Term
| Epidemiology & Social Impact of Epilepsy |
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Definition
| chronic medical condition marked by recurrent seizures; one of most common neurological disorders (1-2% of US pop); Incidence is 35-75 cases per 100,000 persons per yr; approx. 8% of US pop. will experience seizure during lifetime; Huge impact on quality of life & lifestyle --> limits driving, significantly affects education & employability |
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Term
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Definition
| discrete, time-limited alterations in brain function including changes to motor activity, autonomic fcn, consciousness, or sensation that results from abnormal & excessive electrical discharge of a group of neurons within cerebral cortex; reflects area where seizure begins (seizure focus) accompanied by indescribable body sensations, "Pins & needles" sensations, smells or sounds, depression, hallucinations, momentary jerks or head nods; involuntary muscular contractions (Convulsions) |
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Term
| Medications that can cause Seizures/Epilepsy |
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Definition
| tramadol, bupropion, theophylline, antidepressants/antipsychotics, lithium, alcohol/drug withdrawal |
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Term
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Definition
| condition characterized bgy recurrent (2 or more) seizures unprovoked by any immediately identifiable cause |
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Term
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Definition
| subjective disturbance of perception that represents start of certain seizures |
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Term
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Definition
| the actual seizure itself |
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Term
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Definition
| period after seizure where individual may be sleepy, confused, disoriented, or experiences temporary neurological dysfunction |
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Term
| Pathophysiology of Epilepsy/Seizures |
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Definition
| onset occurs when small group of abnormal neurons undergo prolonged depolarization associated w/ rapid firing of repeated APs; these then recruit adjacent neurons --> electrical discharges of large # of cells that becomes abnormally linked together --> storm of electrical activity --> clinical seizure; occurs due to imbalancec between excitatory & inhibitory processes in brain: decreased inhibitory neurotransmission by GABA & enhanced excitatory neurotransmission mediated by glutamate |
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Term
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Definition
| 80% is idiopathic (no specific cause); for infants/children: congenital malformations, perinatal injuries, hypoxia, neurological disorders, metabolic defects, injury, infection; Young adults: head trauma, brain tumors, infection, AVMs; Elderly: cerebrovascular dx, CNS degenerative dx, brain tumors; Genetic: |
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Term
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Definition
| seizures in which initial onset starts from a localized area in brain, then subdivided depending on maintenance of consciousness; most common type experienced by adults |
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Term
| Simple Partial Seizures (SPS) |
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Definition
| NO LOSS OF CONSCIOUSNESS; Clinical manifestations relate to particular area of brain involved (motor, sensory, autonomic, or psychic manifestations); Duration: 30 sec or less; Prognosis: good control in 30-50% of pts |
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Term
| Complex Partial Seizure (CPS) |
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Definition
| IMPAIRMENT or LOSS OF CONSCIOUSNESS; usually occurs with aura (SPS, fear, rising epigastric sensation, picking at clothes, mumbling, etc.); Duration: 1-3 min; Postictal phase: confusion, lethargy, altered behavior, amnesia; EEG: unilateral or bilateral discharge in temporal or frontotemporal region; Prognosis: controlled in 40-60% of pts; Most common type seen in adults |
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Term
| Partial Seizures Secondarily Generalized |
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Definition
| localized seizure that may progress thru several stages reflecting the spread of discharge to different brain areas |
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Term
| Generalized Tonic-Clonic Seizures (GTC) |
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Definition
| LOSS OF CONSCIOUSNESS --> sudden fall to ground; next phase --> muscles become rigid, simultaneous contractions of diaphragm & chest muscles ("epileptic cry") --> series of synchronous clonic movements of head, face, legs, & arms; Occurs most comonly during 2nd decade of life; Duration: 2-5 min; Postictal: lethargic/sleepy lasting several min to hours; Incontinence seen in early postictal stage; Occurs most commonly on awakening & to a lesser extent in evening; Prognosis: good control in 70-85% of pts |
