Hello and welcome back to Synaptic Tails, the podcast where we deep
dive into fascinating and important topics in veterinary epilepsy.
I'm Emma and I'm one of the technical vets from Dômes Pharma, and last
season we introduced listeners to the S.M.A.R.T Approach to canine epilepsy.
Feel free to take a listen if you haven't done so already.
This season, we are going to take a closer look at what I think are the more
difficult areas of epilepsy, including the seizure mimics, the weird and wonderful
adjunctive therapies and even cats.
Today we're going to kick off with a subject that strikes
fear into even the most seasoned veterinarians, status epilepticus.
I'm very pleased to say that joining me again this season is veterinary
neurology specialist Mark Lowrie of Movement Referrals who will
help demystify this challenging condition and provide a step-by-step
approach to managing it effectively.
Welcome, Mark.
I'm so glad to have you back with us again today.
How are you?
Very well, thank you.
Thanks so much for having me.
Really, really excited about this new season and a great
opportunity to talk about the more unusual aspects of epilepsy.
When we spoke last time, we'd opened this new practice in the northwest
of England and we have just exciting news, hot off the press today.
Spoilers for everybody.
We have a new practice,
Oh my goodness.
So we're opening a second movement referrals practice in the Midlands.
Amazing
in Uttoxeter, which, you know, you may have heard of the race
courses there and JCB factory.
Well now we've got a third exciting thing in Uttoxeter
Is that near Alton Towers?
Oh, it's so close.
Oh my goodness.
I'm going to have to come up for the day.
So we're very excited because The Toxicator's just opened at Alton Towers.
My son loves that.
In fact, if my son and daughter were here now, they give you a whole
podcast episode on Alton Towers.
Do you actually just live at Alton Towers?
I'd love to.
That's really exciting though.
And, and congratulations for that.
And good luck for the future, I guess too.
Well, yeah, no, can't wait.
So yes, please do, If ever you do get any questions, anything about
epilepsy, I'm always happy to help.
So feel free to reach out to me and happy to try and guide you through
some of these more difficult cases.
Perfect, thanks Mark.
As I said, today we're going to be looking at status epilepticus and dogs.
What is status epilepticus and why is it so serious?
I think for me, I just fear it so much in practice.
Well, that is a great question and I think fear is a really, really good word there.
I mean, status epilepticus is when a dog experiences either a single seizure
lasting longer than five minutes.
I mean, that's a long time.
Or two or more seizures without really fully recovering in between.
And I suppose traditionally you do think of a dog just continuing to fit, but
don't forget those cases where a dog has had a short seizure, hasn't made a
full recovery and goes into another one.
So they're the two situations we're dealing with here.
It's obviously in a medical emergency because prolonged seizure activity
can lead to irreversible brain damage or sometimes even worse.
It's very rare, but there is such a thing as sudden death
during generalised seizures.
But I don't want to scare monger so early on in the season!
I was going to say you've started on a high note there, haven't you?
But honestly, that is rare and I think that is an owner's big concern when
they see their dog having a fit, that they may suddenly pass away or die.
And that's when they start to intervene, potentially doing crazy things like
putting their hands in their pet's mouth, which obviously is a big no-no.
That's their concern.
And I think it is important to reassure that's exceptionally rare.
Typically these seizures will end, infrequently, they
need intervention from us.
But there's lots we can do there to help.
So normal, in inverted commas, generalised seizures, they,
they tend to be self-limiting.
They generally last only a couple of minutes.
Why is it that in status they go on so long or do we not know?
We really don't.
It's almost like something's triggered in the brain that just won't stop.
Self-limiting is the key with seizures as a rule.
So these are exceptional circumstances.
We don't know why they don't stop.
We presume something's triggered in the brain that makes
them keep going and going.
But this is the key thing because, when a dog has a seizure, what's
happening is you've then got a propensity for the dog to have another
fit and another fit and another fit.
This idea of kindling, it's called.
And so this is where a lot of the discussion comes back to that if we can
prevent one seizure, hopefully, hopefully we'll prevent that wind up towards
having more seizures in the future.
But why status happens, we're really, really not sure of
the answer to that question.
But it doesn't always mean that something bad is happening.
Just because they come in status, it doesn't necessarily mean they
have a bad prognosis, right?
When you see a dog with status epilepticus the thought is that it is bad.
You know, everyone thinks, oh my goodness, my dog must have a brain tumour.
It must have something horrendous happening.
