References
Feasibility of phenytoin as a paramedic-led second-line anti-epileptic drug
Abstract
Background:
Convulsive status epilepticus (CSE) is a medical emergency that is commonly encountered in the prehospital setting. In almost all prehospital settings, treatment is limited to benzodiazepines even though the standard of care in emergency departments includes second-line agents such as phenytoin.
Methods:
A literature search was conducted using PubMed and Google Scholar using the search terms ‘phenytoin’, ‘seizure’ or ‘convulsive’ and ‘prehospital’, ‘EMS’ or ‘ambulance’ or ‘emergency department’. Five articles were analysed and a narrative review formed.
Results:
Phenytoin is an effective and commonly used second-line anti-epileptic agent but there is a distinct lack of evidence on prehospital phenytoin. Phasing the introduction of phenytoin into practice while simultaneously running a well-designed research trial could provide data for prehospital providers and the wider health community.
Conclusion:
Management of CSE will continue to present challenges to prehospital providers. Promoting the introduction of phenytoin to select patients, administered by advanced clinicians, could be an excellent opportunity to generate much-needed clinical data and potentially reduce morbidity and mortality in CSE.
A seizure lasting for more than 5 minutes or consecutive seizures with no return of consciousness are the definitions of convulsive status epilepticus (CSE)—an acute medical emergency with significant morbidity and a high mortality rate (Trinka et al, 2015; Grover et al, 2016; Neligan and Walker, 2016). This prolonged state of abnormal neurological activity is understood to be a result of either: failure of the mechanisms responsible for terminating the seizure; or the instigation of mechanisms leading to prolonged seizure activity (Trinka et al, 2015).
Depending on the duration and type of seizure, CSE is associated with injury, network disruption and neuronal death. It is also associated with significant systemic complications such as pulmonary aspiration, cardiac dysrhythmias, metabolic derangement and impaired ventilation (Millikan et al, 2009; Grover et al, 2016).
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