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Term
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Definition
| Onset: 4-14 yrs old, resolved by age 18; brief episodes of staring w/ impairment of awareness & responsiveness, begins without warning & ends suddenly, leaving pt alert & attentitive; Simple = only staring; Complex = staring with automatic movements (blinking of eyes, drooping of head, chewing); Duration: 10-45 sec, pt unaware of occurrence; Abrupt recovery w/ no residual effects; 25-50% of pts develop generalized tonic-clonic seizures; Long-term prognosis is good; Important in children to differentiate from complex partial seizures since tx & prognosis vary |
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Term
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Definition
| occurs between 2-5 yrs old; Sudden & total loss of muscle tone & postural control --> eyelids drop, head nods, pt falls to ground ("Drop Attack") - must wear a helmet for protection; Duration: 10-60 sec; Prognosis: dependent on presence of underlying neurological deficit and/or mental retardation |
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Term
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Definition
| sudden, brief, shock-like jerk of a muscle or group of muscles that often occurs in healthy pts as they fall asleep; causes synchronous & bilateral jerks of neck, shoulders, upper arms, body, & upper legs |
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Term
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Definition
| sudden bilateral stiffening of body, arms, or legs; Duration: less than 20 sec; more common during sleep; Seen in younger children, associated w/ metabolic disorder or underlying neurological deficit; Duration: 10-60 sec |
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Term
| Infantile Spasms - aka West's Syndrome |
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Definition
| occurs in infants less than 1 yr of age; specific EEG pattern & spasms or jitters; babies often develop other seizure types & epilepsies later in life; Tx: ACTH, prednisone, vigabatrin |
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Term
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Definition
| convulsions brought on by a fever (rectal temp. >102 degress F) in infants or small children; generalized tonic-clonic seizures usually occur; children prone to this syndrome are not considered to have epilepsy; DO NOT tx with oral anticonvulsants (phenobarb, valproate); TREAT with diazepam (Oral or rectal) when infant has fever |
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Term
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Definition
| triad of intractable seizures, mental & developmental retardation, & slow spike & wave pattern on EEG; seizures begin between 1-6 yrs of age & respond poorly to antiepiletpic drugs; common behavioral problems |
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Term
| Juvenile Myoclonic Epilepsy |
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Definition
| myoclonic seizures that begin shortly before or after puberty; myoclonic & tonic-clonic seizures most often occur in early AM, shortly after pt awakes; mental development is normal; Usually well-controlled by valproic acid alone, but requires life-long therapy |
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Term
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Definition
| 1) confirm pt has epilepsy; 2) Correct classification of seizure type &/or epileptic syndrome; 3) Identify any underlying causes of seizures; 4) Treat w/ appropriate drug therapy if indicated |
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Term
| Underlying Factors that Cause Seizures |
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Definition
| metabolic and/or electrolyte imbalance; sedative or EtOH withdrawal; sleep deprivation; AED withdrawal or inadequate AED tx; fever or systemic infection; stimulants (IV drug use, cocaine, ephedrine) |
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Term
| Diagnostic Evaluation of Epilepsy |
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Definition
| History: medical hx, description of seizures (events preceding, during, & after, identify precipitating factors); Physical & Neurological Exam; Clinical Lab Data (CBC, LFTs, Serum chemistry); EEG (electroencephalogram); Neuroimaging studies (MRI, CT) |
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Term
| Precipitating Factors of Epilepsy in Susceptible PTs |
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Definition
| sleep deprivation; fever; emotional stress; lack of food; alcohol/drug withdrawal; pregnancy; menses; various sensory stimuli (photosensitivity, TV, reading, eating, music) |
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Term
| First Aid for Generalized Tonic-Clonic Seizures |
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Definition
| 1) prevent pt from hurting themself; 2) do not force anything into pts mouth; 3) do not restrain pts movements; 4) Turn pt on side; 5) stay w/ pt until seizure ends naturally; 6) Give artificial respiration if pt does not resume breathing after seizure; 7) Provide area for pt to rest until fully awakened; 8) Be reassuring & supportive; 9) Immediate medical attention required if: seizure lasts >10 min, difficulty in rousing at 20 min intervals, complains of difficulty with vision, vomiting, persistent HA, unconsciousness w/ failure to respond, excessively dilated pupils |
