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8/12/2019 8 Convulsions ETAT+
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Management of convulsions after
the neonatal period
Dr Ngugi
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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.
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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
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Diazepam (2)
Level required
to control
seizures
Time after giving diazepam
Diazep
amb
loodco
ncentration
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Diazepam (2 iv)
Level required
to control
seizures
Time after giving diazepam
Diazep
amb
loodco
ncentration
After iv administration adequate
levels are reliably achieved
within 5 minutes with 0.3mg/kg
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Diazepam (2 pr)
Level required
to control
seizures
Time after giving diazepam
Diazep
amb
loodco
ncentration
After pr administration adequate
levels are usually achieved within
5 minutes with 0.5mg/kg
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Diazepam (2 im)
Level required
to control
seizures
Time after giving diazepam
Diazep
amb
loodco
ncentration
After im administration
diazepam levels can rise
very slowly and are
unpredictable
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Diazepam (2 clinical implications)
Level required
to control
seizures
Time after giving diazepam
Diazep
amb
loodco
ncentration To terminate a convulsion iv
is preferred, rectal is OK and
im should not be used
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Diazepam (2 clinical implications)
Level required
to control
seizures
Time after giving diazepam
Diazep
amb
loodco
ncentration Levels stay moderately high for
many hoursmultiple doses
can result in very high,
potentially dangerous levels
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Diazepam (2 clinical implications)
Level required
to control
seizures
Time after giving diazepam
Diazep
amb
loodco
ncentration Give the right doseiv / pr
overdoses can rapidly result in
very high levels that have
serious side effects
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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
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Giving rectal diazepam
45 cm
inside the
anal marginAll of the
barrel of a
2mls syringe
and nearlyall of a 1ml
syringe
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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.
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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
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Phenobarbitone (2 clinical implications)
Level required
to control
seizures
Time after giving Phenobarbitone
Phenobarbitoneblood
concentration
Failure to use a loading dose
will result in inadequate levels
and fail to control seizures
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Phenobarbitone (2 clinical implications)
Level required
to control
seizures
Time after giving Phenobarbitone
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
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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.
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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.
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Clinical dilemma?
Wil l treatment make th ing s better or w orse?
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Managing the risks of seizures and
their treatment
Positioning
Observation
Airway support
Oxygen
Bag & mask
ventilation
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Questions?
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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.