/kg, then 0.5-5 mg/kg/hr

Adjuvant therapy:

• Ketamine loading dose 1.5 mg/kg IV, then infusion 2.5 mg/kg/hr
  • Hypothermia goal temp 32-34°C
  • IV magnesium sulfate 40 mg/kg loading dose

• Key is EEG monitoring to titrate anesthetic infusion

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Key Points

• Give oxygen, secure airway early
• Shock resistant peripheral IV access
• Bedside glucose, anticonvulsant levels
• Treat underlying cause: thiamine if suspected alcohol withdrawal
• Avoid phenytoin in neonates (purple glove syndrome)
• Monitor for hypotension, arrhythmias