But actually it's really common that dogs can have status epilepticus due
to less serious underlying conditions.
And I mean, if you've listened to season one, you'll know that idiopathic
epilepsy is the king of diagnoses here.
And idiopathic epilepsy is definitely a very common diagnosis here.
So I've seen plenty of dogs that present with their first
fit being status epilepticus.
We ultimately find out it's idiopathic epilepsy and those dogs can go on and
have a really good quality of life in spite of that first presentation.
Good.
I think that's reassuring to know for us and the owners.
They don't always die.
That's good to know.
So I guess the first thing we need to do is just make sure
that this is a seizure, right?
And I don't want to give any spoilers away for the next episodes where we're
going to talk more about the mimics, but is there any hallmarks that, you
know, we need to look out for, to know that this is a true seizure or not?
There are.
A classic clue for epilepsy is the presence of autonomic signs.
So, by which I mean things like urination, salivation, but also
things like loss of awareness as well.
These pets, they leave their eyes open during an episode, which might
make an owner feel that they are maintaining some form of awareness.
But if they try and interact with their pet during these episodes, there
would be the fact that they're not aware of what's going on around them.
So these pets lose awareness.
Another big hallmark is the postictal period as well.
So any pet recovering from a seizure will often display
disorientation, maybe ataxia.
I usually say they can look a bit drunk, but even temporary
blindness, which is another big concern for owners, they'll panic.
My pet seems blind but this is temporary.
And patients may have a history of seizures or they may have
other preceding signs, such as tremors or signs of toxicity, that
may raise our suspicion as well.
Yeah.
That makes sense.
So let's say we're definitely sure it's the seizure and it's definitely status.
It's not ending after that kind of five minutes or more by the time
they come to the practice, I guess.
So what's the plan?
I think you've got some kind of steps for us to follow.
Yeah, well don't panic.
Don't Panic is the most important one.
And we're going to talk more about a team approach to
epilepsy later on in this series.
But it is about a team approach.
You can't do this single-handedly.
Now your heart may sink and think, well I'm, I'm on my own.
That's all I've got.
Well, there are things you can still do, but the more hands on deck the better.
And everyone can play a part in this.
But I'd say there are three main goals when you're dealing with
a pet with status epilepticus.
The first is we need to stabilise that patient.
Yep.
Then we need to obviously stop the seizures.
An obvious one, but an important one.
And then we need to investigate the cause.
So you know what do we do first?
I'm often asked that question of what do we do first?
So I'd say ideally we tackle all three simultaneously, which
really shows how important the teamwork is in managing these cases
and these patients effectively.
If I were to prioritise, well stabilising the patient comes first.
This means ensuring things like the airway is patent, usually is,
but it's important you say that.
Then you need to make sure they're breathing and they've
got a good circulation.
There's never any problem with providing oxygen to these pets.
I've yet to meet a pet that's been killed by oxygen.
I think it only ever helps.
So providing oxygen is definitely important.
And we want to be getting IV access.
Now, this is where you just want to get someone in the practice who's
happy with placing IVs to place an IV.
It doesn't have to be you, it can be you, but it can be anyone,
any, any member of the team.
Because the nurses are always better at that than me, to be honest.
I've lost my ability to place IVs.
Was that your like call to help?
It was a bit.
Back in the day I was very happy with it and I'd be picked out as
the person to do it, but now I'm right at the back of that queue.
So find the person who is confident with it, and particularly given
these are difficult situations, you need a steady hand and a calm mind,
and that'll get that IV placed.
If you're presented with a patient with status, then remember they, they've
probably been fitting for some time by the time they get to your practice.
So a really big concern is hyperthermia.
These pets can get really, really hot.
So get someone there to take the temperature and we can see where
we're at because these dogs could be so hot that it could be a life
threatening emergency at that point, and cooling would be actively encouraged.
So check the temperature early on.
I think that's really important because I'm going to put my hand up
and say, I just go straight for the drugs and I forget this extra stuff.
Actually stabilising that patient and doing this, I want to say
like nursing care for instance.
I think it's taking that moment to just step back and look at the bigger picture.
It's really important.
And I love you've said that because I completely agree as vets, we
think the fix is drugs, let's fix with drugs, get the drugs out.
But there are so many other more key things that we need
to be thinking early on.
So yeah, I love that.
I will hold my hand up to and say in the past exactly the same issue.
You want to just get the quick fix.
Yeah.
