Seizure%Diagnosis%&%Treatment%

Transcription

1 Seizure%Diagnosis%&%Treatment% January%5,%2015% William%Bush,%VMD,%DACVIM%(Neurology)% IntroducIon% Justine A. Lee, DVM, DACVECC, DABT CEO, VETgirl IntroducIon% Garret Pachtinger, VMD, DACVECC COO, VETgirl IntroducIon% William Bush, VMD, DACVIM (Neurology) VETgirl on%the%run!% SubscripIon%plans% The tech-savvy way to get CE credit! A subscription-based podcast & webinar service offering veterinary RACE-approved CE Free for veterinary students at AVMA-accredited veterinary schools! 1%

2 Download%our%podcasts%on%iTunes!% Find us on social media! hrp:// Logistics and CE Certificates! No%need%to%raise%your%hand!%! Type%in%quesIons%! ed%to%you%48%hours%aYer%the%webinar%! AcIve%parIcipaIon%=%no%quiz%! Watching%video%later,%must%complete%quiz%! ELITE%members%only%! %/%contact%with%ANY%quesIons%! About%BVNS% Experience% %With%a%team%of%Board_CerIfied%Veterinary%Neurologists,%we%treat%more% %veterinary%neurology%cases%than%anyone%in%the%united%states%and%we%are% %privileged%to%help%thousands%of%pets%and%their%owners%each%year.% Superior+Service:%% %At%BVNS,%we%are%commiRed%to%providing%you,%your%clients%and%your% %paients%not%only%the%%best%neurologic%care,%but%also%the%best%service.% Advanced+Diagnos9cs:%% Onsite%MRI%at%all%full%service%locaIons.%Pre%and%Post_op%imaging%of% complicated%surgeries%under%one%anesthesia.% 2%

3 Our%Team%of%Board%CerIfied%Neurologist%/% Neurosurgeons% Dr.%Joli%Jarboe%(Leesburg)% Dr.%David%Brewer%(Leesburg)% Dr.%Jessica%Barker%(Springfield)% Dr.%Casey%Neary%(Springfield)% Dr.%Lisa%Lipitz%(Rockville)% Dr.%Dan%Cuff%(Rockville)% Dr.%William%Bush%(Rockville)% Dr.%MarIn%Young%(Richmond)% Dr.%Mike%Higginbotham%(Richmond)% Contact%us% ROCKVILLE% The%Hope%Center%Rockville% 1%TaY%Court% Rockville,%MD%20850% P:%301_637_4248% F:%301_637_5246% SPRINGFIELD% Regional%(RVRC)% 6651%Backlick%Road% Springfield,%VA%22150% P:%703_451_3709% F:%703_563_9687% LEESBURG% The%Life%Center% 165%Fort%Evans%Road,%NE% Leesburg,%VA%20176% P:%703_669_2829% F:%703_669_2870% RICHMOND% Dogwood%(DVESC)% 5891%West%Broad%Street% Richmond,%VA%23230% P:%804_716_4716% F:%804_716_4814% Fall 2011 Sugarloaf Mountain, Comus, Maryland Winter, Sugarloaf, Mountain, Comus, MD The%Problem% All%the%most%acute,%most%powerful,%and%most% deadly%diseases,%and%those%most%difficult%to%be% understood%fall%upon%the%brain.% %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% % % % % %%%_%Hippocrates% Four%Vital%QuesIons%% Is%the%event%that%is%witnessed%or%described%likely% seizure?%%(part%1)% Is%it%likely%there%an%underlying%cause%that%can%be% treated%specifically?%%(part%2)% When%to%treat%and%with%what%medicaIon?%%(Part%3)% 3%