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Term
| First Aid for Nonconvulsive (Absence & Complex Partial) Seizures |
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Definition
| 1) do not restrain pt; 2) remove harmful objects from pt's path; 3) calmly try to encourage pt to sit down; 4) Observe but DO NOT approach pt who appears angry or combative; 5) Remain w/ pt until fully alert |
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Term
| Nonpharmacological Treatment of Epilepsy |
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Definition
| 1) surgery (temporal lobectomy); 2) Vagal nerve stimulation ; 3) ketogenic diet; 4) Lifestyle modifications: adequate sleep, avoid EtOH, stimulants, avoid known precipitants, reduce stress |
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Term
| Primary Goal of Drug Therapy |
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Definition
| 1) complete suppression of seizures & absence of disabling side effects; 2) when epilepsy can't be controlled, attain best compromise b/w maximizing seizure control & minimizing side effects; 3) It should maintain or restore pt's lifestyle & ability to lead active life |
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Term
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Definition
| 1) appropriate diagnostic evaluation; 2) identify and correct any underlying causes; 3) treat seizures (assess necessity of drug therapy, begin appropriate AED therapy, identify & avoid any precipitating factors, evaluate for surgery or other options if refractory to AED therapy); 4) Prevent complications due to seizures |
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Term
| Principles of AED Therapy |
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Definition
| 1) select most appropriate drug based on: seizure type (primary criteria), individualized selection based on lifestyle, ADRs, administration convenience); 2) MONOTHERAPY is preferred; 3) Individualization of Dosage - start at low end of recommended dosage range & slowly increasing until seizures are controlled or intolerable adverse effects develop; 4) Monitor Therapy - seizure diary, ADRs, Lab Tests, AED plasma concentrations; 5) Appropriate use of AED plasma concentrations; 6) Evaluate Pt with Chronic Active Epilepsy; 7) Termination of Antiepileptic Drug Therapy; 8) Patient Education |
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Term
| Switching AEDs for Monotherapy |
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Definition
| Titrate 2nd drug to recommended dose range, then start gradually withdrawing initial drug over 1-3 wks; After initial drug has been withdrawn, dose of 2nd drug should be increased until seizures are controlled or intolerable side effects develop |
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Term
| Evaluation of Pt w/ Chronic Active Epilepsy |
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Definition
| 1) review diagnosis/etiology; 2) review adherence; 3) Try to improve adherence; 4) Review drug history; 5) Develop tx plan; 6) Reduce polytherapy if applicable |
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Term
| Tapering Schedule for Withdrawing AED Therapy |
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Definition
| 1) ensure drug plasma conc. of DESIRED drug(s) are in usual therapeutic range, then slowly withdraw UNWANTED drug over several days to wks; 2) Decrease dose of UNWANTED drug by 25% every 1 to 2 wks; 3) If exacerbation of seizures occurs during drug withdrawal, dose should be increased to previous level, then retry withdrawing UNWANTED drug using a more gradual schedule |
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Term
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Definition
| toxic CNS effects: somnolence, fatigue, dizziness, vision changes, nystagmus, ataxia, tremor, GI disturbances, difficulty thinking, & behavioral disorders; Increased suicide risk; Idiosyncratic effects: aplasatic anemia, skin rash, hepatotoxicity, pancreatitis, lupus-like rxn, SJS; SKIN RASH, HEPATOTOXICITy; APLASTIC ANEMIA/AGRANULOCTYOSIS; Chronic: connective tissue, endocrine, GI, hematologic, & neurologic disorders; TERATOGENICITY |
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Term
| Guidelines for Management of AEDs during Pregnancy |
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Definition
| 1) take 1-4 mg folic acid daily; 2) use monotherapy when possible; 3) Use lowest doses that control seizures; 4) Monitor AED serum conc. at start of pregnancy & monthly thereafter; 5) Adjust AED doses to maintain baseline serum conc.; 6) Add supplemental Vitamin K to women receiving enzyme-inducing AEDs; Avoid valproic acid; Counsel pt on risk of potential complications & congenital malformations; |
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Term
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Definition
| Indications: 1st line for PRIMARY GENERALIZED & PARTIAL SEIZURES except absence seizures - NOT EFFECTIVE for absence seizures; Pks: NON-LINEAR, zero-order; prolonged but completely absorbed orally; highly protein bound, enzyme INDUCER, non-linear elimination; Forms: acid - 100% bioavailable, sodium - 92% bioavailable; Chronic ADRs: gingival hyperplasia, hirsutism; Idiosyncratic ADRs: Fetal Hydantoin Syndrome (FHS) |
