In this session, we're gonna talk about emergency seizure control. This includes treatment for both cluster seizures and status epilepticus. Cluster seizures are when we see more than 2 seizures within 24 hour space.
We could see 34, 10 within 24 hours they're all classed in the same way. They are individual seizures lasting about 90 seconds to a couple of minutes. Su as epilepticus refers to two or more seizures though that don't break.
They may have a slight . Improvement in the involuntary movement that is seen, but no improvement in the loss of consciousness, and so, for all intents and purposes it's one seizure and it goes on for more than 5 minutes. The definition used to be one seizure lasting 30 minutes, but it was soon realised that that causes such tremendous damage to the brain that we can't possibly wait 30 minutes before we start treating it as an emergency.
When we, consider status epilepticus, then we see that it is a reasonably common phenomena. Overall, it's seen in about 5% of dogs with idiopathic epilepsy and about 20% of cats with idiopathic epilepsy. So in their lifetime, 5% of dogs are going to experience status epilepticus if they have idiopathic epilepsy.
We know that certain breeds are predisposed to this aggressive type of seizure activity. We see this most in Australian shepherds, border collies, but other breeds are also seen, closely behind this, these highly predisposed breeds such as German shepherds, Irish setters, boxers. The cause overall of status epilepticus is fairly evenly split, so a third of dogs with status epilepticus will have idiopathic epilepsy.
About 1/3 will have structural epilepsy, and the rest will have reactive epilepsy or an unknown cause. But not idiopathic, so potentially, poor medication use, is, has been associated with it. So dogs that are medicated, for epilepsy of any type, but, have not been controlled well.
When we consider cluster seizures, overall, a higher percentage of idiopathic epilepsy dogs will experience this type of emergency. Again, there's breed predispositions, similar, things to consider German shepherds, boxers this time, and border collies. It has been shown that that intact, animals are more likely to be affected than than neutered, but there has been no study to say that neutering, .
A dog which has exhibited cluster seizures will actually improve the situation. Also, females apparently slightly more affected than males. Overall, border collies are highly predisposed to cluster seizures.
If they have idiopathic epilepsy, there's a very high chance they're gonna cluster. Which means that we have to medicate these dogs aggressively in the long term. About 50% of Australian shepherd dogs with idiopathic epilepsy suffer from both cluster seizures and sapilepticus, and when we consider cats, about half of cats with a primary cause of seizure activity will end up having clusters.
So again, common to have cluster seizures with idiopathic epilepsy, but can be related to any underlying cause of brain disease. Focusing for the first part of this session on status epileptics now, we have to consider the systemic effects of this of this emergency when considering overall treatment or management. Initially we've got to chat about respiration.
If we're seeing a patient that has a generalised tonic clonic seizure that's lasting for more than 5 minutes, we have these involuntary movements of the limbs, then we've got to expect involuntary movement of the thorax. So there's a mechanical impairment of respiration. The central nervous system has its abnormal electricity responsible for seizure activity, and that's going to include the central nervous system respiratory centre.
And so this now is not going to cause an even discharge, creating inspiration, expiration, so there's no major drive going on for respiration at the level of the central nervous system. And there's autonomic dysfunction in that. If there, even if there was a drive, there is no appropriate detection of CO2 levels.
And so we have serious situation in that compromised respiration is gonna lead to hypo hypoxia. Additionally, there's gonna be significant cardiac compromise. Again, we have autonomic dysfunction, so we do not have an appropriate drive, to increase the rate appropriately and change the contractility.
So we're gonna have an irregular heart rate and rhythm and contractility. Because we've got hypoxia from respiratory damage, all of this could lead to ischemic damage to the heart walls, myocardial ischemia, and the end result potentially is arrhythmia. Now if a dog is seizuring for about 57, 10 minutes, it's unlikely that we need to be too worried about this and the respiratory compromise.
