1 00:00:00,050 --> 00:00:04,070 Hello and welcome back to Synaptic Tails, the podcast where we deep 2 00:00:04,070 --> 00:00:07,460 dive into fascinating and important topics in veterinary epilepsy. 3 00:00:08,270 --> 00:00:12,170 I'm Emma and I'm one of the technical vets from Dômes Pharma, and last 4 00:00:12,170 --> 00:00:16,070 season we introduced listeners to the S.M.A.R.T Approach to canine epilepsy. 5 00:00:16,400 --> 00:00:18,920 Feel free to take a listen if you haven't done so already. 6 00:00:20,195 --> 00:00:23,945 This season, we are going to take a closer look at what I think are the more 7 00:00:23,945 --> 00:00:28,985 difficult areas of epilepsy, including the seizure mimics, the weird and wonderful 8 00:00:29,315 --> 00:00:31,414 adjunctive therapies and even cats. 9 00:00:32,525 --> 00:00:35,375 Today we're going to kick off with a subject that strikes 10 00:00:35,375 --> 00:00:39,365 fear into even the most seasoned veterinarians, status epilepticus. 11 00:00:40,324 --> 00:00:43,745 I'm very pleased to say that joining me again this season is veterinary 12 00:00:43,745 --> 00:00:47,375 neurology specialist Mark Lowrie of Movement Referrals who will 13 00:00:47,375 --> 00:00:50,734 help demystify this challenging condition and provide a step-by-step 14 00:00:50,734 --> 00:00:52,384 approach to managing it effectively. 15 00:00:52,865 --> 00:00:53,585 Welcome, Mark. 16 00:00:53,585 --> 00:00:55,745 I'm so glad to have you back with us again today. 17 00:00:55,775 --> 00:00:56,345 How are you? 18 00:00:56,540 --> 00:00:57,410 Very well, thank you. 19 00:00:57,410 --> 00:00:59,120 Thanks so much for having me. 20 00:00:59,180 --> 00:01:01,660 Really, really excited about this new season and a great 21 00:01:01,660 --> 00:01:05,290 opportunity to talk about the more unusual aspects of epilepsy. 22 00:01:05,520 --> 00:01:08,449 When we spoke last time, we'd opened this new practice in the northwest 23 00:01:08,449 --> 00:01:12,199 of England and we have just exciting news, hot off the press today. 24 00:01:12,484 --> 00:01:13,504 Spoilers for everybody. 25 00:01:13,819 --> 00:01:14,869 We have a new practice, 26 00:01:15,559 --> 00:01:16,234 Oh my goodness. 27 00:01:16,234 --> 00:01:20,059 So we're opening a second movement referrals practice in the Midlands. 28 00:01:20,249 --> 00:01:20,969 Amazing 29 00:01:21,379 --> 00:01:23,599 in Uttoxeter, which, you know, you may have heard of the race 30 00:01:23,599 --> 00:01:25,699 courses there and JCB factory. 31 00:01:25,699 --> 00:01:28,949 Well now we've got a third exciting thing in Uttoxeter 32 00:01:29,224 --> 00:01:30,544 Is that near Alton Towers? 33 00:01:30,564 --> 00:01:31,519 Oh, it's so close. 34 00:01:31,594 --> 00:01:32,194 Oh my goodness. 35 00:01:32,194 --> 00:01:33,484 I'm going to have to come up for the day. 36 00:01:33,679 --> 00:01:37,369 So we're very excited because The Toxicator's just opened at Alton Towers. 37 00:01:37,369 --> 00:01:38,329 My son loves that. 38 00:01:38,379 --> 00:01:40,549 In fact, if my son and daughter were here now, they give you a whole 39 00:01:40,549 --> 00:01:42,049 podcast episode on Alton Towers. 40 00:01:42,304 --> 00:01:43,984 Do you actually just live at Alton Towers? 41 00:01:44,209 --> 00:01:44,809 I'd love to. 42 00:01:46,654 --> 00:01:47,519 That's really exciting though. 43 00:01:47,539 --> 00:01:49,564 And, and congratulations for that. 44 00:01:49,564 --> 00:01:51,394 And good luck for the future, I guess too. 45 00:01:51,709 --> 00:01:52,819 Well, yeah, no, can't wait. 46 00:01:52,819 --> 00:01:56,254 So yes, please do, If ever you do get any questions, anything about 47 00:01:56,254 --> 00:01:57,674 epilepsy, I'm always happy to help. 48 00:01:57,674 --> 00:02:00,334 So feel free to reach out to me and happy to try and guide you through 49 00:02:00,334 --> 00:02:01,715 some of these more difficult cases. 50 00:02:02,119 --> 00:02:03,350 Perfect, thanks Mark. 51 00:02:04,023 --> 00:02:08,128 As I said, today we're going to be looking at status epilepticus and dogs. 52 00:02:08,178 --> 00:02:11,718 What is status epilepticus and why is it so serious? 53 00:02:11,718 --> 00:02:14,682 I think for me, I just fear it so much in practice. 54 00:02:15,543 --> 00:02:19,773 Well, that is a great question and I think fear is a really, really good word there. 55 00:02:19,833 --> 00:02:25,083 I mean, status epilepticus is when a dog experiences either a single seizure 56 00:02:25,473 --> 00:02:27,393 lasting longer than five minutes. 57 00:02:27,423 --> 00:02:28,563 I mean, that's a long time. 58 00:02:29,493 --> 00:02:32,943 Or two or more seizures without really fully recovering in between. 59 00:02:32,973 --> 00:02:36,543 And I suppose traditionally you do think of a dog just continuing to fit, but 60 00:02:36,543 --> 00:02:39,833 don't forget those cases where a dog has had a short seizure, hasn't made a 61 00:02:39,833 --> 00:02:42,083 full recovery and goes into another one. 62 00:02:42,083 --> 00:02:44,873 So they're the two situations we're dealing with here. 63 00:02:45,593 --> 00:02:49,463 It's obviously in a medical emergency because prolonged seizure activity 64 00:02:49,463 --> 00:02:53,783 can lead to irreversible brain damage or sometimes even worse. 65 00:02:53,783 --> 00:02:56,933 It's very rare, but there is such a thing as sudden death 66 00:02:57,293 --> 00:02:58,463 during generalised seizures. 67 00:02:58,463 --> 00:03:00,453 But I don't want to scare monger so early on in the season! 68 00:03:00,513 --> 00:03:02,888 I was going to say you've started on a high note there, haven't you? 69 00:03:03,998 --> 00:03:06,873 But honestly, that is rare and I think that is an owner's big concern when 70 00:03:06,873 --> 00:03:10,383 they see their dog having a fit, that they may suddenly pass away or die. 71 00:03:10,383 --> 00:03:13,833 And that's when they start to intervene, potentially doing crazy things like 72 00:03:13,833 --> 00:03:16,503 putting their hands in their pet's mouth, which obviously is a big no-no. 73 00:03:16,553 --> 00:03:17,603 That's their concern. 74 00:03:17,633 --> 00:03:20,603 And I think it is important to reassure that's exceptionally rare. 75 00:03:20,993 --> 00:03:23,883 Typically these seizures will end, infrequently, they 76 00:03:23,883 --> 00:03:25,173 need intervention from us. 77 00:03:25,413 --> 00:03:27,483 But there's lots we can do there to help. 78 00:03:28,153 --> 00:03:32,743 So normal, in inverted commas, generalised seizures, they, 79 00:03:32,743 --> 00:03:34,963 they tend to be self-limiting. 80 00:03:34,963 --> 00:03:36,703 They generally last only a couple of minutes. 81 00:03:37,063 --> 00:03:41,018 Why is it that in status they go on so long or do we not know? 82 00:03:41,528 --> 00:03:42,398 We really don't. 83 00:03:42,398 --> 00:03:46,088 It's almost like something's triggered in the brain that just won't stop. 84 00:03:46,178 --> 00:03:48,788 Self-limiting is the key with seizures as a rule. 85 00:03:48,788 --> 00:03:51,278 So these are exceptional circumstances. 86 00:03:51,588 --> 00:03:53,628 We don't know why they don't stop. 87 00:03:54,258 --> 00:03:56,058 We presume something's triggered in the brain that makes 88 00:03:56,058 --> 00:03:57,438 them keep going and going. 89 00:03:57,768 --> 00:04:01,938 But this is the key thing because, when a dog has a seizure, what's 90 00:04:01,938 --> 00:04:04,548 happening is you've then got a propensity for the dog to have another 91 00:04:04,548 --> 00:04:06,978 fit and another fit and another fit. 92 00:04:07,008 --> 00:04:09,498 This idea of kindling, it's called. 