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Term
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Definition
| >20 mcg/mL - nystagmus, ataxia, altered mental status; >30 mcg/mL - ataxia, seizures reported; >40 mcg/mL - lethargy, seizures, coma |
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Term
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Definition
| Indications: PARTIAL & GENERALIZED seizures, NOT absence, 2nd line agent due to SEs; PKs: long half-life, dosed once daily, linear elmination; Dosing: start with low doses & titrate up; ENZYME INDUCER; Acute ADRs: dose-related CNS depression, sedation, nystagmus, dizziness, ataxia, PARADOXICAL EFFECT IN CHILDREN (hyperactivity); |
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Term
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Definition
| Indication: PARTIAL & GENERALIZED, NOT absence seizures; ADRs: dose-related depression, sedation, nystagmus, dizziness, ataxia |
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Term
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Definition
| Indications: trigeminal neuralgia, PARTIAL & GENERALIZED seizures, NOT ABSENCE; DRUG OF CHOICE for complex partial seizures; PKS: enzyme INDUCER, induces its own metabolism (AUTOINDUCTION) -> levels drop after a month; Acute ADRs: dose-dependent CNS depression but MUCH LESS than phenytoin or phenobarb; Chronic ADRs: SIADH - monitor Na levels & signs & symptoms |
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Term
| valproic acid (Depakene), divalproex sodium (Depakote) |
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Definition
| Indications: broad sprectrum - effective for ALL seizure types; 1st line for GENERALIZED seizures (MYOCLONIC, ATONIC, & ABSENCE), monotherapy & adjunctive for PARTIAL, effective for mixed seizure types; PKs: bioavailability of ER product 15% less than EC formulation; metabolized in liver, enzyme INHIBITOR, causes hepatic toxicity; Acute ADRs: fine motor tremor, alopecia; Idiosyncratic ADRs: hepatotoxicity, monitor N/V, lethargy, anorexia, edema, LFTs for first 6-12 months; Chronic ADRs: hyperammonemia, weight GAIN, polycystic ovary-like syndrome, adverse endocrine effects |
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Term
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Definition
| Indications: NARROW spectrum - effective ONLY for ABSENCE seizures; Chronic ADRs: HA, behavioral changes; IS NOT an enzyme inducer or inhibitor; drug levels reduced by carbamazepine & increased by valproic acid |
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Term
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Definition
| Indications: monotherapy or adjunctive therapy of PARTIAL or PARTIAL SECONDARILY GENERALIZED seizures, ATONIC seizures in Lennox-Gastaut syndrome, LAST LINE AGENT (aplastic anemia, hepatotoxicity) |
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Term
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Definition
| water-soluble PRODRUG; parenteral administration; safer & better tolerated than IV parent drug; Dose in terms of phenytoin equivalents (PE), 1 mg PE = 1 mg phenytoin; |
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Term
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Definition
| Indications: adjunctive for PARTIAL & PARTIAL SECONDARILY GENERALIZED seizures, also used for chronic pain, peripheral neuropathy, & other nonepilepsy conditions; PKs: NOT protein bound, NO drug interactions; Acute ADRs: LESS CNS effects than traditional AEDs; Chronic ADRs: weight gain |
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Term
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Definition
| Indications: monotherapy & adjunctive for PARTIAL seizures, effective for GENERALIZED seizures in Lennox-Gastaut syndrome, also used for GENERALIZED TONIC-CLONIC seizures & nonepilepsy disorders like bipolar disorder; PKs: autoinduction occurs & increases CL by 25%; NO enzyme inhibition or induction; Acute ADRs: dizziness, diplopia, ataxia, folic acid deficiency; Idiosyncratic ADRs: RASH - occurs within 3-4 wks, SJS HAS OCCURRED |
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Term
| oxcarbazepine (Trileptal) |
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Definition
| Indication: monotherapy & adjunctive therapy in PARTIAL seizures, potential 1st line for PRIMARY GENERALIZED CONVULSIVE seizures; ENZYME INDUCER tho less than carbamazepine; Idiosyncratic ADRs: rash, 25-30% of pts that develop rash w/ carbazepine will develop rash w/ this drug; Chronic ADRs: SIADH |
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Term
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Definition
| Indications: monotherapy of PARTIAL & GENERALIZED seizures, for children w/ Lennox-Gastaut syndrome, used for migraines, bipolar disorder, & PTSD; Acute ADRs: psychomotor slowing, difficulty with concentration & memory, parasthesias; Idiosyncratic ADRs: metabolic acidosis 2ndary to carboncic anhydrous inhibition; Chronic ADRs: kidney stones, weight LOSS |
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Term
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Definition