However, the longer that things go on, the more likely we need to be concerned about it. And so if we have an extensive period of status epileptic, it may be wise to measure oxygen status if we can, and, at least oxygenate the patient potentially, . Performing the ECG to monitor the heart rate and rhythm.
Finally we have renal compromise, so we have hypotension due to the cardiac abnormality, and additionally, we're gonna have muscle breakdown products, being perfused through the kidneys due to hypothermic damage to these muscles. Any time that the body temperature exceeds 40 °C or 14 °F, we're gonna have breakdown of the muscle. And that potentially will lead to myoglobin urea and poor perfusion is associated with this hypotension, as we've talked about.
And so we can end up having renal insufficiency. Again, nothing that we're gonna be too concerned about in a dog having a seizure for 5, 1015 minutes. But if we see protracted seizure activity, we may need to look at at at fluid therapy in these patients, measuring blood pressure.
And looking at urine production as a mechanism to assess kidney function. In addition to systemic damage, we're gonna, we're gonna believe there has to be some brain damage, and we know based on animal animal work and what has been seen in people with protracted seizures that that end up succumbing to these seizures, that there is irreversible structural damage after about 90 minutes. Now this may be in areas of the brain that we cannot detect in veterinary medicine, so initially it's going to affect things like hippocampus, which may slightly change the behaviour of the patient and in people we can also see abnormalities of memory and social interaction and language skills, difficult things for us to assess in, veterinary medicine.
In addition to the hippocampus, the cerebellum becomes affected. This is our coordinating centre of the nervous system, so we may see ataxia after the event. And the occipital cortex of the cerebrum, is, also affected by extended seizure activity, and so these three areas will give us ataxia behavioural changes and blindness postdictal.
That can be permanent, but it can be something that comes back after a while. Irreversible damage then in 90 minutes often due to hypoxia, a hypoglycemia from the extensive stress and demand that's going on in the patient, in addition to local in the brain, acidosis, electrolyte abnormalities, and cytotoxin abnormalities. So an excess of glutamate, for instance, is building up in the brain, causing local brain damage.
So the more seizure activity that goes on. The more likely that we're going to see local damage which will maybe increase the size and reactivity of the seizure focus that that started this. So if it's, if this is an idiopathic epileptic dog, then the seizure focus may become more reactive in the future, so may make it more likely.
To fire off, so we have a situation where we are always going to be focused on trying to stop the seizures because we don't want to see any brain damage. However, the longer they go on, we're gonna have, the potential for this and not be able to predict it. Additionally, we could have systemic damage, be unable to predict that.
And all in all, we may have a dog who then is more predisposed to having seizures down the line if it has idiopathic epilepsy, but we have to recognise that when this patient comes through the door, many times we're not actually gonna know what the cause is. So we have several things to consider in the management. Here is a video of a cat having initially a focal, motor, and autonomic seizure that progresses into generalised tonic clonic seizure, and in this case it may be that the cat is experiencing just an individual seizure that stops in a minute, but we don't know this.
And so when presented with this case, we have to start preparing for the fact that it may be an unrelenting seizure, something which is status epilepticus. So in this cat, we're supposedly meant to administer intravenous benzodiazepines. However, in addition to the problems we've just mentioned about not knowing the cause of status epilepticus and not knowing how much damage the body and brain is experiencing, we have a problem that we don't have IV access in this cat, so we're not going to be able to give it intravenous drugs.
So as we start thinking about our management, we have to think about the potential at some point to get IV access, but in, prior to that, dealing with a patient that needs to be medicated in another way. When this patient comes in to see us, we need a a team approach, and this is gonna be tough because it may just be one person, after hours dealing with the patient. If there's a chance of having a team approach, then someone needs to be taking the history.
If not, if it's just you, then we try to print out a list of emergency questions that the owner can read and shout out if any of the answers are yes, such as has your dog had seizures before. Has, is the dog on medication for anything including seizures? Is there any other general health issues that we should be aware of?
