Status epilepticus is a medical emergency. Loraze-pam i.v. is now the preferred initial choice. Clonazepam is an alternative. Diazepam i.v. was widely used as the first line drug, but it is more likely to cause hypotension and respiratory depression, and its antiepilepsy effect wears off after about 20 minutes, so that phenytoin i.v must also be given at the same time to suppress further fitting (with ECG and blood pressure monitoring, since cardiac arrhythmias and further hypotension may result). For this reason some consider phenobarbitone to be safer. If resuscitation facilities are not immediately available, diazepam can be given by rectal solution. Midazolam (nasally) may be preferred in institutions, e.g. mental hospitals, rather than diazepam rectally because patient and carer compliance are better. Clomethiazole is often given in status epilepticus since it is easy to administer, but it has no prolonged anticonvulsant effect and is prone
TABLE 20,1 Treatment of status epilepticus in adults
Early status Loraiepam 4 mg i.v.; repeat once after
10 minutes if necessary or Clonazepam I mg i.v. over 30 seconds, repeat if necessary or Diazepam I 0-20 mg over 2—4 min; repeat once after 30 minutes if necessary.
Established status Phenytoin I S-18 mg/kg i.v. at a rate of 50 mg/minute and/or Phenobarbitone 10-20 mg/kgi.v.ata rate of 100 mg,'minute or
Refractory status Thiopental or Propofol or
Midazolam with full intensive care support to cause respiratory depression and hypotension. Details of further management appear in Table 20.1.
Once the emergency is over, exploration of the reason for the episode and reinstitution of normal therapy are essential. Magnesium sulphate may be better than phenytoin for the treatment of the seizure disorder of eclampsia (see also p. 493).5
Paraldehyde is now rarely used. It smells and tastes unpleasant and is partly excreted unchanged via the lungs (75% is metabolised; t |/2 5 h); it is an irritant (avoid in peptic ulcer) and causes painful muscle necrosis when injected i.m. It dissolves plastic syringes.
Pharmacology of individual drugs
The drugs used in the treatment of epilepsy are given in Table 20.2.
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