93 00:04:09,498 --> 00:04:13,158 And so this is where a lot of the discussion comes back to that if we can 94 00:04:13,158 --> 00:04:17,538 prevent one seizure, hopefully, hopefully we'll prevent that wind up towards 95 00:04:17,538 --> 00:04:19,278 having more seizures in the future. 96 00:04:19,698 --> 00:04:23,148 But why status happens, we're really, really not sure of 97 00:04:23,148 --> 00:04:24,198 the answer to that question. 98 00:04:24,658 --> 00:04:28,318 But it doesn't always mean that something bad is happening. 99 00:04:28,368 --> 00:04:32,118 Just because they come in status, it doesn't necessarily mean they 100 00:04:32,118 --> 00:04:34,158 have a bad prognosis, right? 101 00:04:34,253 --> 00:04:37,523 When you see a dog with status epilepticus the thought is that it is bad. 102 00:04:37,703 --> 00:04:40,323 You know, everyone thinks, oh my goodness, my dog must have a brain tumour. 103 00:04:40,343 --> 00:04:41,933 It must have something horrendous happening. 104 00:04:42,263 --> 00:04:45,923 But actually it's really common that dogs can have status epilepticus due 105 00:04:45,923 --> 00:04:48,303 to less serious underlying conditions. 106 00:04:48,303 --> 00:04:51,363 And I mean, if you've listened to season one, you'll know that idiopathic 107 00:04:51,363 --> 00:04:53,968 epilepsy is the king of diagnoses here. 108 00:04:54,018 --> 00:04:57,438 And idiopathic epilepsy is definitely a very common diagnosis here. 109 00:04:57,498 --> 00:05:00,108 So I've seen plenty of dogs that present with their first 110 00:05:00,108 --> 00:05:01,998 fit being status epilepticus. 111 00:05:02,808 --> 00:05:06,888 We ultimately find out it's idiopathic epilepsy and those dogs can go on and 112 00:05:06,888 --> 00:05:10,638 have a really good quality of life in spite of that first presentation. 113 00:05:11,403 --> 00:05:11,613 Good. 114 00:05:11,613 --> 00:05:14,463 I think that's reassuring to know for us and the owners. 115 00:05:15,168 --> 00:05:16,133 They don't always die. 116 00:05:17,313 --> 00:05:18,183 That's good to know. 117 00:05:20,283 --> 00:05:24,273 So I guess the first thing we need to do is just make sure 118 00:05:24,273 --> 00:05:25,713 that this is a seizure, right? 119 00:05:25,713 --> 00:05:30,173 And I don't want to give any spoilers away for the next episodes where we're 120 00:05:30,173 --> 00:05:35,133 going to talk more about the mimics, but is there any hallmarks that, you 121 00:05:35,133 --> 00:05:38,223 know, we need to look out for, to know that this is a true seizure or not? 122 00:05:38,893 --> 00:05:39,583 There are. 123 00:05:40,093 --> 00:05:43,903 A classic clue for epilepsy is the presence of autonomic signs. 124 00:05:43,903 --> 00:05:48,763 So, by which I mean things like urination, salivation, but also 125 00:05:48,763 --> 00:05:50,983 things like loss of awareness as well. 126 00:05:51,083 --> 00:05:54,367 These pets, they leave their eyes open during an episode, which might 127 00:05:54,367 --> 00:05:57,787 make an owner feel that they are maintaining some form of awareness. 128 00:05:58,057 --> 00:06:00,487 But if they try and interact with their pet during these episodes, there 129 00:06:00,487 --> 00:06:04,487 would be the fact that they're not aware of what's going on around them. 130 00:06:04,487 --> 00:06:06,357 So these pets lose awareness. 131 00:06:07,257 --> 00:06:10,857 Another big hallmark is the postictal period as well. 132 00:06:10,857 --> 00:06:14,787 So any pet recovering from a seizure will often display 133 00:06:14,817 --> 00:06:17,187 disorientation, maybe ataxia. 134 00:06:17,577 --> 00:06:19,977 I usually say they can look a bit drunk, but even temporary 135 00:06:19,977 --> 00:06:22,917 blindness, which is another big concern for owners, they'll panic. 136 00:06:22,947 --> 00:06:25,797 My pet seems blind but this is temporary. 137 00:06:26,187 --> 00:06:29,517 And patients may have a history of seizures or they may have 138 00:06:29,517 --> 00:06:34,347 other preceding signs, such as tremors or signs of toxicity, that 139 00:06:34,347 --> 00:06:36,217 may raise our suspicion as well. 140 00:06:36,297 --> 00:06:36,357 Yeah. 141 00:06:36,757 --> 00:06:37,482 That makes sense. 142 00:06:37,724 --> 00:06:41,204 So let's say we're definitely sure it's the seizure and it's definitely status. 143 00:06:41,204 --> 00:06:44,234 It's not ending after that kind of five minutes or more by the time 144 00:06:44,234 --> 00:06:45,614 they come to the practice, I guess. 145 00:06:46,214 --> 00:06:47,354 So what's the plan? 146 00:06:47,354 --> 00:06:49,844 I think you've got some kind of steps for us to follow. 147 00:06:50,309 --> 00:06:51,989 Yeah, well don't panic. 148 00:06:52,049 --> 00:06:53,729 Don't Panic is the most important one. 149 00:06:53,819 --> 00:06:56,519 And we're going to talk more about a team approach to 150 00:06:56,519 --> 00:06:58,199 epilepsy later on in this series. 151 00:06:58,199 --> 00:07:00,209 But it is about a team approach. 152 00:07:00,269 --> 00:07:02,129 You can't do this single-handedly. 153 00:07:02,849 --> 00:07:05,459 Now your heart may sink and think, well I'm, I'm on my own. 154 00:07:05,459 --> 00:07:06,149 That's all I've got. 155 00:07:06,149 --> 00:07:09,209 Well, there are things you can still do, but the more hands on deck the better. 156 00:07:09,209 --> 00:07:11,279 And everyone can play a part in this. 157 00:07:11,829 --> 00:07:14,379 But I'd say there are three main goals when you're dealing with 158 00:07:14,379 --> 00:07:16,269 a pet with status epilepticus. 159 00:07:16,629 --> 00:07:19,509 The first is we need to stabilise that patient. 160 00:07:20,064 --> 00:07:20,334 Yep. 161 00:07:20,649 --> 00:07:22,719 Then we need to obviously stop the seizures. 162 00:07:22,989 --> 00:07:24,729 An obvious one, but an important one. 163 00:07:25,479 --> 00:07:27,879 And then we need to investigate the cause. 164 00:07:28,279 --> 00:07:30,019 So you know what do we do first? 165 00:07:30,019 --> 00:07:32,239 I'm often asked that question of what do we do first? 166 00:07:32,239 --> 00:07:36,259 So I'd say ideally we tackle all three simultaneously, which 167 00:07:36,259 --> 00:07:39,079 really shows how important the teamwork is in managing these cases 168 00:07:39,109 --> 00:07:40,549 and these patients effectively. 169 00:07:41,419 --> 00:07:46,369 If I were to prioritise, well stabilising the patient comes first. 170 00:07:46,789 --> 00:07:50,779 This means ensuring things like the airway is patent, usually is, 171 00:07:50,809 --> 00:07:52,039 but it's important you say that. 172 00:07:52,489 --> 00:07:54,049 Then you need to make sure they're breathing and they've 173 00:07:54,049 --> 00:07:55,309 got a good circulation. 174 00:07:56,119 --> 00:07:58,669 There's never any problem with providing oxygen to these pets. 175 00:07:58,669 --> 00:08:00,739 I've yet to meet a pet that's been killed by oxygen. 176 00:08:00,949 --> 00:08:02,239 I think it only ever helps. 177 00:08:02,599 --> 00:08:05,179 So providing oxygen is definitely important. 178 00:08:05,209 --> 00:08:08,269 And we want to be getting IV access. 179 00:08:08,269 --> 00:08:11,209 Now, this is where you just want to get someone in the practice who's 180 00:08:11,209 --> 00:08:12,859 happy with placing IVs to place an IV. 181 00:08:12,859 --> 00:08:15,979 It doesn't have to be you, it can be you, but it can be anyone, 182 00:08:15,979 --> 00:08:17,179 any, any member of the team. 183 00:08:17,614 --> 00:08:20,494 Because the nurses are always better at that than me, to be honest. 