| Indicaitons: 2nd line for PARTIAL seizures who have failed initial therapy, DOES NOT have role in primary generalized seizures |
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Term
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Definition
| Indications: adjunctive therapy for PARTIAL ONSET seizures, MYOCLONIC seizures, PRIMARY GENERALIZED TONIC-CLONIC seizures; PKs: cleared renally, prolonged T1/2 in pts w/ renal insufficiency. DECREASED dosing in renal infsufficiency; DOES NOT induce or inhibit enzymes; Monitor: decreases in RBC count, Hgb/Hct, WBCs, & neutrophils, monitor CBCs routinely while on therapy |
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Term
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Definition
| Indications: adjunctive for PARTIAL seizures; Idiosyncratic ADRs: rash, oligohydrosis (decreased ability to sweat); Chronic ADRs: kidney stones, weight LOSS; Monitor: BUN/CR, renal fcn, for skin rash, CBC & LFTs |
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Term
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Definition
| Indications: adjunctive for PARTIAL ONSET seizures, also used for neuropathic pain (diabetic neuropathy), post-herpetic neuralgia (PHN), fibromyalgia; NO drug interactions |
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Term
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Definition
| Indications: adjunctive for PARTIAL ONSET seizures, NOT indicated for neuropathic pain yet; ADRs: elevated liver enzymes, ECG changes; Dosing: use w/ caution in hepatic impairment & severe cardiac dx |
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Term
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Definition
| Indications: adjunctive for LENNOX-Gastaut SYNDROME; use with valproic acid increases blood levels of drug |
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Term
| Recommended AEDs for Partial ONSET seizures with or without secondary generalization |
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Definition
| carbamazepine, lamotrigine, oxcarbazepine, phenytoin, topiramate, valproate |
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Term
| Recommended AEDs for PRIMARY GENERALIZED TONIC-CLONIC Seizures |
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Definition
| carbamazepine, lamotrigine, topiramte, valproate, oxcarbazepine, phenytoin |
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Term
| Recommended AEDs for Generalized ABSENCE Seizures |
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Definition
| ethosuximide, lamotrigine, valproate |
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Term
| Recommended AEDs for Generalized MYOCLONIC Seizures |
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Definition
| lamotrigine, valproate, topiramate (for children) |
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Term
| Recommended AEDs for Generalized TONIC Seizures |
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Definition
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Term
| Recommended AEDs for Generalized ATONIC Seizures |
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Definition
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Term
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Definition
| neurologic emergency that can lead to permanent brain damage or death; recurrent epileptic seizures without full recovery of consciousness before next full seizure begins OR continuous electrical seizure activity lasting >30 min; present as Non-convulsive or Generalized convulsive |
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Term
| Non-convulsive Status Epilepticus (NCSE) |
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Definition
| persistent state of impaired consciousness and/or motor or sensory seizures without impaired consciousness; EEG is key to diagnosis |
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Term
| Generalized Convulsive Status Epilepticus (GCSE) |
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Definition
| involves entire brain; characterized by full body tonico-clonic motor seizures; consciousness is impaired |
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Term
| Factors Affecting Outcome of SE |
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Definition
| Age - incidence pks between 60-79 yrs old & children; Duration - responsiveness to 1st line therapy decreases w/ increasing duration of SE;, survival decreases with increasing duration |
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Term
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Definition
| CNS infection or tumor; trauma, hypoxia, stroke, metabolic disorders (hypoglycemia), chronic alcohol abuse, preexisting epilepsy, drug toxicity or withdrawal, AED change or subtherapeutic AED levels |
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Term
| Principles for Management of SE |
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Definition
| Goal: rapid termination of clinical & electrical seizure activity; Medical emergency; Predetermined Rx protocol more effective then letting pt "ride it out" |
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Term
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Definition