4 Part%1%:%Seizure%vs.%Seizure_like% Discuss%definiIon%of%a%true% epilepic %seizure% Discuss%what%we%learned%from%EEG%in%enhancing% your%understanding%of%seizure%in%terms%of:% %a.%disinguishing%seizure%from%seizure_like%episodes% %b.%detecing%%and%treaing%non_convulsive%seizure% Simple%QuesIons?% What%is%a%seizure?% What%is%epilepsy?% Is%epilepsy%a%disorder?% It%is%official.% The%InternaIonal%League%Against%Epilepsy% (ILAE)%and%the%InternaIonal%Bureau%for%Epilepsy% (IBE)%have%recently%agreed%that%epilepsy%is%best% considered%to%be%a%disease % ILAE%_%Epilepsy% At%least%two%unprovoked%(non_reacIve)% seizures%occurring%>24%h%apart%(2005)% One%unprovoked%%seizure%and%a%probability%of% further%seizure%of%at%least%60%%over%the%next% 10%years%(2014)% Fisher%RS,%et%al.%%A%pracIcal%clinical%definiIon%of%epilepsy% Epilepsia,%55(4): ,%2014% ILAE%_%Seizure% Transient%occurrence%of%signs,%symptoms%or%both% due%to%abnormal%excessive%or%synchronous% neuronal%acivity%in%brain%%%%%%%%%%%%%% Best%defined%by%electroencephalography%(EEG)% BVNS%EEG%Program%%% Intramural%technician%cerIficaIon% Collaborate%with%physician%expert% %%%%in%human%and%animal%eeg% Performed%during%suspect%seizure%event% %%%%to%detect%seizure%and%guide%therapy%% 4%

5 Electrical,%Convulsive%Seizure% Maggie%SZ% Transient%Symptoms%%NOT+from% Abnormal%Neuronal%AcIvity%%% Cataplexy,%narcolepsy,%REM% sleep%disorder% VesIbular%episodes% Panic%aRack%*% Metabolic%/%toxic%event% Episodes%of%neuromuscular% disease%or%encephaliis% Myoclonus% Breed%associated%movement% disorders%/%dyskinesia% %% Cervical%muscle%spasm%% Head%bobbing%/%Tremor% syndromes% Feline%hyperesthesia%syndrome% IntermiRent%decerebrate%/ decerebellate%rigidity%% Chiari%malformaIon%/% syringomyelia%associated% episodes% Atlanto% %Axial%subluxaIon% Syncope% Lip%smacking%/%neck%extension% from%gastric%reflux% Squirrel%% 10,%MC%% DSH%% Squirrel% %The%SituaIon%% 36%hours%of%intermiRent%15%second%seizure%(leY%side,% facial%twitching%that%progressing%to%generalized% twitching,%non_responsive,%salivaion)% CBC,%Chem,%MRI,%CSF,%InfecIous%Iters%normal%% Clindamycin,%prednisone,%zonisamide,% leveiracetam,%phenobarbital%and%30%hours%later%this% video% Mark Stecker, MD, PhD, DABNM, FASNM EEG+Diagnosis% %NCSE% Plan+L+???% Pathologic+Diagnosis+ +viral% B.A. in Physics, Mathematics, Biophysics, then PhD in Physics from UPENN Medical Degree at Harvard Medical School/MIT Neurology residency and Dana Fellowship in Neuroscience/Epilepsy at UPENN 5%

6 Endpoints%for%TreaIng%Status%EpilepIcus% 1:55,%6%mg/kg%PB% No%observable%signs%of%seizure%acIvity% ReducIon%or%eliminaIon%of%epilepIform%complexes% 4:30 PM, 50 mg/kg PB Burst%Suppression% 11: 00 PM, 100 mg/kg PB Outcome% Control%of%the%EEG%status%epilepIcus%required%100% mg/kg%phenobarbital% Chronic%heart%condiIon%progressed,%developed% azotemia%and%.% Cuff%DE,%Bush%WW,%Williams%DC,%Stecker%MM.%Use%of%conInuous%electroencephalography% for%the%%diagnosis%and%monitoring%of%treatment%in%nonconvulsive%status%epilepicus% %J%Am%Vet%Med%Assoc.%2014%Mar%15;244(6):708_14.%doi:% /javma % Elmo% 11%yr,%MC% %DSH% Elmo% %The%SituaIon% DiabeIc%on%2%units%of%glargine,%presents%non_ responsive,%hypoglycemic,%facial%twitching%and% tongue%movement% Twitching%has%persisted%for%last%30%hours%despite% normoglycemia,%mgso4,%keppra%25%mg/kg,%q8,%% midazolam,%diazepam,%phenobarbital%16%mg/kg%and% normal%electrolyte%and%ph%% Elmo%would%twitch%during%EEG%% 6%

