Author: Danielle Cassidy, Pharm.D., BCPS Audience: Third year pharmacy students at University of Colorado School of Pharmacy Background: describes common causes of seizures, differentiates dosing of antiepileptic drugs in pediatrics vs. adults, common risk factors associated with febrile seizures, treatment of febrile seizures, treatment of status epilepticus (inpatient & outpatient), & how to dispense/counsel parents on the administration of Diastat.

1. Danielle Cassidy, Pharm.D.
Clinical Pharmacist
cassidy.danielle@tchden.org
March 24, 2009

2.  Define common causes of seizures.
 Differentiate dosing of antiepileptic drugs in kids
as compared to adults.
 List risk factors associated with febrile seizures.
 Define the American Academy of Pediatrics
(AAP) Guidelines for treatment of febrile
seizures.
 Identify appropriate treatment of status
epilepticus in kids (inpatient and outpatient).
 Describe how to dispense and counsel a parent
on the administration of Diastat.

4.  Adults & Kids  Kids
 Partial seizures  Infantile spasms/ West
 Complex syndrome
 Simple  Febrile seizures
 Secondarily  Lennox-Gastaut
generalized syndrome
 Generalized seizures  Juvenile absence
 Absence  Myoclonic absence
 Myoclonic  Benign partial epilepsy
 Clonic of childhood
 Tonic  Juvenile myoclonic
 Tonic-clonic epilepsy
 Atonic

5.  Neonatal asphyxia
 Intraventricular hemorrhage
 Hypoglycemia/hypocalcemia
 Infection (meningitis, fever)
 Genetics
 Medications/ingestion
 Trauma
 Metabolic disorders
 Cranial Tumors
 Idiopathic

6.  Kids versus Adults
 Similarities
 Selection based on seizure type
 Measure serum drug levels
 Monitor for response to therapy and side effects
 Differences
 Higher doses due to increased hepatic metabolism and
volume of distribution
 Dosing is based on mg/kg
 Multiple formulations available

7.  Sprinkle capsules
 Valproic acid
 Topiramate
 Chewable tablets
 Carbamazepine
 Phenytoin
 Lamotrigine

8.  Liquid
 Carbamazepine
 Ethosuximide
 Gabapentin
 Levetiracetam
 Oxcarbazepine
 Phenytoin
 Valproic acid
 Diazepam /lorazepam /midazolam /clonazepam
 Phenobarbital
 Felbamate

9.  How is dosing of pediatric antiepileptic
medications different as compared to adults?
 A) Children are given 50% of the adult dose
 B) Children are dosed on mg/m2
 C) Children are dosed on mg/kg

11.  Generalized seizure occurring during febrile
illness
 Ages 6 months to 5 years
 Exclusion criteria
 Intracranial infections
 Severe metabolic disturbances
 Incidence ~3%

12.  Risk Factors
 Winter months
 Family history
 Daycare attendance
 Neurodevelopmental abnormality
 Rapid elevation of temperature

13.  Simple
 Less than 15 minutes
 Generalized features
 Single occurrence in 24 hour period
 Complex
 Greater than 15 minutes
 Focal features
 More than one occurrence in 24 hours

14.  Treatment not recommended for simple febrile
seziures
 Risk vs. Benefit
 High potential for medication related side effects
 Phenobarbital
 Valproic acid
 Diazepam
 No evidence demonstrating improved long-term
outcomes
 Very low risk of adverse outcomes

16.  Old/Classic
 Single seizure lasting greater than 30 minutes
OR
 Recurrent seizures lasting more than 30 minutes
without full recovery
 Revised
 Single seizure lasting more than 5 minutes
OR
 Two or more seizures with incomplete recovery of
consciousness

17.  Incidence ~1.3-16%
 Risk Factors
 Metabolic abnormalities
 Trauma
 CNS infections
 Hypoxic events
 Intracranial tumors
 Cerebrovascular diseases
 Noncompliance