Has there been any access to toxins, any recent trauma? So, so things here which are going to be essential to us, in terms of coming up with an emergency treatment plan and also predicting a prognosis. We need to initially measure rectal temperature.
Again, our plan is to stop the seizures, but this is gonna be a whole body approach. So . A whole a whole body approach is gonna mean making sure the temperature doesn't rise above 42 degrees C.
Now we're not going to do much in the way of active cooling during status epilepticus, but we need to monitor this because if the temperature does go above, we may need to put fans on, we may need to spray the feet with alcohol, something which can start to take the temperature down a little bit. We don't want to overdo it because if the seizures stop, the temperature could plummet. We're obviously not gonna be able to get much blood work, so, we're gonna need to wait till immediately after, the blood work, the seizure activity has been stopped, but we need to make sure that we do get something that helps us understand an underlying cause.
Maybe there is a systemic cause for the status epilepticus. So we look at glucose levels, electrolyte levels, calcium levels, liver function, maybe, toxicity screen if available. So these are things that we should be looking at.
Now hypoglycemia can be a common cause of seizure activity, status epilepticus in patients that are young, so puppies and kittens, in patients that have parasite burdens. So we may want to treat with a high density syrup, glucose syrup, or orally, or if you have IV access you could give dextrose solution, but many times these patients come in, we don't actually have access, intravenously. So we're gonna go ahead and give honey, syrup, something under the tongue to try and help out via syringe, just a dab of it to try and help out, and it will immediately stop the seizures if it is hypoglycemia, which won't respond to benzodiazepines, for instance.
So, in addition to that, we may need to have someone consider, oxygen administration, so a kind of flow by therapy, someone holding a tube by the nose, is gonna help this patient cos remember re respiratory function is not going to be normal. When we come to think about the drug therapy, we should have a stepwise approach to the patient planned out. Not all, drugs are going to be effective in, patients, in people with idiopathic epilepsy that experienced status epilepticus, there's an approximately 20% mortality rate.
So dogs, cats that have idiopathic epilepsy are probably likely to have a worse, mortality rate, than, than humans because of the facilities that we have available not being as superior as as maybe exists in human medicine. And, but also we've got to consider that we're not gonna know what the cause is. And so if you add in the dogs that have tumours, inflammation, strokes, potentially the mortality rate is even higher.
We need to recognise this, we need to communicate this with the owner, and this is part of our team approach. So when we're considering a stepwise approach, we're always thinking about benzodiazepines as step one. Now if you have been seizuring for more than 30 minutes, benzodiazepines become less effective.
Your brain becomes more resistant to these drugs, and so I'm not saying that we shouldn't use them, but we should be starting to think about step 2 sooner than we would normally do. So classically, we'll give diazepam if we have IV access, great, we give it by intravenous administration. But many times we don't have that luxury, so we would have to give it rectally or nasally.
Rectally it may take about 10 minutes to work, nasally a couple of minutes, but obviously we can recognise that logistically, especially in some dogs and cats, it can be difficult to administer this solution nasally. Midazolam then becomes a more viable option because we can administer this intramuscularly. So midazolam intramuscular is probably the go to step one drug if we don't have intravenous access.
Now this can work very quickly, so within a minute or two, it will be effective if it's going to be. And it can last for 5-10 minutes, and so we need to be ready to give another bolus dose, and if we haven't got an IV access, we could use that time to put an IV catheter in. So we get ready to give another, another dose, .
And it also get ready to consider step two because we can't keep on giving bolus doses. We've got maybe a 234 bolus maximum before we're gonna say that that this is not going to work unless you wanted to consider step 1B. So if a bolus did work and you have IV access, you could follow up with a constant ray infusion of one of the benzodiazepines.
Either or, diazepam or midazolam can be used in, in, normal saline at a constant rate infusion rate of up to 2 mg per gig per hour of diazepam and around 0.3 mg per kg per hour of midazolam, . And so either all of these drugs can be set up at a constant rate in fusion.