7 Lucy% 3%yr,%FS% Shih%Tzu% EEG+Diagnosis+ %normal%% Plan% %wait_and_see,%keppra% Diagnosis% %metabolic%encephalopathy% Lucy% %The%SituaIon% Discovered%6:00%AM%in%crate%with%large%amount%of% saliva,%feces,%and%urine%and%%twitching%of%head%and% legs,%right%worse%than%ley,%unsteady,%glazed% ER%clinic,%treated%for%organophosphate%toxicity%with%% %%%methocarbamol,%atropine,%ani_emeics,%noted%to%%%%% %%%have%knuckling%of%rtl,%eyelid%twitch,%video% EEG+diagnosis+ %non_convulsive%status%epilepicus%% Plan+_%MRI%+/_%CSF,%directed%therapy,%%higher%doses%of%AED%rapidly%% Pathologic+diagnosis+ %%MeningoencephaliIs%of%unknown%origin% Lucy s%% LeY%Forebrain% Nina%% 1%year_old,% FS,% Chihuahua% 7%

8 Ozzie%% 14%month,%MC% German%Shep%Mix% Ozzie% %The%SituaIon% 3%am% %chewing%unfrozen%freezer%pack% 7%am%_%lethargic,%not%ge ng%out%of%bed,%did%not%eat%well%% 8.45%am%_%convulsive%seizure,%T% %107.1,%3%doses%valium%for% seizure% 10%am% %BVNS,%seizure%at%admission,%%lateral%recumbent,%non_ responsive,%eyelid%twitching,%jaw%chomping,%tremor%/% paddling%of%all%4%limbs%% Likely%Possible%Causes%for%Ozzie?% Given%age,%normal%blood%work,%onset,%and%that% %%%he%eats%anything,%%a%toxin%is%likely% InflammaIon%of%the%brain%(encephaliIs)%also%fits%well% CSF%%analysis%should%define%cause%because:% %%%%%%a.%%analysis%normal%with%toxin% %%%%%%b.%%increased%cells%and%protein%with%encephaliis%% Prognosis%&%Plan%for%Ozzie% 25%%%mortality%rate%with%Status%EpilepIcus%%% EEG%advised%to%do%the%following:% %%%%%%%a.%%define%events%as%non_convulsive%%seizure% %%%%%%%b%%%determine%type%and%amount%of%medicaion% Ozzie%Outcome% Door%#1%%_%EEG,%not%assessed%to%be%seizure,%anI_% % %% % % %%%tremor%medicaion%and%sedaion,%home%the%% % % %%%following%day% EEG+Diagnosis+ %normal%% Plan+ %CSF,%muscle%relaxants,%sedaIve% Pathologic+Diagnosis+_%toxin% 10%to%22%%of%human%encephalopathy%paIents%have%paroxysmal%episodes%% %(eye%blinking,%lip%smacking,%fine%jerking%movements,%vital%sign%changes%)%not%% %%associated%with%non_convulsive%seizure%% Door%#2% %No%EEG,%managed%with%seizure%medicaIon%% % % %%%with%endpoint%being%stopping%the%% % % %%%twitching,%sedaive%side_effects%and%% % % %%%addiional%cost%and%risk% 8%