184 00:08:20,539 --> 00:08:23,119 I've lost my ability to place IVs. 185 00:08:23,464 --> 00:08:24,709 Was that your like call to help? 186 00:08:25,099 --> 00:08:25,939 It was a bit. 187 00:08:25,939 --> 00:08:28,879 Back in the day I was very happy with it and I'd be picked out as 188 00:08:28,879 --> 00:08:31,099 the person to do it, but now I'm right at the back of that queue. 189 00:08:31,659 --> 00:08:34,269 So find the person who is confident with it, and particularly given 190 00:08:34,319 --> 00:08:37,499 these are difficult situations, you need a steady hand and a calm mind, 191 00:08:37,649 --> 00:08:39,299 and that'll get that IV placed. 192 00:08:39,779 --> 00:08:43,049 If you're presented with a patient with status, then remember they, they've 193 00:08:43,049 --> 00:08:45,989 probably been fitting for some time by the time they get to your practice. 194 00:08:45,989 --> 00:08:47,959 So a really big concern is hyperthermia. 195 00:08:48,569 --> 00:08:50,399 These pets can get really, really hot. 196 00:08:50,399 --> 00:08:54,419 So get someone there to take the temperature and we can see where 197 00:08:54,419 --> 00:08:57,289 we're at because these dogs could be so hot that it could be a life 198 00:08:57,289 --> 00:09:01,189 threatening emergency at that point, and cooling would be actively encouraged. 199 00:09:01,189 --> 00:09:03,199 So check the temperature early on. 200 00:09:04,309 --> 00:09:07,279 I think that's really important because I'm going to put my hand up 201 00:09:07,279 --> 00:09:12,139 and say, I just go straight for the drugs and I forget this extra stuff. 202 00:09:12,589 --> 00:09:16,454 Actually stabilising that patient and doing this, I want to say 203 00:09:16,454 --> 00:09:18,254 like nursing care for instance. 204 00:09:18,704 --> 00:09:23,204 I think it's taking that moment to just step back and look at the bigger picture. 205 00:09:23,204 --> 00:09:23,984 It's really important. 206 00:09:24,254 --> 00:09:27,494 And I love you've said that because I completely agree as vets, we 207 00:09:27,494 --> 00:09:31,004 think the fix is drugs, let's fix with drugs, get the drugs out. 208 00:09:31,244 --> 00:09:33,434 But there are so many other more key things that we need 209 00:09:33,434 --> 00:09:34,664 to be thinking early on. 210 00:09:34,724 --> 00:09:35,954 So yeah, I love that. 211 00:09:35,954 --> 00:09:39,104 I will hold my hand up to and say in the past exactly the same issue. 212 00:09:39,104 --> 00:09:40,701 You want to just get the quick fix. 213 00:09:40,724 --> 00:09:41,054 Yeah. 214 00:09:41,534 --> 00:09:43,394 So you mentioned cooling the patient. 215 00:09:43,964 --> 00:09:46,844 I mean, what is the current kind of thinking on that? 216 00:09:46,844 --> 00:09:48,824 Is it cold fluids now? 217 00:09:48,824 --> 00:09:50,354 Is it fans and wet towels? 218 00:09:50,404 --> 00:09:51,904 What is your current thinking? 219 00:09:52,444 --> 00:09:55,714 Well, actually nowadays people are starting to think that cold water 220 00:09:55,714 --> 00:09:57,754 immersion is a good method here. 221 00:09:58,374 --> 00:10:02,027 So, allowing what we call conductive cooling for the patient. 222 00:10:02,844 --> 00:10:06,234 I suppose the other method is evaporative cooling, where you use 223 00:10:06,234 --> 00:10:09,834 a water spray and fans to encourage evaporation and air movement. 224 00:10:10,074 --> 00:10:14,154 In honesty, that's far more practical in the setting of clinical practice 225 00:10:14,154 --> 00:10:15,624 when faced with these patients. 226 00:10:16,104 --> 00:10:18,384 But there's no harm in giving cold fluids. 227 00:10:18,624 --> 00:10:21,499 But they've not really been found to be as effective in cooling 228 00:10:21,499 --> 00:10:23,074 patients that are hyperthermic. 229 00:10:23,634 --> 00:10:26,184 So now let's talk about stopping those seizures. 230 00:10:26,184 --> 00:10:27,834 What is the first line of attack? 231 00:10:27,834 --> 00:10:29,334 We've stabilised them at this point, 232 00:10:29,384 --> 00:10:33,444 The go-to drugs are fast acting, short duration, anti epileptics 233 00:10:33,464 --> 00:10:35,714 like diazepam or midazolam. 234 00:10:35,894 --> 00:10:38,714 These enhance the effects of GABA, which is a neurotransmitter 235 00:10:38,714 --> 00:10:40,394 that calms brain activity. 236 00:10:40,529 --> 00:10:40,949 Oh wow. 237 00:10:40,949 --> 00:10:43,049 We've got straight into the neurotransmitters here. 238 00:10:43,049 --> 00:10:44,039 But no, it's fascinating. 239 00:10:44,159 --> 00:10:48,479 Now I think it's fair to say when we're talking about diazepam, if you 240 00:10:48,479 --> 00:10:51,629 reach out for a textbook and you read about status epilepticus, you read, 241 00:10:51,899 --> 00:10:57,029 what you're meant to do is you give maybe half to 1 mg per kg IV if you 242 00:10:57,029 --> 00:11:02,939 can, as a bolus, or you can give rectal diazepam if IV access isn't possible. 243 00:11:03,359 --> 00:11:07,139 The textbooks will tell you that it works within two to three minutes. 244 00:11:07,949 --> 00:11:11,939 But if it works, it really only lasts for about 30 minutes, 245 00:11:11,939 --> 00:11:13,469 so it's a temporary solution. 246 00:11:14,009 --> 00:11:16,889 And if I'm honest, my experience, and I don't know how you feel 247 00:11:16,889 --> 00:11:20,849 with this, but you know, you give half to one mg per kg of diazepam. 248 00:11:21,209 --> 00:11:23,639 You wait and then you wait. 249 00:11:24,839 --> 00:11:25,439 And you wait more. 250 00:11:25,439 --> 00:11:28,709 Now we are waiting here and this, this, well, if I say we wait and 251 00:11:28,709 --> 00:11:30,959 leave a silence, that's awkward. 252 00:11:31,769 --> 00:11:34,919 But when you've got a dog fitting that's a little bit more tense. 253 00:11:35,039 --> 00:11:35,954 It's even more awkward. 254 00:11:36,809 --> 00:11:39,509 It's quite a difficult situation to deal with. 255 00:11:39,509 --> 00:11:39,649 Yeah 256 00:11:40,159 --> 00:11:44,729 So, I would say great, if you can do what the textbooks say and wait 5 to 257 00:11:44,729 --> 00:11:46,659 10 minutes to see if the seizures stop. 258 00:11:47,399 --> 00:11:49,919 In practice, I don't think that's the right thing to do. 259 00:11:50,219 --> 00:11:52,589 And I feel uncomfortable leaving a pet there for 5 or 260 00:11:52,589 --> 00:11:53,699 10 minutes watching them fit. 261 00:11:53,699 --> 00:11:57,109 So I would give that dose once, if it doesn't work, you're meant 262 00:11:57,109 --> 00:12:01,009 to give a second dose and wait, and then you go for a third dose 263 00:12:01,009 --> 00:12:02,538 of diazepam and see what happens. 264 00:12:03,016 --> 00:12:07,036 But I think actually if you're finding it doesn't work, I usually find 265 00:12:07,036 --> 00:12:09,346 it by the third dose of diazepam, we've still not got a response. 266 00:12:09,346 --> 00:12:13,636 I think it's worth trying initially, but I wouldn't persist with it because then 267 00:12:13,636 --> 00:12:16,666 you've potentially lost half an hour in which the dog's continued to fit. 268 00:12:16,666 --> 00:12:20,071 And of course that causes all the other problems associated 269 00:12:20,093 --> 00:12:21,323 with status epilepticus. 270 00:12:21,803 --> 00:12:27,413 So a common mistake is giving diazepam, seeing it work, and then stopping there. 271 00:12:27,713 --> 00:12:31,403 Thinking my job is done, pack your bags, go on to the next case. 272 00:12:32,453 --> 00:12:35,683 But in status epilepticus, well, in any, in any seizure 273 00:12:35,683 --> 00:12:37,753 situation, it's only short acting. 274 00:12:38,113 --> 00:12:41,863 So once that drug wears off, the seizures will often return. 275 00:12:43,213 --> 00:12:47,033 And on the flip side, if diazepam doesn't work within a couple of minutes, well 276 00:12:47,053 --> 00:12:51,523 it's unlikely to work at all, so we should quickly consider another option. 