We sometimes we need, based on the solution we're using, we need to keep changing the administration set every couple of hours because these drugs can adhere to the PVC and in the plastic in the, in the administration setting, so by the time it gets into the vein, there's less of it than you actually put in the. Administration syringe. It also can be light sensitive and so we may need to shield the administration line and and set from the light, again trying to maintain the amount of of diazepam or midazolam in the tube, so that the patient actually gets it by the time it travels down to the vein.
We certainly can see respiratory depression, with this approach, so we're gonna need to make sure that we have oxygen on standby and monitor maybe with pulse oximetry. And if we are able to control the seizures, we can look at starting to reduce the dose in about 3 to 6 hours. Every time we'll try and notch down by about 10 to 20%.
And if it, He works will then repeat that again in about 2 to 3 hours, so gradually wean them off. Some patients may need 24 hours or so of a constant rate infusion, so it, it can be a long and expensive approach to stop these, these seizures. One thing to say about, about benzoa beams is if the dog or cat already comes in on, a phenobarbital administration, so it's already been treated with phenobarbital, we're gonna need to use the higher end of the dose for the benzodiazepines, because phenobarbital increases the metabolic capabilities of the liver.
Which will metabolise the benzodiazepines more rapidly. And so, we really need to, look at using a high end. So we're gonna go immediately, for instance, with Diazepa to 2 migs per gig rather than starting at 0.5 mg per gig.
So another thing to consider, with, with these patients. So step 2 then is starting to consider a longer acting anticonvulsant and if available, one of the most commonly step two approaches is phenobarbitone. So phenobarbitone, then our barbiturate can be given peremptorily, and if you don't have ivy access still at this point in time, you could go ahead and give it intramuscularly.
It's quite safe, and we'll give it as a bolus and repeat it. So ultimately, we're giving 2 to 4 migs per kg intravenously or intramuscular, and then we'll wait in about 20 to 30 minutes to see if it works and if it doesn't, we'll repeat that bowl. It's up to a maximum of 24 migs per kg in 24 hours.
This obviously includes any phenobarton that the dog has had that morning, for instance, because, it's already on phenobarb, for instance, so. We need to make sure that, we, we look at that. Most dogs won't, we won't get that far up the, dosing schedule, but we need to realise that there is a ceiling to this.
If you're successful and you stop the seizures by doing this, you have effectively low dosed your dog, so we've given it up to 24 migs per gig over that 24 hour period, and we can now start them on an oral version of phenobarbitone, . And you've bypassed the need to wait for 10 to 14 days for it to reach steady state. So you've already achieved steady state.
So this is a good, a good thing, for us to, to know. You don't have to follow up with phenobarbitum, you could go to another drug, but at this stage, if you've used it as a bolus, then, we're certainly going to be able to follow up with an oral oral, . Administration at long term.
Quickly replacing phenobarbitone if you have access to this drug is parenteral levaterracetam. Now oral levaterracetam is a very safe drug and has no concerns in terms of organ toxicity. Giving it intravenously or intramuscully is also pretty safe.
Sedation and ataxia is all that we really see. We usually have to consider diluting this, in the data sheets. We'll give you specific details on this, but 1 to 1 in sterile saline is, is acceptable, and we give it slowly over about 10 minutes.
Again, we can use quite high doses, particularly if they're already on phenobar. We need to use high doses, and we'll routinely bolus our patients at 60, 60 mg per gig, over 10 minutes. If you don't have IV access yet.
You could still give this drug intramuscular, and so this is something which again is a, and it's an advantage, in that we can go ahead and, and give something intramuscular, to the patient if we don't have the IV access. Takes about 40 minutes to get to peak, but we'll see an effect within 10 minutes, so pretty powerful and lasts 8 hours. So unlike phenobar, which, if it does work only lasts about 4 hours and will need to repeat.