So you mentioned cooling the patient.
I mean, what is the current kind of thinking on that?
Is it cold fluids now?
Is it fans and wet towels?
What is your current thinking?
Well, actually nowadays people are starting to think that cold water
immersion is a good method here.
So, allowing what we call conductive cooling for the patient.
I suppose the other method is evaporative cooling, where you use
a water spray and fans to encourage evaporation and air movement.
In honesty, that's far more practical in the setting of clinical practice
when faced with these patients.
But there's no harm in giving cold fluids.
But they've not really been found to be as effective in cooling
patients that are hyperthermic.
So now let's talk about stopping those seizures.
What is the first line of attack?
We've stabilised them at this point,
The go-to drugs are fast acting, short duration, anti epileptics
like diazepam or midazolam.
These enhance the effects of GABA, which is a neurotransmitter
that calms brain activity.
Oh wow.
We've got straight into the neurotransmitters here.
But no, it's fascinating.
Now I think it's fair to say when we're talking about diazepam, if you
reach out for a textbook and you read about status epilepticus, you read,
what you're meant to do is you give maybe half to 1 mg per kg IV if you
can, as a bolus, or you can give rectal diazepam if IV access isn't possible.
The textbooks will tell you that it works within two to three minutes.
But if it works, it really only lasts for about 30 minutes,
so it's a temporary solution.
And if I'm honest, my experience, and I don't know how you feel
with this, but you know, you give half to one mg per kg of diazepam.
You wait and then you wait.
And you wait more.
Now we are waiting here and this, this, well, if I say we wait and
leave a silence, that's awkward.
But when you've got a dog fitting that's a little bit more tense.
It's even more awkward.
It's quite a difficult situation to deal with.
Yeah
So, I would say great, if you can do what the textbooks say and wait 5 to
10 minutes to see if the seizures stop.
In practice, I don't think that's the right thing to do.
And I feel uncomfortable leaving a pet there for 5 or
10 minutes watching them fit.
So I would give that dose once, if it doesn't work, you're meant
to give a second dose and wait, and then you go for a third dose
of diazepam and see what happens.
But I think actually if you're finding it doesn't work, I usually find
it by the third dose of diazepam, we've still not got a response.
I think it's worth trying initially, but I wouldn't persist with it because then
you've potentially lost half an hour in which the dog's continued to fit.
And of course that causes all the other problems associated
with status epilepticus.
So a common mistake is giving diazepam, seeing it work, and then stopping there.
Thinking my job is done, pack your bags, go on to the next case.
But in status epilepticus, well, in any, in any seizure
situation, it's only short acting.
So once that drug wears off, the seizures will often return.
And on the flip side, if diazepam doesn't work within a couple of minutes, well
it's unlikely to work at all, so we should quickly consider another option.
Okay.
Now I'm often asked about the difference between diazepam and midazolam.
I understand they're the same class of drug, but, have you got a preference?
Are there pros and cons of each?
Now obviously I have to caveat with this, midazolam is not licensed, but
it's becoming increasingly popular.
It is.
And actually the evidence is pointing far more in favour
of midazolam than diazepam.
So there's been a recent consensus statement.
This again sounds fancy, but there's a group of key opinion
leaders that come together.
And this was done through A-C-V-I-M, so the American Board of medicine
and neurology specialists.
And they sat round and kind of looked at the evidence for diazepam and
midazolam in these emergency situations.
And actually they came to the conclusion that midazolam is more effective.
So the dose for Midazolam, if we're giving that IV, it's
roundabout 0.2 to 0.5 mgs per kg.
And very similarly to diazepam, we give that, we see if we see a response and
we can give that up to three times.
Again, I wouldn't be leaving that long pause, that wait, observing the patient.
I'd be fairly quick in giving it maybe every couple of minutes, the time
it takes you to drop the next dose.
And what about if you just can't get IV access?
I mean, it can be really difficult, and you just can't seem to get
an IV line in these patients.
Absolutely.
Well, that is really important.
So if it is just me on my own in the practice and I've confessed, I can't
get IV access on my, I can't do it with five helpers, if I'm honest.
I can't place-
Let alone by yourself.
I can't place an IV anymore.
I've lost that skill.
But that's where other routes need to be considered.
Now, rectal diazepam, that's a tried and tested option.
And I suppose with rectal diazepam it's especially helpful because it bypasses
the liver, so it allows the drug to reach effective levels quickly in the blood.
