second line seizure medications

[paramatt_]

Hey there, new thread!

Just after some anecdotal information on those providers who carry multiple or second-line antiepileptic medications, epscially non benzos. I've had a few cases over the past year or so where pts have responded poorly to treatment, including a couple of pediatric febrile status epilepticus.  (we only carry midaz with weight based dosing).

I've done a bit of research on the topic but just interested to know what others are actually doing/using including how often they get used and indications for use.

[medicgirl05]

In my 10 years I've only had 1 patient who's seizures didn't respond to Valium, and it was a really awful call. 30 minute transport time if back to back seizures. Young lady with no history, didn't carry sedation, so I gave all my Valium and tried to maintain her airway when she couldn't. It turned out she had a brain bleed causing her to seize. 

I'm interested to see how others respond to this.

[rock_shoes]

Our air-evac crews carry phenytoin, propofol, and worst case scenario paralytics in addition to the usual benzo's. We can also make use of any second line agent a sending hospital has in stock if we need to. We use second line agents for certain categories of intracranial bleed with a propensity to seize more often than anything. Scene responses are mainly trauma patient's for us which typically respond to benzo's. Inter-facility patients are definitely where we use them the most frequently.

Second line agent's aren't terribly useful on a city ALS unit and require a pump which few ground services have. For a rural unit with long transport times I can certainly see potential value in carrying a second line agent. The further you are from a hospital the more valuable second line treatments of any variety become. The amount of gear we take with us on air-evac calls can attest to that lol.

[Just Plain Ruff]

I worked for a service that was hospital based.  We had all the 1st and 2nd line antiseizure meds.  We basically had what the ED had in it's formulary on our rigs.  yes we had a crap load of meds that often went expired before we ever used them.  

I've used most if not all the anti seizure meds on one patient or another.  

Flash forward to my second time working there, the list was decreased significantly due to a new medical director.  

sometimes more is better, often times more is worse in my opinion, I cannot imagine how much money we wasted on expired drugs.  

To expand,  our formulary on our rigs included  Dilaudid, mepergan, demerol, Fentanyl and Morphine.  We also carried toradol and tylenol, ibuprofen and aspirin.  

 

Our patients were very well pain controlled.  

[DartmouthDave]

Hello,

I have attached a link to a outstanding review article from BRAIN: JOURNAL OF NEUROLOGY on the management of status epilepticus.  Very helpful information.  Also, if you look at their step approach they are much more cautious than one typically see in emergency medicine (i.e. three+ seizures without recovery is status).  More time is given for medications to work before intubation and general anesthesia.

 

The treatment of super-refractory status epilepticus: a critical review of available therapies and a clinical treatment protocol

http://oup.silverchair-cdn.com/oup/backfile/Content_public/Journal/brain/134/10/10.1093/brain/awr215/2/awr215.pdf?Expires=1485878433&Signature=EYWaFW2VPwjf75aa7W90l-zxtW~X2vCN5dh0wnuXw1SgIo7wor2U3CZ75HwaPiUX5QyfF4uN0tzJlVUFYsGtr8XelQ5JbPfy7l55Gz~xqy1TXE4g1lap8KQjNGicehxghlAq6P3BP0jQ22ZD-lJnaCLJt8nxTMDMDrAvBnbrs5I72AhtoFQs8cTFuHcgCNmgTROXIpUf9FnxJfZMtnNU6raI3gl1HB2BVGYrlFeX6gZZze3Wthk~cuQqSoQTCAPMegLPzQIR9MnGXXyc2OWA~a6IwbC2dKBywvIbnQ-V8EMCK7sh0CEa~ovWSosPHINRPHgnOTn4CutQfd0LLjhz4A__&Key-Pair-Id=APKAIUCZBIA4LVPAVW3Q

[Just Plain Ruff]

Dartmouth,  I agree with their premise.  I always felt that in most ED's they are too quick to resort to the next medication before allowing the first to work.  

 

Are we causing more harm than good sometimes when we move on to the next med.  I think we found that we were in a code situation but this is promising research.   