| Assess/Monitor: vitals, airway, cardiac function (EKG), pulse ox, check blood glucose, check lab tests; Tx: stabilize airway, administer O2, secure IV access & start fluids, give THIAMINE 100 mg + glucose if hypoglycemic |
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Term
| Time 0-10 min during Tx of SE |
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Definition
| Assess/monitor: vitals, PhEx, Pt hx (Rx, OTCs, herbals); Tx: give lorazepam 0.1 mg/kg IVP (MAX = 4 mg) at 2 mg/min - may repeat in 10-15 min to MAX = 8 mg if no response, IF NO IV ACCESS --> give diazepam 10 mg PR OR midazolam 0.2 mg/kg IM |
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Term
| Time 10-30 min for Tx of SE |
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Definition
| Assess/monitor: vitals, review lab results & correct any underlying abnormalities, CT scan (if controlled); Tx: phenytoin 15-20 mg/kg IV at MAX rate of 50 mg/min (or fosphenytoin 15-20 mg PE/kg IV at max rate of 150 mg/min), IF NO IV ACCESS --> give fosphenytoin IM, tx for possible infection |
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Term
| Time 30-60 min for Tx of SE |
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Definition
| Assess/monitor: vitals, consult neurologist/epileptologist, consider amdit to ICU, consider EEG; Tx: IF SEIZURES continue --> additional phenytoin bolus 5-10 mg/kg (or fosphenytoin 5-10 mg PE/kg) OR start phenobarbital at 20 mg/kg IV at MAX rate of 100 mg/min |
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Term
| Time >60 min for Tx of SE |
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Definition
Assess/Monitor: vitals, transfer to ICU, obtain EEG, consider MRI when controlled; Tx: IF SEIZURES CONTINUE: repeat boluses of phenobarbital 10 mg/kg until seizures stop
OR valproate sodium 20 mg/kg at 6 mg/kg/min MAX followed by 1-4 mg/kg/hr continuous infusion
OR midazolam 2 mg/kg bolus followed by 0.05-2 mg/kg/hr CI
OR propofol 1 mg/kg bolus followed by 2-15 mg/kg/hr CI
OR pentobarbital 10-15 mg/kg bolus over 1-2 hrs followed by 0.5-4 mg/kg/hr;
Consider intubation;
Consider pressor support if needed |
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Term
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Definition
Adv: rapid onset of action (1-3 min), can give rectally;
Disadv: short duration of action (15-30 min), depresses consciousness (10-30 min), respiratory depression/hypotension, accumulation of parent/active metabolies w/ repeated administration |
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Term
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Definition
Preferred agent when treating SE;
ADV: rapid onset of action (5-10 min), long duration (12-24 hrs)
DISADV: depresses consciousness, respiratory depression/hypotension, tolerance may develop w/ long-term use |
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Term
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Definition
ADV: can give IM, buccally, or intranasally, fewer repiratory & cardiovascular effects
DISADV: expensive, short half-life |
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Term
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Definition
ADV: long duration of action (24 hr), low risk of respiratory depression, little effect on consciousness, continued as chronic therapy
DISADV: IV administration only, hypotension & arrhythmias, infusion rate no > than 50 mg/min, extravasation can cause local color change edema, pain, & necrosis, can only give with D5W |
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Term
| Problems with Parenteral Phenytoin Administration |
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Definition
| contains 40% propylene glycot at pH 12; incompatibility problems with common IV fluids; venous irritation, pain, phlebitis at IV site; soft tissue damage, necrosis with extravasation; Slow, erratic IM absorption, tissue necrosis at IM injection site; DO NOT GIVE IM!!! |
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Term
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Definition
ADV: greater water solubility, pH 8.5 --> compatible w/ most IV fluids including dextrose, reduction in infusion-related AEs, can administer at higher IV rates, Feasible IM administration (large injection volumes)
DISADV: paresthesias around lips & groin, very expensive
Prodrug of phenytoin, converted to phenytoin (delayed onset of action), administration at rates up to 3x max for phenytoin, use a dedicated line for IV administration, monitor ECG, BP |
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Term
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Definition
ADV: long duration of action (>48 hrs), no tolerance, continued as chronic therapy, IM/rectal administration possible
DISADV: depresses consciousness, respiratory depression/hypotension |
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Term
| valproate sodium injection (Depacon) |
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Definition
| substitute when oral therapy is not feasible; 1:1 conversion from oral to IV dose; administer as 60 min infusion no faster than 20 mg/min; infusion rates of 1.5-3 mg/kg/min well tolerated; |
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Term
| rectal diazepam (Diastat) |
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Definition
| drug has comparable efficacy to IV form |
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