9 CLNICAL+CHARACTERISTICS+AND+OUTCOME+OF+CASES+ DIAGNOSED+WITH+ELECTRICAL+SEIZURE+IN+74+DOGS,+11+CATS% L%Granum 1,%WW%Bush 1,%CW%Weaver 1,%DC%Williams 2,%MM%Stecker 3 % 1 Bush%Veterinary%Neurology%Service,%Rockville,%MD,%USA% 2% William%R.%Pritchard%Veterinary%Medical%Teaching%Hospital,%Davis,%CA,% USA.% 3 %Winthrop%University%Hospital,%Mineola,%NY,%USA.%% Determine%number%%and%appearance%of%cases%with% ES/ESE%among%all%cases%that%had%EEG%for%seizure%% Findings%with%ES/ESE%Study% 15/86%(17%)%had%electrical%seizure% Determine%if%there%were%any%characterisIcs%/%risk% factors%in%the%es/ese%group%that%could%disinguish% them%from%non_es/ese%group%such%that%might%not% need%eeg% Mortality%in%the%ES/ESE%group%was%40%% compared%to%21%%%in%non_es/ese%group% Determine%mortality%rate%in%ES/ESE%and%non_ES/ESE% Findings%with%ES/ESE%Study% Cats%at%risk%for%ESE%,%younger%animals%and% those%with%other%eeg%abnormality%were%at%risk% for%es% Seizure%within%8%hours,%cluster%seizure,%and% twitching%more%prevalent%in%es/ese%group%but% not%significant% Part%1:%Take%Home%Points% There%are%many%events%that%appear%to%be%seizure%that%are%non_ epilepiform%events% Non_convulsive%seizure%and%non_convulsive%status%epilepIcus% are%serious%diseases%that%are%underdiagnosed%in%veterinary% medicine% EEG%pivotal%for%diagnosis%and%best%treatment%of%NCSE% % referral%to%bvns%advised%for%paients%where%ncse%suspected% Part%2% %Structural%Disease?%% Many%Causes%for%Seizure%% Discuss%evoluIon%off%classificaIon%system%for%seizure% based%on%underlying%cause% Discuss%ways%to%determine%the%probability%a%paIent% with%new%onset%seizure%is%likely%to%have%a%structural% cause%for%the%seizure% 9%

10 ILAE%Seizure%ClassificaIon%by%Cause%% GeneIc%Epilepsy% %Border%Collie% 1989% Idiopathic%(<%6,%unknown)% SymptomaIc%(tumor,%stroke)% Cryptogenic%(%>6,%unknown)% 2005% GeneIc% Unknown% Structural%/%Metabolic% %%2%year%average%survival%from%seizure%onset% %94%%had%cluster%seizure%and%53%%Status%epilepIcus%% %71%%drug%resistant%and%on%2%or%more%AED% Hulsmeye%r%V,%et%al.%Epilepsy%in%Border%Collies:%Clinical%ManifestaIon,% %Outcome,%and%Mode%of%Inheritance.%JVIM%2010;%24:%171_178% Seizure%Generated%in%Forebrain% What%if%This%Happens?%%% R+ R+ Exam%Findings%?% MUST%REMEMBER%THE%FOLLOWING% With%a%leY%forebrain%lesion%the%paIent%is% unaware%of%the%right%side% Right%Forebrain%Lesion%% %Seizure% %Wide%circling%%or/and%head%turn%to%right%% %Bumping%into%things%% LeY_side%menace,%sensory%and%%postural% deficits% 10%

11 Your%Neighbor%Calls%..% Using%Age%Alone% What%are%the%odds%this%paIent%will%have%a% structural%lesion?% More%on%Age% 70%%of%%dogs%with%first%seizure%at%7%or%older%will%have% structural%epilepsy?% 88%%%of%dogs%with%first%seizure%10%or%older%will%have% structural%epilepsy% Cause%in%Structural%Epilepsy% 72%%of%the%169%dogs%with%structural%epilepsy%%had%a% brain%tumor%(next%most%common%was%stroke%at%12%)% Therefore%if%7%or%older,%70%%chance%structural%and% 50%%chance%it%is%a%brain%tumor% Schwartz%M,%et%al.%Assessment%of%the%prevalence%and%clinical%features%of% cryptogenic%epilepsy%in%45%dogs.%javma,%vol%242,%no%5,%march%1,%2013% Are%you%ready%to%tell%neighbor%that%Lucky%has%a%brain% tumor?%% Further%Clues%on%Signalment% Does%considering%the%breed%or%weight%help%you% in%assessment%whether%or%not%this%paient%has% structural%lesion?% Breed%&%Weight% Boxer,%Golden,%French%Bulldog,%and%Boston%Terrier%are%at% higher%risk%of%brain%tumor% Dogs%>%15%Kg%are%2.3%Imes%more%likely%to%have%a%brain% tumor% Pug,%Minature%poodle,%Maltese,%Bichon,%Dachshund%are% at%higher%risk%for%encephaliis%% Song%RB,%et%al.%Post_mortem%evaluaIon%of%435%cases%of%intracranial%neoplasia% in%dogs%and%the%relaionship%between%neoplasm%and%breed,%age%and%% body%weight.%jvim%2013;%27:%1143_1152% 11%