The drug, then this lasts about 8 hours, so, we can then repeat and if, if the seizures are still have stopped, we could actually follow up with oral medication, at 3 times a day, just the standard, the standard version of levotratam. So it is quickly becoming step 2, safe and very effective. It's an anti anti-convulsant and an anti-epileptic, and what this means is it will stop the seizures as well as protect the brain from developing further damage from extensive seizure activity.
So, something which may help with protracted seizures and preventing a an increased seizure focus from developing. Now after the use of these drugs, if we've still got seizure activity, the patient is considered to have refractory status epilepticus. And so at this stage, we have to start thinking about the use of certain anaesthetic drugs which can have anti-convulsant properties too.
At this stage we're also going to need IV access for most of these, and we're gonna need some critical care support because we're gonna need to support them ventilating, for instance, and probably their blood pressure as well. So firstly, and here we're at step 4, firstly, propofol can be used to induce a coma, much like, we, we use it routinely as an anaesthetic, and, that can be as a bolus followed up by a constant rate infusion if you like, and may be expensive, but this is one way to manage patients that have toxin exposures. If you don't want to do a CRI of a benzodiazepine for those patients, then sometimes we need a CRI of propofol, and human patients are managed for up to about 48 hours on this drug and can be quite safe.
However, obviously oxygen support and fluid therapy for blood pressure support is necessary. So it is a drug that, that obviously has potent anaesthetic properties, but it also has been noted to have anti-convulsant properties. Some dogs unfortunately have intense muscle spasm in response to giving propofol, but this is not a common phenomenon.
And so, we are, we use the fact that it's more likely to benefit the patient than, than the risks that are that are out there, but they, they must be borne in mind. If you haven't, if you don't want to use propofol or it's too expensive to go in a protracted way, then we actually now have started using ketamine, which seems a bit strange cos we're often told not to use ketamine for intracranial disease. .
Now we're using this in a specific manner, meaning that we have to wait 30 minutes before we are able to use this. 30 minutes of seizuring must take place before we can use ketamine. This is because, after about 30 minutes, the brain has started to produce a lot of glutamate, and what happens is it enters a phase called self-sustaining.
Status epilepticus self-sustaining status epilepticus is then where this glutamate, which is a very potent excitatory neurotransmitter in the brain, is released by the damaged brain, and it causes more seizure activity to occur, and ketamine is in effect an anti-glutamate drug. And so after about 30 minutes, ketamine becomes anti-convulsant. Not something that we, we, we considered, and don't, it's certainly not to be used straight away and in some, for some forms ketamine can be proconvulsant, so certainly is a, is a concern to to use this drug, but now studies are out there suggesting that it's extremely effective as an initial bolus and in some cases followed up with a constant rate infusion.
It is metabolised by the liver in the dog, so we need to make sure that that is something that is not going to cause a problem, particularly in dogs that are seizuring from hepatic encephalopathy. And occasionally we may add benzos to this to try to prevent the dysphoria that happens when the drug starts to wear off the so-called emergence reactions. So ketamine has certainly changed our approach to status epilepticus and can be extremely effective at stopping the seizures.
Just becoming available is a drug called phosphenytoin, and phosphenytoin is a prodrug of phenytoin. Phenytoin is a potent anticonvulsant, in people and in, veterinary medicine, but phenytoin on its own is cardiotoxic, so we can't, we can't use phenytoin in veinary medicine intravenously. However, the prodrug has been shown to be quite safe, because all the toxicity is related to phenytoin.
What has been seen in a few dogs is ataxia post administration and vomiting from the use of this drug, which is a concern because you don't want a dog with status epilepticus to start vomiting. So that's a problem, which is why we're really holding this drug back to a kind of last ditch attempt. So research has shown that a dose of about 15 mg per gig has been tolerated.
And it can be reasonably effective, within about 30 minutes or so, there's there's a very strong, activity. So it's not widely used at this stage, but it is out there as kind of a, a rescue drug, for patients with status epileptics that haven't responded to anything else. Now as a last ditch attempt, we have a couple of other options.