277 00:12:52,663 --> 00:12:53,113 Okay. 278 00:12:53,923 --> 00:12:59,313 Now I'm often asked about the difference between diazepam and midazolam. 279 00:13:00,303 --> 00:13:05,159 I understand they're the same class of drug, but, have you got a preference? 280 00:13:05,159 --> 00:13:06,749 Are there pros and cons of each? 281 00:13:06,749 --> 00:13:11,189 Now obviously I have to caveat with this, midazolam is not licensed, but 282 00:13:11,729 --> 00:13:13,049 it's becoming increasingly popular. 283 00:13:13,099 --> 00:13:13,459 It is. 284 00:13:13,459 --> 00:13:16,159 And actually the evidence is pointing far more in favour 285 00:13:16,339 --> 00:13:18,409 of midazolam than diazepam. 286 00:13:18,739 --> 00:13:21,659 So there's been a recent consensus statement. 287 00:13:21,689 --> 00:13:25,009 This again sounds fancy, but there's a group of key opinion 288 00:13:25,009 --> 00:13:26,209 leaders that come together. 289 00:13:26,269 --> 00:13:30,169 And this was done through A-C-V-I-M, so the American Board of medicine 290 00:13:30,189 --> 00:13:31,359 and neurology specialists. 291 00:13:31,839 --> 00:13:35,989 And they sat round and kind of looked at the evidence for diazepam and 292 00:13:35,989 --> 00:13:38,379 midazolam in these emergency situations. 293 00:13:38,859 --> 00:13:41,859 And actually they came to the conclusion that midazolam is more effective. 294 00:13:42,309 --> 00:13:45,729 So the dose for Midazolam, if we're giving that IV, it's 295 00:13:45,729 --> 00:13:49,179 roundabout 0.2 to 0.5 mgs per kg. 296 00:13:49,419 --> 00:13:53,079 And very similarly to diazepam, we give that, we see if we see a response and 297 00:13:53,079 --> 00:13:54,819 we can give that up to three times. 298 00:13:55,149 --> 00:14:00,609 Again, I wouldn't be leaving that long pause, that wait, observing the patient. 299 00:14:00,609 --> 00:14:04,644 I'd be fairly quick in giving it maybe every couple of minutes, the time 300 00:14:04,644 --> 00:14:06,264 it takes you to drop the next dose. 301 00:14:06,364 --> 00:14:10,229 And what about if you just can't get IV access? 302 00:14:10,769 --> 00:14:13,849 I mean, it can be really difficult, and you just can't seem to get 303 00:14:13,849 --> 00:14:15,469 an IV line in these patients. 304 00:14:16,324 --> 00:14:16,954 Absolutely. 305 00:14:16,954 --> 00:14:19,024 Well, that is really important. 306 00:14:19,024 --> 00:14:22,654 So if it is just me on my own in the practice and I've confessed, I can't 307 00:14:22,654 --> 00:14:26,794 get IV access on my, I can't do it with five helpers, if I'm honest. 308 00:14:26,794 --> 00:14:27,304 I can't place- 309 00:14:27,304 --> 00:14:28,724 Let alone by yourself. 310 00:14:28,724 --> 00:14:30,214 I can't place an IV anymore. 311 00:14:30,214 --> 00:14:31,024 I've lost that skill. 312 00:14:31,714 --> 00:14:34,084 But that's where other routes need to be considered. 313 00:14:34,114 --> 00:14:38,444 Now, rectal diazepam, that's a tried and tested option. 314 00:14:38,894 --> 00:14:43,694 And I suppose with rectal diazepam it's especially helpful because it bypasses 315 00:14:43,694 --> 00:14:47,324 the liver, so it allows the drug to reach effective levels quickly in the blood. 316 00:14:47,594 --> 00:14:49,544 So it's really, really good to do that. 317 00:14:49,544 --> 00:14:55,504 Now the dose is one to two mgs per kg. These diazepam, what 318 00:14:55,504 --> 00:14:56,854 do we call them, suppositories? 319 00:14:56,874 --> 00:14:57,134 Yeah. 320 00:14:57,134 --> 00:14:58,214 Or Rectal tubes. 321 00:14:58,629 --> 00:14:59,409 Rectal tubes. 322 00:14:59,454 --> 00:15:00,264 That's much better. 323 00:15:00,714 --> 00:15:05,458 These diazepam rectal tubes come in sort of five milligram, 10 milligram aliquots. 324 00:15:05,548 --> 00:15:11,518 And so if we have a 30 kilo Labrador that's fitting, according to my dose 325 00:15:11,518 --> 00:15:14,108 range, you want to give 30 to 60 mgs. 326 00:15:14,488 --> 00:15:16,258 That's a lot of rectal diazepam. 327 00:15:17,188 --> 00:15:20,208 Can I take a moment to confess something else? 328 00:15:20,538 --> 00:15:22,093 Oh my god, I'm nervous. 329 00:15:22,483 --> 00:15:23,623 What are you going to confess? 330 00:15:23,668 --> 00:15:25,438 Well, I don't know. 331 00:15:25,438 --> 00:15:30,058 No one ever talks about this, but when, we'll move away from status briefly. 332 00:15:30,128 --> 00:15:32,408 Imagine a first vaccination, for example. 333 00:15:32,768 --> 00:15:35,138 And you've got the puppy there, you know, lovely, lovely, happy, the 334 00:15:35,138 --> 00:15:36,548 family are there, everyone's delighted. 335 00:15:36,878 --> 00:15:39,818 And it gets to that moment when you just need to check the dog's temperature. 336 00:15:40,868 --> 00:15:42,038 Do you know where this is going yet? 337 00:15:42,188 --> 00:15:42,938 I think I know. 338 00:15:42,938 --> 00:15:43,448 Yeah. 339 00:15:43,873 --> 00:15:48,283 Taking the rectal temperature of a dog I think is actually very difficult. 340 00:15:48,403 --> 00:15:49,903 Why is it so hard? 341 00:15:50,113 --> 00:15:51,763 Well, locating the dog's bum hole. 342 00:15:53,273 --> 00:15:55,703 It's, they just make it harder for us. 343 00:15:55,753 --> 00:15:59,503 Well, it's covered in fur and it's hidden away, and so I actually think 344 00:15:59,503 --> 00:16:02,563 it's a very difficult thing to do and there's nothing more incompetent 345 00:16:02,563 --> 00:16:06,313 for a vet to not be able to find a dog's bum hole in a consultation. 346 00:16:06,973 --> 00:16:12,013 Now, fast forward to the emergency seizuring patient, trying to 347 00:16:12,013 --> 00:16:16,793 do that in a frantic stressful environment suddenly becomes harder. 348 00:16:17,363 --> 00:16:19,913 So rectal diazepam is hard to give. 349 00:16:20,153 --> 00:16:23,703 And remember these are drugs that we actually can give an owner, we can 350 00:16:23,703 --> 00:16:27,333 empower an owner at home to be able to do this because they are helpless, they're 351 00:16:27,333 --> 00:16:32,193 watching their pet seizure and there's very little they can feel they can do. 352 00:16:32,373 --> 00:16:34,923 But allowing them to have the rectal diazepam tubes means there's 353 00:16:34,923 --> 00:16:38,433 something they can do either at home or on route to the practice. 354 00:16:38,773 --> 00:16:43,063 I mention all this because I do think finding a bum in an emergency 355 00:16:43,063 --> 00:16:44,383 is very, very difficult indeed. 356 00:16:44,413 --> 00:16:46,663 And I think owners do struggle a lot with this. 357 00:16:46,663 --> 00:16:49,183 So we do need to think about that. 358 00:16:49,183 --> 00:16:51,523 It's really just not as straightforward as you might think. 359 00:16:51,613 --> 00:16:53,898 I think we've said the word bum quite a lot now. 360 00:16:53,953 --> 00:16:55,283 But But it's not just me though, is it? 361 00:16:56,033 --> 00:16:56,933 It was mostly you. 362 00:16:59,138 --> 00:17:00,143 Did I say it too much? 363 00:17:00,363 --> 00:17:01,148 No, it's fine. 364 00:17:01,328 --> 00:17:01,748 It's good. 365 00:17:01,898 --> 00:17:04,358 I've heard there is a, an alternative option though. 366 00:17:04,538 --> 00:17:05,348 A newer option. 367 00:17:05,348 --> 00:17:07,478 Intranasal midazolam maybe. 368 00:17:07,538 --> 00:17:08,378 What is that all about? 369 00:17:08,378 --> 00:17:09,188 I've not used it. 370 00:17:09,458 --> 00:17:11,078 Well, this is where I think it's important. 371 00:17:11,078 --> 00:17:14,588 Moving away from rectal diazepam, I think an intranasal route is 372 00:17:14,588 --> 00:17:17,858 another up and coming route That is, is very, very effective. 