12 What%Next%to%Help%Neighbor?% a. Run%blood%work% b. Perform%MRI% c. Refer%to%neurologist%% d. Perform%examinaIon% e. Regret%not%telling%neighbor%you%were%grade% school%teacher% What%Next%to%Help%Neighbor?% a. Run%blood%work% b. Perform%MRI% c. Refer%to%neurologist%% d. Perform+examina9on+ e. Regret%not%telling%neighbor%you%were%grade% school%teacher% 3%Step%Neurological%Exam% 3%Step%Neurological%Exam% Neighbor s%dog%exam%is%normal% Does%this%mean%that%there%is%not%a%structural% lesion%in%this%dog?% Accuracy%of%Exam%in%PredicIng% Structural%Lesion% 31%%of%%dogs%with%Structural%Epilepsy%(neoplasia%or% stroke)%will%have%normal%exam% 18%%of%dogs%without%a%structural%lesion%will%have%an% abnormal%examinaion% 12%

13 Anything%Else%to%Help%Neighbor?% Historical%Findings?% Is%there%anything%else%that%you%can%do%to% determine%if%there%is%a%structural%lesion%and% best%advise%your%neighbor?% Inappropriate%eliminaIon%in%a%dog%>%6%typically%will% oyen%indicate%the%paient%has%a%brain%tumor% More%Historical%Findings%?% Referral%When?% Underlying%cause%is%suspected%based%on%signalment,% exam%findings,%history%or/and%when%cbc,%chemistry% do%not%elucidate%cause% Poor%seizure%control%% No%Referral% %EncephaliIs%Supected%% AnIbioIc:%Doxy_%or%Mino_cycline%10%mg/kg,%Q24%x%4%weeks%&% Clindamycin%15%mg/kg,%Q12%% InfecIous%TesIng:%+/_Titers%(PCR%CDV,%Toxoplasmosis,% Neospora,%SarcocysIs,%Tick%serology%or%PCR,%Fungal)% No%Referral% %Tumor%Suspected% %Prednisone%%0.5%mg/kg,%Q12%and%maybe%taper%to%0.25%mg/kg,% Q12% Prompt,%higher%dose%AED%treatment%or%mulIple%AEDs% Empiric%Treatment:%Prednisone%0.5%mg/kg,%Q12%+/_% Cyclosporine%5_6%mg/kg,%Q12% 13%

14 Part%2%:%Take%Home%Points% Age, Breed / Weight, History, Exam Findings Part%3% %When%and%How%Treat% Discuss%my%perspecIve%on%when%to%treat%epilepsy% Review%currently%available%anI_epilepIc%drugs%(AED)% and%opimizing%their%use%in%treaing%epilepsy% Unknown Structural When%%To%Start%Treatment% Under%what%condiIons%would%YOU%start%treatment%of% a%seizure%disorder?% Treat%aYer%1_2%in%6_12%months% What%do%owners%think%?%% Seizure%begets%seizure%% New%AED%have%few%to%no%side%effects%or%toxicity,%BID% dosing,%inexpensive%and%effecive% Wessman%A.,%et%al.%Living%with%canine%epilepsy:%A%quesIonnaire_based%evaluaIon%% of%the%quality%of%%life.%%ecvn%abstract%2012,%glascow%and%london,%uk% AED%Mechanism%of%AcIon% What%is%Distance%to%Seizure%?% New%AED%work%by%different%mechanism%from% phenobarbital%and%bromide% Much%different%side_effect%profile% Threshold% %%%%%ResIng%% 14%