So if you've still got seizure activity, we can actually now use inhalational anaesthesia. Another thing that we were told not to, to use in patients that have brain disease because it will destabilise brain function. And it's not something we want when we're having seizures.
However, it has been shown now that that isofluorane and sevofluorine can have some protective qualities and be anticonvulsant, . When used for patients in status epilepticus, not least though, its effect on causing anaesthesia may buy you some time to then get an intravenous catheter in. So if you just cannot stop the seizures, maybe masking them down with a gaseous anaesthetic could be the way to go.
Dextermatomidine has also been used as an antigonvulse and has been shown to reduce some of the neurotransmitters in the brain that are responsible for seizure activity. So in conjunction with ketamine, even, this is a drug that has been shown to help out those patients that don't respond to anything else. Using the lower dose, we'll start with the lower dose and make sure that we've got the reversal agent on hand.
We can give it intravenously or intramuscularly or even subcutaneously. And then we can give it on a per hour constant rate fusion basis. And so this is something which, has again changed the way we deal with our very refractory, seizures.
After we've stopped the seizures, if we can stop the seizures, obviously we, may have some brain damage. Now, the brain damage can result from hypoxia and hypotension, and this can result in edoema that's both vasogenic and cytotoxic. So steroids may be helpful.
Low doses of anti-inflammatory steroids for a day or 2 may be helpful. Often we, we shy away from the use of steroids when we have any brain damage due to hypoxia or trauma itself, because we know that. It actually can make the situation worse, but that's when used in high doses in a hypoxic environment.
So many times, yeah, we'll, we'll only use, low doses of steroids for 2 or 3 days when there's been some stability or the, or they, they are, at least well oxygenated. Diuretics like rosamide and Manitol may help with the reduction of local edoema in the brain. And obviously oxygenation as well can, play a vital part in reducing swelling.
So these are things which should be considered, post status epilepticus. Post epileptics we're often also thinking about trying to diagnose what's going on in the patient, realising that we may have any type of damage in the brain causing this. We ultimately may need to do advanced imaging.
We often may need to look for systemic disease with thoracic and abdominal imaging, as well as what damage the protracted seizure activity may have done, round the body. So we need to look at kidney function with an indwelling urinary catheter. Cardiac function with ECG and blood pressure assessments.
CSF may be helpful to to evaluate the patient for underlying inflammatory disease, and some people will suggest at this stage, once you've stopped the seizures that you could treat intoxications with gastric lavage. But I would shy away from that because most of your patients at this stage are still going to be extremely. Sedate and poorly responsive and yeah, that's probably not a good combination to go ahead and lavage the patient cos you're gonna risk aspiration pneumonia.
Now let's talk about cluster seizures and how we manage these. These could be in hospital, or they could be, on an at home basis. And we have, we have several approaches that we need to consider.
Firstly, in the long term, we're gonna need to do a better job of managing the seizure focus. So we need to do better with our chronic maintenance medications. That's the first thing.
Second thing is we must look at considering what could stop the roll-on seizures, so the immediate seizures, if you're having a seizure right now and you, you are likely to have another one soon, whether that's your pattern or we're just gonna suspect there's a possibility for that, what can we do? And then also. Look at trying to stop seizures in the medium term, so over the next 2 or 3 days.
So, what are we gonna do to advise the immediate, time, . And that is option one. We could look at again at benzodiazepines here.
This is for in the hospital, cluster seizures, if, especially if you've not got intravenous access, or more commonly at home. Now we don't like prescribing benzodiazepines to, to clients, although there are There are several formulations that can be made now, rectal suppositories, intranasal gel formulations that maybe make it less attractive for people to abuse the drug, but it's still a possibility. If we do prescribe it, then again, we may need to use the higher dose of diazepam if we're using this rectally.
Or nasally, although we prefer midazolam nasally, we need to use the higher dose of either if they're already on, phenobarbital. So we'll, we'll use that high dose and advise the owner to use it if they have a seizure at home. This is not to avoid veterinary attention, but it may be that it helps the patient out on the way to .