373 00:17:17,858 --> 00:17:20,348 And this is again, where the evidence is pointing. 374 00:17:20,768 --> 00:17:24,578 So what we're talking about here is giving intranasal midazolam. 375 00:17:24,698 --> 00:17:26,168 That's the route we want to take. 376 00:17:26,588 --> 00:17:30,578 Now, what you need to do for this, there's a device, it's called a 377 00:17:30,578 --> 00:17:33,338 mucosal administration device. 378 00:17:33,518 --> 00:17:33,878 Wow. 379 00:17:33,968 --> 00:17:34,928 Sounds very fancy. 380 00:17:35,558 --> 00:17:37,838 it sounds even better when you abbreviate it to MAD. 381 00:17:38,623 --> 00:17:38,913 Okay. 382 00:17:38,913 --> 00:17:39,113 Yep. 383 00:17:39,338 --> 00:17:44,263 So we going to use this MAD device to administer midazolam intranasally. 384 00:17:44,683 --> 00:17:47,863 Now we can call it a mucosal administration device. 385 00:17:47,863 --> 00:17:52,923 Some people call it mucosal atomisation device because, 386 00:17:52,923 --> 00:17:53,523 Oo even fancier 387 00:17:53,523 --> 00:17:55,543 well atomisation, I read this because I had to learn this because 388 00:17:55,543 --> 00:17:58,543 I wasn't really sure, but it is probably obvious when you've read it. 389 00:17:58,573 --> 00:18:01,183 It's, it just means turning a liquid into a fine spray. 390 00:18:02,353 --> 00:18:04,983 So if you remember the, the kennel cough vaccine. 391 00:18:05,283 --> 00:18:06,993 You get that little conical. 392 00:18:07,768 --> 00:18:08,048 Device. 393 00:18:08,048 --> 00:18:12,273 Plastic thing, device, it's, it's a MAD, you put it on the end of your syringe 394 00:18:12,273 --> 00:18:13,653 and you spray it up a dog's nose. 395 00:18:13,683 --> 00:18:15,513 I mean, that's effectively what we're doing here. 396 00:18:15,513 --> 00:18:17,403 So we're putting midazolam into a syringe. 397 00:18:17,703 --> 00:18:20,163 We're putting that device on the end and we're spraying it in the nose. 398 00:18:20,583 --> 00:18:24,933 Now that works really, really effectively and it's another really good thing for 399 00:18:24,933 --> 00:18:29,763 owners to do at home, and it actually works really well for cluster seizures. 400 00:18:29,823 --> 00:18:32,673 So we're talking about status epilepticus, and remember I said 401 00:18:32,673 --> 00:18:36,663 that that can be these dogs that have cluster seizures without full recovery. 402 00:18:37,413 --> 00:18:42,363 So intranasal midazolam, great at home, great in the practice, the dose 403 00:18:42,363 --> 00:18:48,153 is very similar to the IV dose, 0.2 to 0.5 mgs per kg. And it basically just 404 00:18:48,153 --> 00:18:51,693 works by absorbing through the nasal mucosa directly into the bloodstream. 405 00:18:52,233 --> 00:18:54,993 Again, it bypasses the gastrointestinal system. 406 00:18:55,293 --> 00:18:59,223 So it's helpful in emergency situations where time is really critical. 407 00:18:59,763 --> 00:19:03,363 And it's particularly useful when the dog's seizing and handling them 408 00:19:03,363 --> 00:19:06,633 for rectal or IV administration is either unsafe or impractical. 409 00:19:07,213 --> 00:19:10,423 Personally, I find that easier than giving the rectal diazepam. 410 00:19:11,233 --> 00:19:13,423 I'm often asked about cats as well. 411 00:19:13,423 --> 00:19:14,659 Can we do this in cats? 412 00:19:15,319 --> 00:19:18,319 The simple answer is yes, it's safe, it can be done. 413 00:19:18,799 --> 00:19:21,379 Safe for the cat, might not be safe for you. 414 00:19:21,754 --> 00:19:25,234 Do you have to worry about like chomping mouths and things like that? 415 00:19:25,261 --> 00:19:27,301 A cat's, cat's teeth would get in the way. 416 00:19:27,301 --> 00:19:28,481 Dog's teeth get in the way. 417 00:19:28,801 --> 00:19:31,171 But cats have the added defence of claws as well. 418 00:19:32,326 --> 00:19:34,006 I think yes, it can be done. 419 00:19:34,256 --> 00:19:36,476 But just be careful when trying to administer it. 420 00:19:36,526 --> 00:19:36,826 Okay. 421 00:19:37,396 --> 00:19:40,066 And so you definitely need one of these devices. 422 00:19:40,066 --> 00:19:43,336 You can't just spray a syringe full up the nose. 423 00:19:43,636 --> 00:19:46,246 Well, I think the answer is if you don't have one, of course you should 424 00:19:46,246 --> 00:19:48,256 still spray a syringe full up the nose. 425 00:19:48,496 --> 00:19:50,566 But these devices are really quite cheap. 426 00:19:50,656 --> 00:19:53,596 And actually if you go away and google this, can we mention Google? 427 00:19:53,926 --> 00:19:55,636 Other search engines are available. 428 00:19:55,936 --> 00:19:56,566 Very good. 429 00:19:56,746 --> 00:20:01,006 We can find these devices quite cheaply for a few pence online and you know, 430 00:20:01,036 --> 00:20:03,706 just getting them in, you can just have 'em on the side so you've got them 431 00:20:03,706 --> 00:20:05,986 there to give owners at home as well. 432 00:20:06,436 --> 00:20:08,836 Probably keep them in your emergency kit. 433 00:20:09,316 --> 00:20:09,916 Ready to go. 434 00:20:10,096 --> 00:20:11,506 That's a fantastic tip. 435 00:20:11,629 --> 00:20:12,229 You're welcome. 436 00:20:12,675 --> 00:20:14,115 That's really great advice, Mark. 437 00:20:14,115 --> 00:20:17,385 I love how these alternatives make it a lot easier for us to respond 438 00:20:17,385 --> 00:20:19,615 quickly in these high pressure moments. 439 00:20:20,095 --> 00:20:21,265 Anything else to add there? 440 00:20:22,390 --> 00:20:23,650 Well, just one tip. 441 00:20:24,100 --> 00:20:28,180 Always have the doses pre-calculated and clearly documented in your 442 00:20:28,180 --> 00:20:29,920 clinic's emergency protocol. 443 00:20:30,640 --> 00:20:33,040 That way when the status epilepticus hits, you're ready 444 00:20:33,040 --> 00:20:34,960 to act without any hesitation. 445 00:20:35,155 --> 00:20:37,975 You're not having to rummage around for the formulary or anything like that. 446 00:20:38,165 --> 00:20:40,760 And that's it, you want to go and reach for your notes, you want to 447 00:20:40,760 --> 00:20:41,900 go and find out what's happening. 448 00:20:41,930 --> 00:20:45,580 So we need to, do things as quickly as we can, but effectively. 449 00:20:46,825 --> 00:20:51,085 So what about if you've given your diazepam or midazolam and it doesn't 450 00:20:51,085 --> 00:20:55,615 seem to be working, we might need to reach for some longer acting medications. 451 00:20:55,615 --> 00:20:56,815 Where would you start with those? 452 00:20:57,400 --> 00:21:01,510 Well, we do, and I'd add to there that also if it does work, we still want to 453 00:21:01,510 --> 00:21:03,640 reach for longer acting medications. 454 00:21:03,640 --> 00:21:08,350 But yes, if the dog's still fitting, we want to find a longer acting medication. 455 00:21:08,350 --> 00:21:11,860 They're really crucial to prevent the seizures recurring once the 456 00:21:11,860 --> 00:21:13,240 short acting drugs wear off. 457 00:21:13,700 --> 00:21:15,530 Phenobarbital is a classic choice. 458 00:21:15,530 --> 00:21:18,890 So it's, it's a barbiturate that takes about 30 minutes to 459 00:21:18,890 --> 00:21:20,180 cross the blood-brain barrier. 460 00:21:20,960 --> 00:21:24,530 And when it's used orally at a standard maintenance dose, it takes about 461 00:21:24,530 --> 00:21:27,710 two to three weeks to reach steady state concentration in the blood. 462 00:21:28,940 --> 00:21:32,420 But when we want to give it in status epilepticus, we need to really administer 463 00:21:32,420 --> 00:21:37,700 it much faster in IV boluses of about four mgs per kg every four to five 464 00:21:37,700 --> 00:21:39,560 minutes until the seizures stop. 465 00:21:39,890 --> 00:21:44,220 So trying to achieve those therapeutic blood concentrations a lot quicker. 