18.  Initial management
 Maintaining vitals
 Adequate oxygenation of the brain
 Termination of seizure activity
 Prevention of seizure reoccurrence

19. Lorazepam IV 0.1 mg/kg
3-10 mins
Fosphenytoin IV 20 PE/kg or Phenytoin
IV 20mg/kg
20-30 mins
Phenobarbital IV 20 mg/kg
60 mins
Midazolam, propofol, thiopental, Keppra, or
pentobarbital

20.  Infants
 Second line therapy: Phenobarbital
 Out-patient
 Rectal diazepam

21.  What is the correct order of medication
administration for status epilepticus?
 A) Lorazepam, propofol, leviteracitam
 B) Fosphenytoin, phenobarbital, leviteracitam
 C) Lorazepam, phenobarbital, fosphenytoin
 D) Lorazepam, fosphenytoin, phenobarbital

29.  SB is a 3 year old female presenting with new
onset seizure activity.
 POC report SB began having tactile fevers and
HA 3 days PTA.
 Over the weekend, SB was treated with
IBU, which would help periodically, but
symptoms would return.
 On day of admit, she went to her PCP, was dx
with a viral illness, and sent home.

30.  When SB arrived home, FOC noticed eye
deviation to the left, jerking head
movements, and teeth gritting.
 He took her inside and laid her down at which
point she was breathing hard and then stopped
breathing for 1 minute.
 He administered 2 rescue breaths which caused
her to cough and resume breathing.

31.  SB then started having left arm and left leg
jerking.
 At this point the paramedics arrived and
administered diazepam 2 mg x 2 doses.
 The entire episode lasted for about 5-10
minutes.

32.  What is SB’s likely diagnosis?
 Upon arrival to TCH the patient is still seizing
and the MD asks your advice about what
medication to give next. What is your
recommendation? Why?
 Should SB be sent home with abortive therapy?
Why?

34.  MK is a 4 year old female (20 kg) with a hx of
Lennox-Gastaut syndrome presenting in status
epilepticus .
 MOC reports antiepileptic medication changes
by a pediatric neurologist 2 months PTA.
 MK was well controlled during this time without
any breakthroughs seizures.
 7 days PTA, MK began experiencing 1
breakthrough seizure per day.

35.  The pediatric neurologist initiated oxcarbazepine
with a rapid dose titration schedule.
 On day of admission MK had 4-5 seizures in the
morning, with none lasting more than 5 minutes.
 In the afternoon, MK continued to experience
multiple seizures and POC took her to the ED.
 She experienced another seizure in the ED,
lasting for more than 5 minutes.

36.  MD administered lorazepam 2mg IV. Was the
dose of lorazepam appropriate?
 MK continues seizing despite a second doses of
lorazepam. What medication would you
recommend next? Why?
 MK is still seizing after 30 minutes and the MD is
considering phenobarbital. What serious side
effect(s) are we worried about with this
medication?

37.  Conway EE Jr. (2008). Management of seizures and status epilepticus in
the PICU. In T. Shanley & J. Zimmerman (Eds.), Current Concepts in
Pediatric Critical Care (pp. 59-67). Society of Critical Care Medicine, Mount
Prospect, IL.
 Epilepsy in children. First Consult®. Elsevier Inc., St Louis, MO. 18
February 2008. Available at: www.mdconsult.com. Accessed on March
1, 2008.
 American Academy of Pediatrics: Committee on Quality
Improvement, Subcommittee on Febrile Seizures. Practice Parameter: long-
term treatment of the child with simple febrile seizures. Pediatrics
1999;103(6):1307-1039.
 Status epilepticus in children. First Consult®. Elsevier Inc., St Louis, MO.
18 February 2008. Available at: www.mdconsult.com. Accessed on March
1, 2008.
 Behera MK, Rana KS, et al. Status epilepticus in children. MJAFI
2005;61:174-178.
 American Medical Association: Working Group on status epilepticus.
Treatment of convulsive status epilepticus: recommendations of the
epilepsy foundation of American’s Working Group on status epilepticus.