15 Increased%Distance%to%DepolarizaIon%% Inside%more%negaIve%by% increasing%flow%of% negaive%ions%into%cytosol% Outside%more%posiIve%by% slowing%%the%flow%of% posiive%ions%into%the% cytosol% Increase inward negative ion flow Reduce inward positive ion flow Rossmeisl%J,%hRp:// ng_edge/ alternaive_aniconvulsants_dogs_cats% What%Do%You%Do?% In%a%two_year%old%dog%with%geneIc/unknown%epilepsy% that%you%have%decided%to%treat,%which%aed%would%you% choose?% XXX+ Q%24%H% Drug+ GabapenIn% Pregabalin%% Dose+ Mg/Kg+ 10_30,%B% 1_2,%B% Side+Effect+ Scale+ Primary+Side+Effect+ Toxicity+ Dysfunc9on+ 2% S% No% LeveIracetam% 20_40,%B_T% 1% S,%not%eaIng,% salivaion% Renal%(rare)% Phenobarbital% 2_6,%%S% 3% PU/PD/PP/S/W/A% Less%Liver% Zonisamide% 5_10,%S_B% 2% Less%eaIng,%S,V,A,D% Liver%/Renal% (rare)% Urinary%%Calculi% Bromide% 25,%S% 5% PU/PD/PP/W/A/T/V/D% Severe%Asthma% Diazepam% 0.5%_1,%B% 3% S,A,W% Liver% Principles%of%Chronic%AEDT% Use%just%one%medicaIon%at%a%Ime% Pick%meds%with%best%%efficacy,%safety,%%side_effect,%cost% and%ease%of%administraion%% Determine%a%serum%concentraIon%when%iniIaIng% therapy%in%hard%to%control%cases%and/or%before% increasing%when%at%high%end%of%dose%and%poor%seizure% control% 15%

16 Will%An%AED%Work%?%%What%Do%YOU%Tell%Client?% What%percent%canine%epilepsy%paIents%have%frequent%or%severe% seizure%or%intolerable%side_effect%despite%appropriate%serum% concentraion%of%an%aed?% 30%% Honeymoon%Phenomenon%% T/F%%_%An%AED%might%only%work%well%for%6%months?% True%in%people,%probably%in%dogs% T/F% %a%majority%of%canine%paients%on%phenobarbital%or%bromide% become%seizure_free%(%1%year%without%seizure)%without%adverse% side_effects% False% How%oYen%do%YOU%think%a%placebo%will%reduce%the%seizure% frequency%in%dogs?%by%greater%than%50%?% 22/28%(79%)%demonstrated%decrease%in%seizure% compared%to%baseline% 8/28%(29%)%could%be%considered%responders%with%a% 50%%reducIon%from%baseline% Switching%AED%Therapy% MulIple%AED%will%have%addiIve%side_effects% Adequate%serum%concentraIons%of%at%least%one%AED% must%be%maintained%in%the%transiion% Consider%half_life%when%making%transiIon% Munana%KR,%et%al.%Placebo%Effects%in%Canine%Epilepsy%Trials.% %J"Vet"Intern"Med"2010;24:%166_170% TransiIoning%AED% Pulse%Therapy%% Pulse%therapy%defined%as%giving%addiIonal%and/or% different%aed%ayer%one%seizure%and%based%on%idea% that%seizure%suscepibility%waxes%and%wanes%% Cluster%seizure%and%Status%EpilepIcus%common%and% life%threatening%condiion%% Define%interval%between%cluster%of%seizure%and%ability% to%swallow%to%decide% %parenteral%vs.%per%os% 16%

