Time Is Brain: Acute Control of Repetitive Seizures and Status Epilepticus Using Alternative Routes of Administration of Benzodiazepines

Abstract

Time plays a major role in seizure evaluation and treatment. Acute repetitive seizures and status epilepticus are medical emergencies that require immediate assessment and treatment for optimal therapeutic response. Benzodiazepines are considered the first-line agent for rapid seizure control. Thus, various routes of administration of benzodiazepines have been studied to facilitate a quick, effective, and easy therapy administration. Choosing the right agent may vary based on the drug and route properties, patient’s environment, caregiver’s skills, and drug accessibility. The pharmacokinetic and pharmacodynamic aspects of benzodiazepines are essential in the decision-making process. Ultimately, agents and routes that give the highest bioavailability, fastest absorption, and a modest duration are preferred. In the outpatient setting, intranasal and buccal routes appear to be equally effective and more rapidly administered than rectal diazepam. On the other hand, in the inpatient setting, if available, the IV route is ideal for benzodiazepine administration to avoid any potential absorption delay. In this article, we will provide an overview and comparison of the various routes of benzodiazepine administration for acute control of repetitive seizures and status epilepticus.

Management of Status Epilepticus, Refractory Status Epilepticus, and Super-refractory Status Epilepticus

“…The EEG identified the subtle jerks as epileptic in origin (FIGURE [12][13][14][15]. In this recording, the contralateral muscle artifacts prove the time-locked relationship between the periodic discharges and the clinical phenomena.…”

“…On the one hand, clinicians may misinterpret the neurophysiologist's diagnosis of "possible status" as "status epilepticus" without critically reviewing the full clinical and paraclinical information (imaging, laboratory, toxicology) as to whether the diagnosis of nonconvulsive status epilepticus should be confirmed or rejected (FIGURE and FIGURE [12][13][14]. On the other hand, clinicians reading "ictal-interictal continuum" in the report may be satisfied and not further investigate the patient with ictal MRI or ictal SPECT to confirm status epilepticus (FIGURE [12][13][14]. Because the terms ictal-interictal continuum and possible electrographic status epilepticus are synonyms, the authors of this article recommend using all available clinical, imaging, laboratory, and toxicologic information to understand as to what extent pathologic EEG patterns are the result of structural or metabolic derangements (concept for high specificity) (FIGURE 12-11, FIGURE FIGURE 12-13, and FIGURE [12][13][14].…”

“…107 However, a few notes of caution should be added. On the one hand, clinicians may misinterpret the neurophysiologist's diagnosis of "possible status" as "status epilepticus" without critically reviewing the full clinical and paraclinical information (imaging, laboratory, toxicology) as to whether the diagnosis of nonconvulsive status epilepticus should be confirmed or rejected (FIGURE and FIGURE [12][13][14]. On the other hand, clinicians reading "ictal-interictal continuum" in the report may be satisfied and not further investigate the patient with ictal MRI or ictal SPECT to confirm status epilepticus (FIGURE [12][13][14].…”

“…Increased secondary hyperperfusion has been revealed by cerebral hexamethylpropyleneamine oxime (HMPAO)-SPECT. [124][125][126][127] Lateralized periodic discharges (LPDs) faster than 2.0 Hz have been associated with a drop in partial pressure of oxygen in interstitial brain tissue, 114 suggesting a failure to compensate the increased metabolic demand coming with the periodic discharges (FIGURE [12][13][14][15][16].…”

“…On the other hand, clinicians reading "ictal-interictal continuum" in the report may be satisfied and not further investigate the patient with ictal MRI or ictal SPECT to confirm status epilepticus (FIGURE [12][13][14]. Because the terms ictal-interictal continuum and possible electrographic status epilepticus are synonyms, the authors of this article recommend using all available clinical, imaging, laboratory, and toxicologic information to understand as to what extent pathologic EEG patterns are the result of structural or metabolic derangements (concept for high specificity) (FIGURE 12-11, FIGURE FIGURE 12-13, and FIGURE [12][13][14]. Concerning the EEG or clinical response to IV administered antiseizure medication, no consensus has been reached as to which time points to test and which criteria define an EEG-based or clinical improvement.…”