July 2016

If you tremor in fear when a seizure patient presents to the clinic, let this VETgirl blog post be your diazepam injection of tranquility!

Here are 5 pearls to consider when evaluating a seizure patient.

1) There are 2, true seizure emergencies:

  • Cluster seizures: Considered 2 or more seizures within a 24-hour period.
  • Status Epilepticus: While there are several definitions, I often consider this to be the case when there is a seizure lasting longer than 5 minutes.

Both of those scenarios require immediate evaluation, stabilization and in most cases, anticonvulsant therapy.

NOTE: it is important to rule out other causes of seizures before solely using anticonvulsant therapy (e.g. hypoglycemia, etc)

2) If possible, an intravenous catheter should be placed on admission with the goal of intravenous access for anticonvusalnt therapy. This is likely to be more effective on the emergent basis than other routes of administration (i.e. rectal valium). As a friend and colleague, Dr. Jane Quandt, DACVECC, DACVAA once said…(paraphrasing) – I’m not sure how coating a turd with valium will help.

3) The reason we stop seizure behavior is not because it is scary to watch, rather cerebral injury may result from persistent excitotoxicity in combination with hypoxemia, hyperthermia and hypotension. This is why therapy such as mannitol is considered following prolonged seizure behavior.

4) During a seizure crisis, a best guess estimate may be life saving rather than finding the scale, calculator, concentration of the diazepam, and converting pounds to kilograms to other metric units. Based on the recommended diazepam dose of 0.5mg/kg, VETgirl’s general guideline is:

    • Toy breed or cat ½ mL IV
    • Small dog (15-30 lb) 1 mL IV
    • Medium dog (35–60 lb) 2 mL IV
    • Large/giant breed (70+ lb) 3 mL IV

Valium Bottle

5) Remember that common diseases happen commonly. While we do not have a magic ball…we can discuss the likelihood of illness with clients. Notably, epilepsy is more common when:

  • The patient has their first seizure between the age of 6 months and 5 years
  • The seizures are more commonly generalized
  • There are no detectable abnormalities (e.g., cranial nerve deficits) on the neurological examination, including normal mental status and behavior, between seizures.

When in doubt, don’t be nervous about treating seizure disorders. The biggest mistake we see being made? Not using enough of an appropriate anticonvulsant to stop the seizure (VETgirl likes Keppra!). Also, make sure to appropriately work up the patient (e.g., CBC, chemistry, bile acids, urinalysis, etc.) depending on the signalment, severity, etc. You don’t want to miss a portosystemic shunt, metabolic cause, or underlying neurologic cause (e.g., brain tumor, GME, etc.). When in doubt, consider having the pet owner make an appointment with a board-certified neurologist; I always tell them it doesn’t commit them necessarily to doing a MRI and CSF tap (or other advanced diagnostics), but may be beneficial, especially with long term management,

Dr. Garret Pachtinger, DACVECC
Co-Founder, VETgirl

PS For at home seizure management in severe cases, the use of intranasal midazolam can be considered (instead of rectal diazepam) based on the newest studies.

Here is an example of an atomizer for how to dispense or administer intranasal midazolam. Please note that VETgirl does not directly endorse this product.

Reference:
1. Charalambous M, Bhatti SFM, Van Ham L, et al. Intranasal Midazolam versus Rectal Diazepam for the Management of Canine Status Epilepticus: A Multicenter Randomized Parallel‐Group Clinical Trial. J Vet Intern Med 2017;31(4):1149–1158.

  1. michael braunstein says:

    greetings….the clinic I work at uses midazolam. During a seizure, is this comparable to Diazapam?I understand its the sam class, but just want to make sure …..thanks!

    • vetgirl says:

      Yup, totally fine to use too – but you can use midazolam IM and IV. With diazepam, you should only give it IV (as it contains propylene glycol). Personally, I think diazepam works for a LONGER duration of time than midazolam as an anticonvulsant, so prefer diazepam.

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