Overview
Definition:
Seizure first aid for families involving rescue medications refers to the immediate administration of specific anti-seizure drugs by caregivers at home to terminate prolonged or recurrent seizures in a child, typically administered via non-intravenous routes
This is crucial for managing convulsive status epilepticus in a timely manner
Febrile seizures are common in children and may require rescue medication if prolonged or recurrent
For children with epilepsy, breakthrough seizures may also necessitate rescue therapy.
Epidemiology:
Convulsive status epilepticus occurs in approximately 4-10 per 100,000 children annually
Febrile seizures affect 2-5% of children, with prolonged or recurrent seizures occurring in a subset
Families of children with epilepsy and those prone to febrile seizures are candidates for home-based rescue medication protocols
The majority of prolonged seizures in children are convulsive.
Clinical Significance:
Promptly stopping a prolonged seizure is critical to prevent neurological injury, secondary complications like hyperthermia or hypoxia, and the development of status epilepticus
Educating families on the appropriate use of rescue medications empowers them to act effectively in emergency situations, potentially reducing emergency room visits and hospital admissions
It is a vital component of comprehensive epilepsy and febrile seizure management for pediatric residents preparing for board examinations.
Rescue Medications
Options:
Commonly prescribed rescue medications include benzodiazepines due to their rapid onset of action
These include rectal diazepam, buccal midazolam, and intranasal midazolam
Oral formulations like lorazepam are also used, but absorption can be slower and more variable
The choice of medication and route depends on availability, ease of administration, local protocols, and physician preference.
Mechanism Of Action:
Benzodiazepines enhance the inhibitory effects of gamma-aminobutyric acid (GABA) at the GABA-A receptor, leading to hyperpolarization of neurons and reduced neuronal excitability, thus terminating the seizure
They work by increasing the frequency of chloride channel opening.
Indication For Use:
Rescue medications are indicated for prolonged seizures, typically defined as seizures lasting longer than 5 minutes, or for recurrent seizures occurring within a short period (e.g., multiple seizures within an hour) without the child regaining consciousness between episodes
Specific protocols will outline precise timeframes and seizure patterns
Parents should always call emergency medical services after administering rescue medication, especially if the seizure does not stop promptly.
Administration And Dosing Pediatrics
Rectal Diazepam:
Dosage is typically 0.3-0.5 mg/kg per dose, with a maximum single dose of 10 mg
It can be administered every 5-10 minutes for up to 3 doses if needed, or as per specific physician order
Administration involves inserting the pre-filled syringe into the rectum
Note that absorption can be variable.
Buccal Midazolam:
Dosage is typically 0.1-0.3 mg/kg per dose, with a maximum of 10 mg per dose
It can be given every 5-10 minutes for up to 3 doses
The liquid formulation is administered to the buccal (inside of the cheek) mucosa
It offers faster absorption than oral and is often preferred over rectal routes due to ease of administration and better tolerability.
Intranasal Midazolam:
Dosage is typically 0.2 mg/kg per dose, with a maximum of 10 mg per dose
It can be administered every 5-10 minutes for up to 3 doses
The medication is sprayed into one or both nostrils
This route also provides rapid absorption and is well-tolerated
It is a valuable alternative when buccal administration is difficult.
Oral Lorazepam:
Dosage is typically 0.1 mg/kg per dose, with a maximum of 4 mg per dose
It can be administered every 5-10 minutes for up to 3 doses
While effective, oral absorption can be unpredictable and slower than other routes, making it less ideal for acute rescue scenarios where rapid termination is paramount.
Family Education And Training
Importance Of Training:
Comprehensive training for families is essential, including understanding when and how to administer the medication, potential side effects, and when to seek emergency medical help
Training should be hands-on where possible, with demonstration and return demonstration of administration techniques
This preparedness is key for residents to advise families effectively.
Key Teaching Points:
Educate families on recognizing seizure types that require intervention, understanding the prescribed medication and its correct dosage, proper administration technique for the chosen route, signs of effective termination of seizure, and potential side effects (e.g., drowsiness, lethargy)
Emphasize calling emergency services (108/102 in India) after administration, regardless of seizure cessation.
Storage And Dispensing:
Families must be instructed on proper storage of rescue medications (e.g., at room temperature, away from light, out of reach of children)
Prescription details should be clearly documented
The importance of having medication readily accessible during potential seizure events, such as during travel or at school, should be stressed
Regular checks for expiry dates are vital.
Emergency Protocols:
Families should have a written emergency plan from their physician, outlining the specific medication, dosage, frequency of administration, and when to call emergency medical services or attend the nearest hospital
They should be educated on how to provide clear information to emergency responders about the seizure event and the medication administered.
Complications And Side Effects
Common Side Effects:
The most common side effects are central nervous system depression, including somnolence, lethargy, ataxia, and confusion
Respiratory depression can occur, particularly with higher doses or co-administration of other sedating medications
Hypotension is also a possible adverse effect.
Rare But Serious Complications:
Rare complications include paradoxical excitement, laryngospasm, and the development of respiratory arrest
Long-term use or frequent administration might be associated with tolerance and dependence, though this is less common with intermittent rescue therapy
The risk of aspiration exists if the child is unable to protect their airway.
Management Of Adverse Effects:
Mild somnolence and lethargy are often expected and transient
If significant respiratory depression or hypotension occurs, immediate medical attention is required
Airway support and, if necessary, reversal agents (like flumazenil for benzodiazepine overdose, though rarely used in rescue scenarios due to risk of rebound seizures) may be considered by medical professionals
Close monitoring after administration is crucial.
Role Of Healthcare Professionals
Physician Responsibility:
Physicians are responsible for diagnosing the underlying cause of seizures, determining the need for rescue medication, prescribing the appropriate agent and dosage, and providing comprehensive education to families
They must also ensure appropriate follow-up and re-evaluation of the treatment plan
This includes providing clear, written instructions for home use.
Nurse Role In Education:
Pediatric nurses play a crucial role in reinforcing physician instructions, demonstrating medication administration techniques, answering family questions, and assessing family understanding and preparedness
They are frontline educators for families and essential in ensuring adherence to the treatment plan.
Pharmacist Contribution:
Pharmacists ensure that the correct medication and dosage are dispensed and can provide additional counseling to families regarding storage, administration, and potential drug interactions
They are a valuable resource for families regarding their prescribed medications
Pharmacists also play a role in advising physicians on appropriate formulations and dosages.
Key Points
Exam Focus:
Focus on the indications for rescue medication, preferred agents (benzodiazepines), common routes of administration (rectal, buccal, intranasal), typical pediatric dosages, and the importance of family education
Understand the definition of status epilepticus and the immediate management goals
Recall that these medications are for terminating prolonged seizures, not for chronic seizure prevention.
Clinical Pearls:
Always emphasize calling emergency services after administering rescue medication
Ensure families know the difference between a typical brief febrile seizure and one requiring intervention
Practice return demonstration for administration techniques with families
Keep rescue medications accessible and check expiry dates regularly
Be aware of potential for sedation and respiratory depression and advise parents accordingly.
Common Mistakes:
Mistakes include administering rescue medication for brief or typical seizures, incorrect dosage calculation, improper administration technique leading to ineffectiveness, delaying emergency medical services contact, and not checking medication expiry dates
Failure to adequately educate families about side effects and when to seek further medical help is also a significant error.