[paramatt_]

Thanks for the replies. I definitely agree with you Ruff that cost and potential lack of use has merits what medications are stocked. However, working for a government funded service that generally transports to government funded hospitals one would think there might be better continuity of care..which unfortunately isn't the case. Can be frustrating to see pt's with prolonged seizures or those high risk for multiple seizures get phenytoin loaded upon arrival to emerg which is probably something we could safely do (all our trucks have syringe drivers)..not meaning to digress...more interested in hearing about other services do things.

DD, thanks for that resd. Very interesting information and definitely picked up some new terminology. Just briefly, although I appreciate the treatment approach and timing structure including giving an opportunity for meds to take effect, I don't know how generaliable it would outside be the hospital/icu setting. Just thinking about TBI or suspected intracranial hemorrhage pt's which I've seen go straight to GA after poor or limited effect from benzos with a goal of not only seizure control but getting prompt imaging and definitive treatment started.

Looking forward to some more discussion 

 

 

 

[rock_shoes]

22 hours ago, Ruffmeister Paramedic said:

Dartmouth,  I agree with their premise.  I always felt that in most ED's they are too quick to resort to the next medication before allowing the first to work.  

 

Are we causing more harm than good sometimes when we move on to the next med.  I think we found that we were in a code situation but this is promising research.   

The caveat always being ability to maintain oxygenation/ventilation. In my own experience the decision to intubate these patients prior to the 90 to 120 minute mark has nothing to do with seizure control. Perhaps Canadian ER's are a little more cautious about taking these patient's airway's? I can only speak for myself but the only time I've ever intubated one of these patients in the field was because the patient was hypoxic, high risk for aspiration, had already aspirated, or they were in ventilatory failure (air-evac transports being a somewhat different of course as that initial 90 to 120 minute may have passed before our arrival).

Emergency medicine has a bit of a "shoot from the hip" reputation amongst the ICU crowd and I think in many ways they have a great deal to learn from each other. Emergency medicine can learn that it isn't always necessary to shoot first ask questions later and Critical Care medicine needs to understand that in the initial phases of treatment morbidity/mortality can increase by failure to act decisively. ED patient's are not typically admitted intubated with initial ventilation optimization and appropriate central/arterial lines. ICU's are presented with patients where critical interventions have been completed making it easier to armchair quarterback how things were done after the fact. This is actually great feedback for the ED but it must be delivered tactfully or the message will invariably be lost.

[DartmouthDave]

Hello,

I agree Matt, outside the hospital, things are more worrisome with many unknown factors.  In fact, in most cases, the etiology of the seizures is unknown and airway protection is a great idea. Especially, in the case of a TBI, SAH, and so forth. As opposed to a 'neurology' consult with a chart and background information.  In fact, many difficult to manage seizure patients (if local) are know by the neurology service.

I was referring to the approach outlined by the authors and not critiquing ED seizure management at all.  Again, it is better to have a secured airway in most situations.

Cheers

[Just Plain Ruff]

On 1/28/2017 at 4:08 PM, DartmouthDave said:

Hello,

I agree Matt, outside the hospital, things are more worrisome with many unknown factors.  In fact, in most cases, the etiology of the seizures is unknown and airway protection is a great idea. Especially, in the case of a TBI, SAH, and so forth. As opposed to a 'neurology' consult with a chart and background information.  In fact, many difficult to manage seizure patients (if local) are know by the neurology service.

I was referring to the approach outlined by the authors and not critiquing ED seizure management at all.  Again, it is better to have a secured airway in most situations.

Cheers

I've been in a situation on a uncontrolled airway on status seizures.  IT was awful,  the mother was right outside the room when she heard the physician(local general practitioner) and a CRNA saying "I can't intubate her, we're losing her"  

IN the end, we were able to get the tube but not after some very very tense minutes.  She never lost oxygenation but we paralized her and then had a very difficult time intubating her.  Took about 10 minutes to fully secure the tube but all her numbers and color was what you would expect from oxygenating her well.  This patient made the CRNA earn his on call pay.  But I was sure we were going to code her.  But someone was watching over her that night.  She had no negative issues based on our intubation attempts except for some scratches on her soft palette.  She should be about 15 years old now.  

Edited January 29, 2017 by Ruffmeister Paramedic
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