So it's really, really good to do that.
Now the dose is one to two mgs per kg. These diazepam, what
do we call them, suppositories?
Yeah.
Or Rectal tubes.
Rectal tubes.
That's much better.
These diazepam rectal tubes come in sort of five milligram, 10 milligram aliquots.
And so if we have a 30 kilo Labrador that's fitting, according to my dose
range, you want to give 30 to 60 mgs.
That's a lot of rectal diazepam.
Can I take a moment to confess something else?
Oh my god, I'm nervous.
What are you going to confess?
Well, I don't know.
No one ever talks about this, but when, we'll move away from status briefly.
Imagine a first vaccination, for example.
And you've got the puppy there, you know, lovely, lovely, happy, the
family are there, everyone's delighted.
And it gets to that moment when you just need to check the dog's temperature.
Do you know where this is going yet?
I think I know.
Yeah.
Taking the rectal temperature of a dog I think is actually very difficult.
Why is it so hard?
Well, locating the dog's bum hole.
It's, they just make it harder for us.
Well, it's covered in fur and it's hidden away, and so I actually think
it's a very difficult thing to do and there's nothing more incompetent
for a vet to not be able to find a dog's bum hole in a consultation.
Now, fast forward to the emergency seizuring patient, trying to
do that in a frantic stressful environment suddenly becomes harder.
So rectal diazepam is hard to give.
And remember these are drugs that we actually can give an owner, we can
empower an owner at home to be able to do this because they are helpless, they're
watching their pet seizure and there's very little they can feel they can do.
But allowing them to have the rectal diazepam tubes means there's
something they can do either at home or on route to the practice.
I mention all this because I do think finding a bum in an emergency
is very, very difficult indeed.
And I think owners do struggle a lot with this.
So we do need to think about that.
It's really just not as straightforward as you might think.
I think we've said the word bum quite a lot now.
But But it's not just me though, is it?
It was mostly you.
Did I say it too much?
No, it's fine.
It's good.
I've heard there is a, an alternative option though.
A newer option.
Intranasal midazolam maybe.
What is that all about?
I've not used it.
Well, this is where I think it's important.
Moving away from rectal diazepam, I think an intranasal route is
another up and coming route That is, is very, very effective.
And this is again, where the evidence is pointing.
So what we're talking about here is giving intranasal midazolam.
That's the route we want to take.
Now, what you need to do for this, there's a device, it's called a
mucosal administration device.
Wow.
Sounds very fancy.
it sounds even better when you abbreviate it to MAD.
Okay.
Yep.
So we going to use this MAD device to administer midazolam intranasally.
Now we can call it a mucosal administration device.
Some people call it mucosal atomisation device because,
Oo even fancier
well atomisation, I read this because I had to learn this because
I wasn't really sure, but it is probably obvious when you've read it.
It's, it just means turning a liquid into a fine spray.
So if you remember the, the kennel cough vaccine.
You get that little conical.
Device.
Plastic thing, device, it's, it's a MAD, you put it on the end of your syringe
and you spray it up a dog's nose.
I mean, that's effectively what we're doing here.
So we're putting midazolam into a syringe.
We're putting that device on the end and we're spraying it in the nose.
Now that works really, really effectively and it's another really good thing for
owners to do at home, and it actually works really well for cluster seizures.
So we're talking about status epilepticus, and remember I said
that that can be these dogs that have cluster seizures without full recovery.
So intranasal midazolam, great at home, great in the practice, the dose
is very similar to the IV dose, 0.2 to 0.5 mgs per kg. And it basically just
works by absorbing through the nasal mucosa directly into the bloodstream.
Again, it bypasses the gastrointestinal system.
So it's helpful in emergency situations where time is really critical.
And it's particularly useful when the dog's seizing and handling them
for rectal or IV administration is either unsafe or impractical.
Personally, I find that easier than giving the rectal diazepam.
I'm often asked about cats as well.
Can we do this in cats?
The simple answer is yes, it's safe, it can be done.
Safe for the cat, might not be safe for you.
Do you have to worry about like chomping mouths and things like that?
A cat's, cat's teeth would get in the way.
Dog's teeth get in the way.
But cats have the added defence of claws as well.
I think yes, it can be done.
But just be careful when trying to administer it.
Okay.
And so you definitely need one of these devices.
You can't just spray a syringe full up the nose.
Well, I think the answer is if you don't have one, of course you should
still spray a syringe full up the nose.