17 Keppra%Pulse%Therapy% Double%blinded,%placebo%controlled,%crossover%study% of%6%epilepic%dogs%with%cluster%seizure%while%on% phenobarbital%and%bromide%% AYer%1%seizure%given%placebo%or%keppra%30%mg/kg,% PO,%Q8%for%24%hours%aYer%last%seizure% Keppra%group%had%1%seizure%per%cluster%(range%0_2)% while%placebo%had%4%(range%1_7)%_%%p=0.052% Bentley%RT,%et%al.%%A%pilot%study%of%leveIracetam%pulse%therapy%for%% cluster%seizure.%acvim%abstract%2014% Performing%Pulse%Therapy%% PO%meds%should%not%be%given%closer%than%every%hour% in%order%to%allow%for%absorpion%% Consider%trying%candidate%rescue%medicaIon%outside% of%when%there%is%a%cluster%to%assess%tolerability% Any%AED%with%excepIon%of%bromide%suitable%for%pulse% therapy% %Pulse%% Therapy% Examples% Seizure%Management%With%Acepromazine%% Treats%toxicity%%and%stress%induced%seizure%in%dog%and%reduces% neuronal%damage%in%se%in%rat%model% Rapid%bolus%of%Chlorpromazine%induced%EEG%changes%in%22/43% dogs%and%caused%seizure%in%2%dogs%(holliday,%1970)%% In%2%studies,%low%dose%acepromazine%(0.01_0.1%m/kg,%IV%or%1% mg/kg,%po)%in%64/67%dogs%hospitalized%for%seizure%or%with% seizure%history%did%not%cause%seizure%in%observaion%period% Tobias%KM,%et%al.%A%retrospecIve%study%on%the%use%of%acepromazine%maleate%in%dogs%with%seizures.% JAAHA%2006:42:%283_289% McConnell%J,%AdministraIon%of%acepromazine%maleate%to%31%dogs%with%a%history%of%seizures.%% JVECC%2007;%17%(3):%252_267c% At%Home%Parenteral%AEDT% Midazolam 0.5 mg/kg, IM or IN %%%Keppra%%60%mg/kg,%SC% %%%Valium%injectable%soluIon%2%mg/kg,%IN,%PR%(not%%%%%% suppository)% Hardy%BT.%Subcutaneous%AdminstraIon%of%Keppra%in%Healthy%Dogs% 2011%ACVIM%Abstract,%P_3,%p.%742% In%Hospital%Parenteral%AEDT% Valium%1%mg/kg%+%Keppra%60%mg/kg% Phenobarbital%10%mg/kg%x%2%doses% Phenobarbital%anesthesia%10%mg/kg%every%20% minutes%up%to%70%mg/kg%total% %end%point% should%be%no%twitching%or%abrupt%changes%in% vital%signs% 17%

18 Part%3%:%Take%Home%Points% Newer%AED%are%aRracIve%first%choice%medicaIons%for% treaing%seizure%% Pulse%or%rescue%therapy%can%limit%cluster%seizure%and% status%episodes%and%save%lives% Check%out%our%2015%upcoming%VETgirl%appearances!% Questions? Dr. Justine Lee NAVC 2015 WVC 2015 Dr. Garret Pachtinger NAVC 2015 WVC VetGirlOnTheRun% This%material%is%copyrighted%by%VetGirl,%LLC.%%None%of%the%materials%provided%may%be%used,% reproduced%or%transmired,%in%whole%or%in%part,%in%any%form%or%by%any%means,%electronic%or% otherwise,%including%photocopying,%recording%or%the%use%of%any%informaion%storage%and% retrieval%system,%without%the%consent%of%vetgirl,%llc.%%unless%expressly%stated%otherwise,%the% findings,%interpretaions%and%conclusions%expressed%do%not%necessarily%represent%the%views%of% VetGirl,%LLC.%%Medical%informaIon%here%should%be%references%by%the%pracIIoner%prior%to%use.% Under%no%circumstances%shall%VetGirl,%LLC.%be%liable%for%any%loss,%damage,%liability%or%expense% incurred%or%suffered%that%is%claimed%to%have%resulted%from%the%use%of%the%informaion%provided% including,%without%limitaion,%any%fault,%error,%omission,%interrupion%or%delay%with%respect% thereto.%%if%you%have%any%quesions%regarding%the%informaion%provided,%please%contact% 18%