466 00:21:44,540 --> 00:21:47,360 The important point here to make is by doing them at these high 467 00:21:47,360 --> 00:21:50,090 doses, of course we're going to provoke far more side effects. 468 00:21:50,180 --> 00:21:53,350 So high doses can cause more side effects. 469 00:21:53,680 --> 00:21:57,280 So we really need to reserve these for, for much less severe cases. 470 00:21:57,280 --> 00:22:01,420 And I've certainly seen situations where they have been given in a situation 471 00:22:01,630 --> 00:22:03,580 that maybe wasn't quite as urgent. 472 00:22:04,090 --> 00:22:07,090 And then complaints can arise from owners because they're left with a dog 473 00:22:07,090 --> 00:22:11,320 that's very, very subdued and flat, when actually that dog may have only been 474 00:22:11,320 --> 00:22:13,090 having one fit every couple of weeks. 475 00:22:13,120 --> 00:22:16,600 If their dog was having endless seizures or cluster seizures without 476 00:22:16,600 --> 00:22:21,670 recovery, then that's a very acceptable outcome, initially, for that dog to 477 00:22:21,670 --> 00:22:25,540 then recover over the coming weeks from the higher doses of that medication. 478 00:22:26,425 --> 00:22:27,020 Makes sense. 479 00:22:27,157 --> 00:22:31,327 For patients with liver issues or those already on phenobarbital, that 480 00:22:31,327 --> 00:22:33,007 can be quite a difficult situation. 481 00:22:33,437 --> 00:22:35,427 Levetiracetam's a great alternative. 482 00:22:35,857 --> 00:22:38,697 It's minimally metabolised by the liver, so it's mainly 483 00:22:38,697 --> 00:22:40,017 cleared through the kidneys. 484 00:22:40,437 --> 00:22:45,357 And it can be given at 20 to 30 mgs per kg every eight hours. 485 00:22:45,777 --> 00:22:48,657 I suppose it's important for me to say this is off license, but 486 00:22:48,657 --> 00:22:52,527 it's a really effective medication and one we reach for commonly. 487 00:22:53,187 --> 00:22:57,297 And the oral formulation is far more affordable than the IV formulation. 488 00:22:58,212 --> 00:23:00,792 Needless to say, the IV formulation is probably far easier to give 489 00:23:00,792 --> 00:23:03,342 in Status Epilepticus, but it is quite a bit more expensive. 490 00:23:03,342 --> 00:23:06,522 So it's a difficult thing to have on the shelves sometimes, and have 491 00:23:06,522 --> 00:23:07,902 available in these situations. 492 00:23:07,902 --> 00:23:12,409 But if you have it, fantastic, and reach for that first, and if all these 493 00:23:12,409 --> 00:23:17,595 options fail, we need to escalate to continuous rate infusions with drugs 494 00:23:17,595 --> 00:23:23,595 like midazolam or propofol and they're effectively anaesthetising the patient. 495 00:23:23,695 --> 00:23:27,805 So intensive care is required, but this can be lifesaving and it's 496 00:23:27,805 --> 00:23:31,535 something we do need to consider in a small proportion of these patients. 497 00:23:32,270 --> 00:23:33,350 Yeah, that makes sense. 498 00:23:33,350 --> 00:23:38,090 I used to work in quite a small practice and okay, thankfully we didn't see many 499 00:23:38,090 --> 00:23:42,760 status epilepticus dogs, which was good, but that also meant that I didn't have 500 00:23:42,760 --> 00:23:47,500 things like injectable phenobarbital or levetiracetam on the shelf. 501 00:23:48,010 --> 00:23:51,850 I just had diazepam and straight for kind of propofol. 502 00:23:51,850 --> 00:23:53,260 Is, is that acceptable? 503 00:23:53,260 --> 00:23:55,060 What do you suggest in that situation? 504 00:23:55,375 --> 00:23:58,035 Well, when you're in a panic state, you find doing things 505 00:23:58,035 --> 00:23:59,295 you're familiar with far easier. 506 00:23:59,925 --> 00:24:03,555 And so one thing that general practitioners are best at 507 00:24:03,825 --> 00:24:04,975 is performing anaesthesia. 508 00:24:05,805 --> 00:24:09,930 I suppose every day we're doing dentals, spays, all sorts of 509 00:24:09,930 --> 00:24:14,744 procedures that have the same common method in performing anaesthesia. 510 00:24:15,214 --> 00:24:18,514 So when you are panicking in this situation, do not be afraid to 511 00:24:18,514 --> 00:24:21,844 anaesthetise the patient in the way that you would anaesthetise any other patient 512 00:24:21,844 --> 00:24:23,644 in the practice for routine procedures. 513 00:24:24,154 --> 00:24:27,274 If nothing else, it gives you thinking time and it'll stop the seizure. 514 00:24:27,274 --> 00:24:31,234 So don't be afraid of that and then work out from there how to manage 515 00:24:31,234 --> 00:24:34,354 the fits once you're in a more calm situation and environment. 516 00:24:34,834 --> 00:24:36,034 That's really helpful. 517 00:24:36,134 --> 00:24:41,437 I think in my mind, fine to induce anaesthesia, but how do you then stop. 518 00:24:42,157 --> 00:24:44,757 What would be your protocol for stopping that anaesthesia? 519 00:24:45,307 --> 00:24:46,477 Well, it depends what you've done. 520 00:24:46,597 --> 00:24:49,957 So if you've anaesthetised the patient and you are in that very difficult 521 00:24:49,957 --> 00:24:53,887 situation of having no other medications available, that is a very, very tough one. 522 00:24:54,037 --> 00:24:57,367 And all I'd say is you'd get the dog onto isoflurane, intubated. 523 00:24:58,297 --> 00:25:02,107 You just then have to turn the isoflurane down and hope to not see twitching 524 00:25:02,107 --> 00:25:03,637 as that dog starts to come round. 525 00:25:04,087 --> 00:25:07,717 If it is twitching, you probably have to keep it on a little bit longer, and then 526 00:25:07,717 --> 00:25:11,887 maybe thinking of some form of long-term anti epileptic medication administered 527 00:25:11,887 --> 00:25:13,447 rectally might be the way to go. 528 00:25:13,777 --> 00:25:17,677 One choice there I favour when we can is, is potassium bromide. 529 00:25:17,737 --> 00:25:22,117 Potassium bromide, it is licensed in conjunction with phenobarbital as an 530 00:25:22,117 --> 00:25:24,127 oral long-term maintenance medication. 531 00:25:24,337 --> 00:25:27,727 Potassium bromide did used to come in a liquid, so we could give that 532 00:25:27,727 --> 00:25:31,897 rectally through a urinary catheter to a loading dose to achieve the right 533 00:25:31,897 --> 00:25:35,497 level within the blood very rapidly, but it's not available anymore. 534 00:25:36,307 --> 00:25:38,107 And really all we can get is the tablets. 535 00:25:38,467 --> 00:25:41,707 So you can get the potassium bromide tablet and you can crush it up. 536 00:25:42,322 --> 00:25:44,212 And mix it with water and give that rectally. 537 00:25:44,512 --> 00:25:48,232 So that can work really well if you've got a patient that you have no other 538 00:25:48,322 --> 00:25:51,202 medication for, but you've got that on the shelf and that's something that's 539 00:25:51,202 --> 00:25:53,182 fairly common on a pharmacy shelf. 540 00:25:53,232 --> 00:25:58,062 We give a loading dose of 600 mgs per kg spread out over whatever 541 00:25:58,062 --> 00:25:59,982 period of time we want to give it. 542 00:25:59,982 --> 00:26:03,612 Now typically we like to load that over five days because it 543 00:26:03,612 --> 00:26:07,062 does cause profound side effects, but we can give it much faster. 544 00:26:07,152 --> 00:26:10,242 So if you're in the situation we've described, then giving that over an 545 00:26:10,242 --> 00:26:14,472 hour or two is possible, but don't be surprised if that patient wakes up very 546 00:26:14,532 --> 00:26:16,592 severely affected from the bromide. 