But these devices are really quite cheap.
And actually if you go away and google this, can we mention Google?
Other search engines are available.
Very good.
We can find these devices quite cheaply for a few pence online and you know,
just getting them in, you can just have 'em on the side so you've got them
there to give owners at home as well.
Probably keep them in your emergency kit.
Ready to go.
That's a fantastic tip.
You're welcome.
That's really great advice, Mark.
I love how these alternatives make it a lot easier for us to respond
quickly in these high pressure moments.
Anything else to add there?
Well, just one tip.
Always have the doses pre-calculated and clearly documented in your
clinic's emergency protocol.
That way when the status epilepticus hits, you're ready
to act without any hesitation.
You're not having to rummage around for the formulary or anything like that.
And that's it, you want to go and reach for your notes, you want to
go and find out what's happening.
So we need to, do things as quickly as we can, but effectively.
So what about if you've given your diazepam or midazolam and it doesn't
seem to be working, we might need to reach for some longer acting medications.
Where would you start with those?
Well, we do, and I'd add to there that also if it does work, we still want to
reach for longer acting medications.
But yes, if the dog's still fitting, we want to find a longer acting medication.
They're really crucial to prevent the seizures recurring once the
short acting drugs wear off.
Phenobarbital is a classic choice.
So it's, it's a barbiturate that takes about 30 minutes to
cross the blood-brain barrier.
And when it's used orally at a standard maintenance dose, it takes about
two to three weeks to reach steady state concentration in the blood.
But when we want to give it in status epilepticus, we need to really administer
it much faster in IV boluses of about four mgs per kg every four to five
minutes until the seizures stop.
So trying to achieve those therapeutic blood concentrations a lot quicker.
The important point here to make is by doing them at these high
doses, of course we're going to provoke far more side effects.
So high doses can cause more side effects.
So we really need to reserve these for, for much less severe cases.
And I've certainly seen situations where they have been given in a situation
that maybe wasn't quite as urgent.
And then complaints can arise from owners because they're left with a dog
that's very, very subdued and flat, when actually that dog may have only been
having one fit every couple of weeks.
If their dog was having endless seizures or cluster seizures without
recovery, then that's a very acceptable outcome, initially, for that dog to
then recover over the coming weeks from the higher doses of that medication.
Makes sense.
For patients with liver issues or those already on phenobarbital, that
can be quite a difficult situation.
Levetiracetam's a great alternative.
It's minimally metabolised by the liver, so it's mainly
cleared through the kidneys.
And it can be given at 20 to 30 mgs per kg every eight hours.
I suppose it's important for me to say this is off license, but
it's a really effective medication and one we reach for commonly.
And the oral formulation is far more affordable than the IV formulation.
Needless to say, the IV formulation is probably far easier to give
in Status Epilepticus, but it is quite a bit more expensive.
So it's a difficult thing to have on the shelves sometimes, and have
available in these situations.
But if you have it, fantastic, and reach for that first, and if all these
options fail, we need to escalate to continuous rate infusions with drugs
like midazolam or propofol and they're effectively anaesthetising the patient.
So intensive care is required, but this can be lifesaving and it's
something we do need to consider in a small proportion of these patients.
Yeah, that makes sense.
I used to work in quite a small practice and okay, thankfully we didn't see many
status epilepticus dogs, which was good, but that also meant that I didn't have
things like injectable phenobarbital or levetiracetam on the shelf.
I just had diazepam and straight for kind of propofol.
Is, is that acceptable?
What do you suggest in that situation?
Well, when you're in a panic state, you find doing things
you're familiar with far easier.
And so one thing that general practitioners are best at
is performing anaesthesia.
I suppose every day we're doing dentals, spays, all sorts of
procedures that have the same common method in performing anaesthesia.
So when you are panicking in this situation, do not be afraid to
anaesthetise the patient in the way that you would anaesthetise any other patient
in the practice for routine procedures.
If nothing else, it gives you thinking time and it'll stop the seizure.
So don't be afraid of that and then work out from there how to manage
the fits once you're in a more calm situation and environment.
That's really helpful.
I think in my mind, fine to induce anaesthesia, but how do you then stop.
What would be your protocol for stopping that anaesthesia?
Well, it depends what you've done.
So if you've anaesthetised the patient and you are in that very difficult
situation of having no other medications available, that is a very, very tough one.
And all I'd say is you'd get the dog onto isoflurane, intubated.
