Epilepsia
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Evidence from studies of experimental animals indicates that electrical stimulation of the vagus nerve alters behavioral and electrographic seizure activity. We report on effects of electrical stimulation of the vagus nerve in five patients with medically intractable seizures as part of a clinical trial of chronic vagal stimulation for control of epilepsy. The mechanism of action of the vagal antiepileptic effect is unknown, and it is hoped that analysis of electrophysiological effects of vagal nerve stimulation will help elucidate which brain areas are affected. ⋯ Field distribution studies indicate that this potential is generated in the neck, in the region of the stimulating electrodes. Muscle paralysis confirms this observation. Stimulation at various frequencies had no noticeable effect on electroencephalographic (EEG) activity regardless of whether the patient was under general anesthesia, awake, or asleep.
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Seven patients with complex partial or secondarily generalized tonic-clonic status epilepticus (SE) refractory to benzodiazepines (BZDs) and phenytoin (PHT) were treated with pentobarbital (PTB) coma with an EEG burst suppression (BSP) pattern. PTB administered by continuous intravenous (i.v.) infusion pump at a loading dose of 6-8 mg/kg in 40-60 min was usually sufficient to produce BSP activity and seizure control. PTB was continued 0-24 h at 1-4 mg/kg/h, adjusted to maintain blood pressure (BP) and BSP. ⋯ Patients who had poor outcomes had prolonged seizures (16 h to 3 weeks) before institution of PTB anesthesia, and all had significant underlying central nervous system (CNS) pathology. PTB-induced BSP appears to be safe and effective for refractory SE if it is started soon after failure of a BZD and PHT. Ultimate prognosis depends on SE etiology.
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Comparative Study
A comparison of intraosseous and intravenous routes of administration for antiseizure agents.
Intravenous (i.v.) access for administration of antiepileptic drugs can be time-consuming and difficult in an infant during a seizure. This study examined the intraosseous (i.o.) route as an alternative means of vascular access for drug administration in an animal-seizure model. Domestic swine (13-20 kg) were anesthetized with ketamine (20 mg/kg i.m.) and alpha-chloralose (80 mg/kg i.v.) and given gallamine (4 mg/kg i.v.) to prevent muscle fasciculations. ⋯ Sixty seconds after onset of epileptogenic activity, the animals received saline or diazepam (DZP) (0.1 mg/kg) or propranolol (2.5 mg/kg) i.v. or via the i.o. route (18-gauge spinal needle placed in the right proximal tibia). Both DZP and propranolol were effective in suppressing epileptogenic activity via the i.v. or i.o. routes. Thus, the i.o. route is a rapid and effective alternative route for the administration of antiepileptic drugs when an i.v. route cannot be readily established.
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We evaluated the nature and significance of seizure problems in an emergency department (ED) by studying seizures in an urban community hospital. In 6 months, there were 29,131 ED visits; of these, 200 (0.7%) were for diagnosed seizures. Among these 200 seizure visits, were 69 (34.5%) new-onset seizures, 30 (15%) febrile seizures, and 92 (46%) seizures in epilepsy patients with prescribed antiepileptic drugs (AEDs). ⋯ A hospital ED is a major source for epilepsy and seizure care, but this care is not always optimum. EDs need to be prepared to manage common acute seizure problems. However, EDs must also place greater emphasis on significant nonemergency aspects of seizure care such as AED compliance, associated psychosocial problems, and effective communication with primary care providers.
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The drugs currently used in the emergency management of seizures are chiefly phenytoin, phenobarbital, diazepam, lorazepam, and paraldehyde. The combination of intravenous phenytoin and lorazepam has the advantages of rapid onset of action, sustained efficacy, and freedom from drug interactions. ⋯ Unlike phenytoin, it does not require propylene glycol and high alkalinity for solubility and therefore does not produce soft-tissue injury after parenteral administration. It appears to be close to an ideal drug for the emergency management of seizures.