547 00:26:16,592 --> 00:26:21,632 I'd probably go sort of 100, 200 mgs per kg rectally, recover the dog and see 548 00:26:21,632 --> 00:26:23,552 where you're at and add more to effect. 549 00:26:23,587 --> 00:26:23,732 Yeah, 550 00:26:24,227 --> 00:26:24,737 That makes sense. 551 00:26:25,427 --> 00:26:29,447 So we've talked about stabilising the patient, we've talked about 552 00:26:29,447 --> 00:26:31,127 giving these emergency drugs. 553 00:26:31,697 --> 00:26:34,967 One of the other things you wanted to talk about was looking at the 554 00:26:34,967 --> 00:26:39,167 underlying cause of the status epilepticus and, and diagnosing that. 555 00:26:39,417 --> 00:26:43,107 How do you figure that out whilst stabilising the patient and 556 00:26:43,107 --> 00:26:44,577 doing all of the rest of this? 557 00:26:45,297 --> 00:26:46,887 Well, this is where teamwork shines. 558 00:26:47,277 --> 00:26:50,787 While one part of the team stabilises the dog, another can gather history 559 00:26:50,877 --> 00:26:52,257 and run initial diagnostics. 560 00:26:53,337 --> 00:26:57,987 Reactive causes like low blood glucose or toxin exposure are common. 561 00:26:58,047 --> 00:27:00,117 So tests for blood glucose are really important. 562 00:27:00,417 --> 00:27:04,647 Maybe check calcium while you're there and liver function are essential. 563 00:27:04,797 --> 00:27:09,357 Remember, urea, albumin, cholesterol, and triglycerides are the four we want 564 00:27:09,357 --> 00:27:11,067 to be looking at with liver function. 565 00:27:11,397 --> 00:27:12,267 Good to remember that list. 566 00:27:13,692 --> 00:27:16,492 Then we are moving on to things like advanced imaging, like 567 00:27:16,497 --> 00:27:18,802 MRI or spinal fluid analysis. 568 00:27:18,802 --> 00:27:22,042 And so they're needed for, you know, seeing if we've got structural 569 00:27:22,042 --> 00:27:25,912 epilepsy or to rule things out to know if it's idiopathic epilepsy. 570 00:27:26,452 --> 00:27:29,442 Just remember what I said earlier though, that a dog with idiopathic 571 00:27:29,442 --> 00:27:34,002 epilepsy may still present with status epilepticus either as their first 572 00:27:34,002 --> 00:27:36,522 episode or after years of good control. 573 00:27:36,792 --> 00:27:40,832 So if seizures are brought under control, the prognosis can still be favourable. 574 00:27:41,411 --> 00:27:46,841 So how do we know if some of these are the cause or the consequence? 575 00:27:47,381 --> 00:27:51,821 For example, you mentioned looking at blood glucose and low blood sugar. 576 00:27:52,241 --> 00:27:56,331 I mean that can often happen because of the seizure or the seizure 577 00:27:56,331 --> 00:27:57,711 happens because of the glucose. 578 00:27:57,711 --> 00:28:00,231 Like how do you know what's the cause or the consequence? 579 00:28:00,411 --> 00:28:03,411 Same potentially with things like hyperthermia as well. 580 00:28:04,071 --> 00:28:05,421 I think that's a really good point Emma. 581 00:28:05,421 --> 00:28:09,021 I mean hyperthermia is definitely something to watch out for in dogs 582 00:28:09,291 --> 00:28:13,131 that have had prolonged seizures, it's likely to be a consequence of the 583 00:28:13,131 --> 00:28:17,181 sustained muscle activity during the fits rather than the primary cause. 584 00:28:17,511 --> 00:28:21,081 I know when I go for my really big workouts in the gym, it doesn't work 585 00:28:21,081 --> 00:28:24,351 on audio, but I'm not the most well built and I don't go to the gym. 586 00:28:24,416 --> 00:28:25,971 I tried to hold in my snigger, I'm sorry 587 00:28:26,476 --> 00:28:29,661 but if I were to go to the gym and I was to work out for hours 588 00:28:29,661 --> 00:28:31,161 on end, I would get very hot. 589 00:28:31,221 --> 00:28:35,331 This is the nature of activity, being the sedate individual I am, I don't 590 00:28:35,331 --> 00:28:36,411 really know what I'm talking about. 591 00:28:36,801 --> 00:28:38,931 But it is likely to be that rather than a primary cause. 592 00:28:38,931 --> 00:28:42,471 So if I see hyperthermia, yes, I would absolutely treat it symptomatically 593 00:28:42,471 --> 00:28:45,771 in the way we've talked, cooling the dog down in a controlled way and 594 00:28:45,771 --> 00:28:47,271 monitor their temperature closely. 595 00:28:47,331 --> 00:28:50,261 Hypoglycaemia is a bit different for me. 596 00:28:50,831 --> 00:28:55,211 During a seizure if a dog's glucose levels are low, I may supplement 597 00:28:55,211 --> 00:28:59,471 glucose at that moment but it is important to address it acutely. 598 00:28:59,921 --> 00:29:04,391 However, I'm far more interested in what the glucose concentration is between the 599 00:29:04,391 --> 00:29:06,611 seizures, particularly in a fasted state. 600 00:29:06,851 --> 00:29:11,201 So we manage it in the moment, but I'd want to be getting that patient back in 601 00:29:11,411 --> 00:29:16,841 a few days later, hopefully controlled, in a fasted state to recheck what the 602 00:29:16,841 --> 00:29:18,941 blood glucose concentration actually is. 603 00:29:19,556 --> 00:29:20,846 That's really interesting. 604 00:29:20,856 --> 00:29:21,966 Why do you look at that? 605 00:29:21,966 --> 00:29:25,596 I guess it's to check whether it's still low or? 606 00:29:26,181 --> 00:29:26,511 Yeah. 607 00:29:26,511 --> 00:29:29,871 Well, if glucose concentration remains low in a fasted patient a few days 608 00:29:29,871 --> 00:29:34,641 later, that points to a much more persistent hypoglycaemia state, and 609 00:29:34,641 --> 00:29:38,661 potentially that means it's a primary issue that's contributing to the seizures 610 00:29:38,661 --> 00:29:39,981 rather than the secondary effect. 611 00:29:40,761 --> 00:29:42,081 I know owners worry about that. 612 00:29:42,081 --> 00:29:43,761 They'll say, well, you know, I've starved my dog. 613 00:29:43,761 --> 00:29:47,181 Of course the blood sugar levels are low, but that's not the case. 614 00:29:47,261 --> 00:29:51,851 If we have low blood sugar levels after having starved ourselves, that's wrong. 615 00:29:51,851 --> 00:29:54,551 The body should compensate for this and release glucose. 616 00:29:54,551 --> 00:29:58,301 So if we find we've got low levels in ourselves or in dogs 617 00:29:58,301 --> 00:30:00,221 after fasting, that is abnormal. 618 00:30:00,341 --> 00:30:02,111 That means there's something pathologically wrong 619 00:30:02,201 --> 00:30:03,386 that we need to address. 620 00:30:04,146 --> 00:30:05,706 It's such a valuable approach. 621 00:30:05,916 --> 00:30:09,966 So treating that acute problem, but also thinking about the bigger picture, 622 00:30:10,551 --> 00:30:11,181 Exactly. 623 00:30:11,181 --> 00:30:15,321 I mean, it's all about keeping a cool head and planning for follow-up investigations 624 00:30:15,321 --> 00:30:17,511 once the immediate crisis is managed. 625 00:30:19,056 --> 00:30:21,816 And so when you have stabilised that patient then, thinking about 626 00:30:21,816 --> 00:30:25,476 that long-term plan, is there anything we need to do afterwards? 627 00:30:26,203 --> 00:30:30,523 Once a seizure patient is stabilised, then the next steps are really just as 628 00:30:30,523 --> 00:30:32,863 crucial as that emergency management. 629 00:30:33,183 --> 00:30:36,213 We really need to sit down and discuss with the owner the likelihood 630 00:30:36,213 --> 00:30:39,843 of recurrence because these dogs aren't fixed, they're managed. 631 00:30:40,503 --> 00:30:43,713 And I think we mentioned this in season one, that, we can't treat 632 00:30:43,713 --> 00:30:45,723 a dog and get rid of the fits. 633 00:30:45,903 --> 00:30:48,573 They're always going to be part of the long-term picture. 