You just then have to turn the isoflurane down and hope to not see twitching
as that dog starts to come round.
If it is twitching, you probably have to keep it on a little bit longer, and then
maybe thinking of some form of long-term anti epileptic medication administered
rectally might be the way to go.
One choice there I favour when we can is, is potassium bromide.
Potassium bromide, it is licensed in conjunction with phenobarbital as an
oral long-term maintenance medication.
Potassium bromide did used to come in a liquid, so we could give that
rectally through a urinary catheter to a loading dose to achieve the right
level within the blood very rapidly, but it's not available anymore.
And really all we can get is the tablets.
So you can get the potassium bromide tablet and you can crush it up.
And mix it with water and give that rectally.
So that can work really well if you've got a patient that you have no other
medication for, but you've got that on the shelf and that's something that's
fairly common on a pharmacy shelf.
We give a loading dose of 600 mgs per kg spread out over whatever
period of time we want to give it.
Now typically we like to load that over five days because it
does cause profound side effects, but we can give it much faster.
So if you're in the situation we've described, then giving that over an
hour or two is possible, but don't be surprised if that patient wakes up very
severely affected from the bromide.
I'd probably go sort of 100, 200 mgs per kg rectally, recover the dog and see
where you're at and add more to effect.
Yeah,
That makes sense.
So we've talked about stabilising the patient, we've talked about
giving these emergency drugs.
One of the other things you wanted to talk about was looking at the
underlying cause of the status epilepticus and, and diagnosing that.
How do you figure that out whilst stabilising the patient and
doing all of the rest of this?
Well, this is where teamwork shines.
While one part of the team stabilises the dog, another can gather history
and run initial diagnostics.
Reactive causes like low blood glucose or toxin exposure are common.
So tests for blood glucose are really important.
Maybe check calcium while you're there and liver function are essential.
Remember, urea, albumin, cholesterol, and triglycerides are the four we want
to be looking at with liver function.
Good to remember that list.
Then we are moving on to things like advanced imaging, like
MRI or spinal fluid analysis.
And so they're needed for, you know, seeing if we've got structural
epilepsy or to rule things out to know if it's idiopathic epilepsy.
Just remember what I said earlier though, that a dog with idiopathic
epilepsy may still present with status epilepticus either as their first
episode or after years of good control.
So if seizures are brought under control, the prognosis can still be favourable.
So how do we know if some of these are the cause or the consequence?
For example, you mentioned looking at blood glucose and low blood sugar.
I mean that can often happen because of the seizure or the seizure
happens because of the glucose.
Like how do you know what's the cause or the consequence?
Same potentially with things like hyperthermia as well.
I think that's a really good point Emma.
I mean hyperthermia is definitely something to watch out for in dogs
that have had prolonged seizures, it's likely to be a consequence of the
sustained muscle activity during the fits rather than the primary cause.
I know when I go for my really big workouts in the gym, it doesn't work
on audio, but I'm not the most well built and I don't go to the gym.
I tried to hold in my snigger, I'm sorry
but if I were to go to the gym and I was to work out for hours
on end, I would get very hot.
This is the nature of activity, being the sedate individual I am, I don't
really know what I'm talking about.
But it is likely to be that rather than a primary cause.
So if I see hyperthermia, yes, I would absolutely treat it symptomatically
in the way we've talked, cooling the dog down in a controlled way and
monitor their temperature closely.
Hypoglycaemia is a bit different for me.
During a seizure if a dog's glucose levels are low, I may supplement
glucose at that moment but it is important to address it acutely.
However, I'm far more interested in what the glucose concentration is between the
seizures, particularly in a fasted state.
So we manage it in the moment, but I'd want to be getting that patient back in
a few days later, hopefully controlled, in a fasted state to recheck what the
blood glucose concentration actually is.
That's really interesting.
Why do you look at that?
I guess it's to check whether it's still low or?
Yeah.
Well, if glucose concentration remains low in a fasted patient a few days
later, that points to a much more persistent hypoglycaemia state, and
potentially that means it's a primary issue that's contributing to the seizures
rather than the secondary effect.
I know owners worry about that.
They'll say, well, you know, I've starved my dog.
Of course the blood sugar levels are low, but that's not the case.
If we have low blood sugar levels after having starved ourselves, that's wrong.
The body should compensate for this and release glucose.
So if we find we've got low levels in ourselves or in dogs
after fasting, that is abnormal.