The hospital or maybe just buy some time because the dog or cat won't seizure again for a a a a good period of time. So, this is something that's been shown to reduce the number of cluster seizures. So if the dog normally has 345 seizures in a cluster, it has been shown to reduce that dramatically, and the number of clusters over a period of a month as well.
So it's quite an effective way forward as we said, it has some issues, not least that we need to use high doses of it if they're already on phenobarb. The more medium term solution is to prescribe something like chlorazepate, so it's not gonna help stop the next seizure in the next 5 minutes, but over the next 8 to 12 hours it can do a reasonable job. It's a very sedative drug.
It is a benzodiazepine that is potently anti-convulsant. But it is something that we can't use for more than 2 or 3 months because the dogs start to develop tolerance to it a lot slower than other benzos like diazepam, but we can see a tolerance, so we just give it as a breakthrough drug, . Meaning we give it for 2 to 3 days, you know, when the dog exhibits cluster seizures, and we start off low, you can give this anywhere from 0.5 to 2 migs per gig, but we'll often start off low because of how sedating it is.
And we'll often start off at, at, at 12 hours, but we can go to every 8 hours if needed. Obviously because it's an oral drug, then we need to make sure that the patient is, is a long way past the status epilepticus and that the owners aren't putting themselves in any danger here. But it is metabolised to the same thing that diazepam is metabolised to, and so is, is, is a potent anti-convulsant.
And if it works, then owners are pretty happy with this as a, a drug that they can keep at home and give to their dog or cat when, they have a seizure to prevent them having many more over the next 24 hours or so. And finally, we could actually use a pulsed lever terratan protocol. What this means is that we can give, preferably the instant release, on a pulsed basis every 8 hours starting at 20 MB per gig, but up to 60 MBs per gig, orally, again, like Clorazeate they need to be orally capable to obviously have this protocol, and we treat them.
Until they go at least 8, if not 12 hours seizure free. So carry on giving it every 8 hours until they go at least 12, 8 to 12 hours seizure free. We use the instant release rather than the extended release, because as you can see here, the red line is the instant release.
It peaks pretty quickly, so within half an hour or so we get a peak plasma for the instant release, whereas the extended release is a very slow grower and so it doesn't peak for, way after 2 hours, so it, it's not really effective to give in these circumstances. If you don't have access to intravenous levarete. To give in this manner, and you don't have anything else, then you can actually crush up standard lever terraam, so just mortar and pestle it, so break it up, crush it up, and dissolve it in, in, in saline, and it can be given rectally 20 to 60 mgs per gig rectally and it has been shown to be pretty effective, within about 10 minutes or so can be.
Quite effective reaching anticonvulsant levels. No need to give this if, if they're already capable, but, if you, if you don't have that available or you can't get the oral medication into the dog because they're so sedate. Then rectal levitrester may be an option.
It's the, it's, it's really the only drug which quickly rectally will work besides benzodiazepine. Zennisamide is not a suitable, rectal rectal drug in this circumstance. So overall emergency seizures are obviously life threatening, as we said, a 20% mortality rate for status epileptics in humans with idiopathic epilepsy.
So, so a big concern there, we need a team approach because there are multiple things that need to be focused on not just giving the drugs, but in terms of giving the drugs, we need a stepwise approach. We need to be ready to move quickly through these steps so that we can . make sure that we're giving the dog or cat the best possible chance of stopping these seizures.
So no single approach is really always effective. We, we have this logical plan, but we just end up using what down that sequence is either available or suitable for the individual patient. And when we talk about cluster seizures, it's always gonna be a mixture of chronic and acute advice therapy.
So acute we're looking at. Things like rectal and nasal benzodiaze beams and clorazepa and Keppra on a pulsed basis, and then chronic, we need to do a better job of controlling the seizures in that patient long term. So thanks for your attention during this session.
Hopefully we've provided some practical advice on how to manage this pretty common set of emergencies, but please let me know if you have any questions.