634 00:30:48,573 --> 00:30:51,093 So these owners need to understand a recurrence is likely. 635 00:30:51,723 --> 00:30:54,633 That doesn't mean we're going to have a recurrence of status epilepticus, 636 00:30:54,693 --> 00:30:57,693 but that always will be a risk and something the owners need to be aware 637 00:30:57,693 --> 00:31:01,183 of, so we need to educate them on how to manage that safely at home. 638 00:31:01,795 --> 00:31:06,415 So do we always continue with long-term meds or am I referring 639 00:31:06,415 --> 00:31:07,925 to people like you perhaps? 640 00:31:09,025 --> 00:31:12,235 Well, I think in most cases, yes, we're giving long-term 641 00:31:12,235 --> 00:31:13,585 anti epileptic medication. 642 00:31:13,585 --> 00:31:17,485 It's very rare that I wouldn't send a dog home that's had status epilepticus 643 00:31:17,485 --> 00:31:22,542 without prescribing long acting, long-term anti-epileptic medication. 644 00:31:22,698 --> 00:31:26,893 Phenobarbital is often one of the first line drugs we consider, it's effective, 645 00:31:26,953 --> 00:31:30,253 but it does require therapeutic blood monitoring to make sure we're hitting the 646 00:31:30,253 --> 00:31:32,773 right levels without causing toxicity. 647 00:31:33,763 --> 00:31:37,633 It's important to educate the owner about the need for periodic blood tests too, 648 00:31:37,633 --> 00:31:41,773 because that can be disruptive to their daily routine and ensure they understand 649 00:31:41,773 --> 00:31:43,813 that this isn't a one and done treatment. 650 00:31:45,163 --> 00:31:46,003 That makes sense. 651 00:31:46,633 --> 00:31:50,033 And I guess it's useful as well to make sure that they are on 652 00:31:50,033 --> 00:31:51,623 board with follow-ups as well. 653 00:31:51,993 --> 00:31:55,906 Follow ups are essential, one thing I always ask owners to do is 654 00:31:55,906 --> 00:31:57,646 to keep a detailed seizure diary. 655 00:31:58,276 --> 00:32:02,056 The diary should include things like the date, time and duration of fits. 656 00:32:02,536 --> 00:32:05,566 And this helps us track the frequency and pattern of seizures over time 657 00:32:05,566 --> 00:32:09,086 to make sure that we are getting effective control of those fits. 658 00:32:10,091 --> 00:32:15,256 One of my biggest fears I guess is that we've stabilised them in their status 659 00:32:15,256 --> 00:32:21,106 epilepticus, we send them home and I just fear that owner calling me back the 660 00:32:21,106 --> 00:32:24,826 day later or two days later and going, oh my goodness, he's seizuring again. 661 00:32:24,886 --> 00:32:26,926 Like what do we do then? 662 00:32:27,026 --> 00:32:28,286 What if the seizures recur? 663 00:32:28,751 --> 00:32:32,256 Well, if seizures are breaking through despite treatment, that's when you need 664 00:32:32,256 --> 00:32:36,996 to reassess and it might involve adjusting the dose of the current medication, adding 665 00:32:36,996 --> 00:32:41,756 in a second line medication like potassium bromide or potentially levetiracetam, 666 00:32:42,036 --> 00:32:46,236 or even considering referral to a neurologist for more advanced diagnostics. 667 00:32:46,476 --> 00:32:48,156 I would definitely be sending it your way. 668 00:32:48,156 --> 00:32:49,836 I'm not going to lie, is that okay? 669 00:32:50,031 --> 00:32:54,546 Well, it's always okay to refer a patient and it really depends. 670 00:32:54,606 --> 00:32:57,666 Some owners just will not be able to go down that route for whatever reason. 671 00:32:57,666 --> 00:33:00,216 They may not want to, they may have a good bonded relationship with you 672 00:33:00,216 --> 00:33:01,626 and want it all managing in house. 673 00:33:02,196 --> 00:33:04,986 But the referrals to a neurologist, there are two things there. 674 00:33:05,021 --> 00:33:07,781 The advanced imaging is obviously one thing that can be helpful, 675 00:33:07,841 --> 00:33:09,461 but it isn't always necessary. 676 00:33:09,491 --> 00:33:13,751 And I hope we've got that across, over these episodes, that an MRI scan of a dog 677 00:33:13,751 --> 00:33:15,371 is not always something we have to do. 678 00:33:15,911 --> 00:33:18,941 But the other part of it is giving that owner a sort of time and space 679 00:33:18,941 --> 00:33:20,681 to discuss the outcome and epilepsy. 680 00:33:20,681 --> 00:33:24,221 And I think that's where referral to a neurologist can be helpful because we just 681 00:33:24,221 --> 00:33:27,671 don't have the time in general practice to have those sorts of conversations. 682 00:33:27,791 --> 00:33:28,421 Definitely. 683 00:33:28,811 --> 00:33:32,501 Particularly if they come in with status, they're often just emergencies 684 00:33:32,501 --> 00:33:34,511 on the side of our consult list as well. 685 00:33:34,511 --> 00:33:37,031 So absolutely just having that time to talk to them. 686 00:33:37,641 --> 00:33:41,382 So stabilising is really just the start of a longer journey, isn't it really? 687 00:33:41,697 --> 00:33:42,207 Exactly. 688 00:33:42,297 --> 00:33:45,057 I mean, seizure management is a long-term commitment. 689 00:33:45,117 --> 00:33:48,537 It's about finding the right balance between controlling the seizures and 690 00:33:48,537 --> 00:33:52,347 minimising those side effects from medication while also involving the 691 00:33:52,347 --> 00:33:54,237 owner in monitoring and decision making. 692 00:33:55,302 --> 00:33:56,802 That's brilliant advice, Mark. 693 00:33:56,802 --> 00:33:57,312 Thank you. 694 00:33:57,922 --> 00:34:01,972 So is there any parting advice for us GP vets facing this 695 00:34:01,972 --> 00:34:04,162 high stake situation of status? 696 00:34:04,927 --> 00:34:05,707 Don't panic. 697 00:34:05,827 --> 00:34:07,567 Stick to the stepwise approach. 698 00:34:07,777 --> 00:34:11,437 Stabilise, stop the seizures and investigate the cause. 699 00:34:11,887 --> 00:34:13,747 I mean, recovery can take days. 700 00:34:13,747 --> 00:34:17,017 So patience and monitoring are absolutely essential here. 701 00:34:17,507 --> 00:34:21,527 Epilepticus management is a group effort and delegation is so important. 702 00:34:21,987 --> 00:34:24,417 it's honestly been such valuable insights today. 703 00:34:24,417 --> 00:34:25,647 I've learned so much. 704 00:34:25,947 --> 00:34:29,277 So thank you so much, Mark, for breaking this down so clearly. 705 00:34:29,877 --> 00:34:31,677 And thank you to our listeners for tuning in. 706 00:34:31,677 --> 00:34:33,717 I think that's all we've got time for today. 707 00:34:34,437 --> 00:34:37,617 If you found this episode helpful, please obviously share it with 708 00:34:37,617 --> 00:34:41,187 your colleagues and don't forget to subscribe for more veterinary content. 709 00:34:41,847 --> 00:34:45,367 You can also find many free resources available at the Dômes Pharma 710 00:34:45,387 --> 00:34:49,617 website, including status epilepticus triage sheets and guidelines. 711 00:34:49,617 --> 00:34:51,237 And you can find the link in the bio. 712 00:34:52,317 --> 00:34:56,097 Next episode, we'll pick up the conversation about seizure mimics we 713 00:34:56,097 --> 00:34:57,597 sort of alluded to it the beginning. 714 00:34:58,077 --> 00:35:01,077 And there are many things that might look like a seizure in practice or 715 00:35:01,137 --> 00:35:04,647 owners might mistake for a seizure and Mark will be offering his tips 716 00:35:04,647 --> 00:35:06,327 on how to differentiate all of these. 717 00:35:06,477 --> 00:35:09,057 So until then, take care and stay curious. 718 00:35:09,237 --> 00:35:09,867 Thanks, Mark. 719 00:35:10,272 --> 00:35:10,482 Thank you.