That means there's something pathologically wrong
that we need to address.
It's such a valuable approach.
So treating that acute problem, but also thinking about the bigger picture,
Exactly.
I mean, it's all about keeping a cool head and planning for follow-up investigations
once the immediate crisis is managed.
And so when you have stabilised that patient then, thinking about
that long-term plan, is there anything we need to do afterwards?
Once a seizure patient is stabilised, then the next steps are really just as
crucial as that emergency management.
We really need to sit down and discuss with the owner the likelihood
of recurrence because these dogs aren't fixed, they're managed.
And I think we mentioned this in season one, that, we can't treat
a dog and get rid of the fits.
They're always going to be part of the long-term picture.
So these owners need to understand a recurrence is likely.
That doesn't mean we're going to have a recurrence of status epilepticus,
but that always will be a risk and something the owners need to be aware
of, so we need to educate them on how to manage that safely at home.
So do we always continue with long-term meds or am I referring
to people like you perhaps?
Well, I think in most cases, yes, we're giving long-term
anti epileptic medication.
It's very rare that I wouldn't send a dog home that's had status epilepticus
without prescribing long acting, long-term anti-epileptic medication.
Phenobarbital is often one of the first line drugs we consider, it's effective,
but it does require therapeutic blood monitoring to make sure we're hitting the
right levels without causing toxicity.
It's important to educate the owner about the need for periodic blood tests too,
because that can be disruptive to their daily routine and ensure they understand
that this isn't a one and done treatment.
That makes sense.
And I guess it's useful as well to make sure that they are on
board with follow-ups as well.
Follow ups are essential, one thing I always ask owners to do is
to keep a detailed seizure diary.
The diary should include things like the date, time and duration of fits.
And this helps us track the frequency and pattern of seizures over time
to make sure that we are getting effective control of those fits.
One of my biggest fears I guess is that we've stabilised them in their status
epilepticus, we send them home and I just fear that owner calling me back the
day later or two days later and going, oh my goodness, he's seizuring again.
Like what do we do then?
What if the seizures recur?
Well, if seizures are breaking through despite treatment, that's when you need
to reassess and it might involve adjusting the dose of the current medication, adding
in a second line medication like potassium bromide or potentially levetiracetam,
or even considering referral to a neurologist for more advanced diagnostics.
I would definitely be sending it your way.
I'm not going to lie, is that okay?
Well, it's always okay to refer a patient and it really depends.
Some owners just will not be able to go down that route for whatever reason.
They may not want to, they may have a good bonded relationship with you
and want it all managing in house.
But the referrals to a neurologist, there are two things there.
The advanced imaging is obviously one thing that can be helpful,
but it isn't always necessary.
And I hope we've got that across, over these episodes, that an MRI scan of a dog
is not always something we have to do.
But the other part of it is giving that owner a sort of time and space
to discuss the outcome and epilepsy.
And I think that's where referral to a neurologist can be helpful because we just
don't have the time in general practice to have those sorts of conversations.
Definitely.
Particularly if they come in with status, they're often just emergencies
on the side of our consult list as well.
So absolutely just having that time to talk to them.
So stabilising is really just the start of a longer journey, isn't it really?
Exactly.
I mean, seizure management is a long-term commitment.
It's about finding the right balance between controlling the seizures and
minimising those side effects from medication while also involving the
owner in monitoring and decision making.
That's brilliant advice, Mark.
Thank you.
So is there any parting advice for us GP vets facing this
high stake situation of status?
Don't panic.
Stick to the stepwise approach.
Stabilise, stop the seizures and investigate the cause.
I mean, recovery can take days.
So patience and monitoring are absolutely essential here.
Epilepticus management is a group effort and delegation is so important.
it's honestly been such valuable insights today.
I've learned so much.
So thank you so much, Mark, for breaking this down so clearly.
And thank you to our listeners for tuning in.
I think that's all we've got time for today.
If you found this episode helpful, please obviously share it with
your colleagues and don't forget to subscribe for more veterinary content.
You can also find many free resources available at the Dômes Pharma
website, including status epilepticus triage sheets and guidelines.
And you can find the link in the bio.
Next episode, we'll pick up the conversation about seizure mimics we
sort of alluded to it the beginning.
And there are many things that might look like a seizure in practice or
owners might mistake for a seizure and Mark will be offering his tips
on how to differentiate all of these.
So until then, take care and stay curious.
Thanks, Mark.
Thank you.