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You are seeing a 1yo child in status epilepticus (first time seizure). The child received 0.2 mg/kg intranasal midazolam in the field, 0.1 mg/kg IV lorazepam in the ED, then 20 mg/kg fosphenytoin, 60 mg/kg levetiracetam, and 40 mg/kg valproate, with no cessation of seizures. The bedside glucose and i-stat Na and Ca are normal. Which vitamin might you try next?
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March 19, 2019 at 6:00 pm
B) Vitamin B6
Pyridoxine-dependent epilepsy is a very rare genetic disorder involving seizures that typically begin in infancy, but rarely do not begin until age 1-3years. These seizures are resistant to usual anti-convulsants. Patients may also have hypotonia and hypothermia. If considering this entity, one can give a trial dose of 100 mg pyridoxine IV. Some may have answered Vitamin K, thinking of Ketamine. While some case series and reports show promise in treatment of refractory status epilepticus, ketamine has not been studied well. A recent review (Rosati et al CNS Drugs 2018;32(11):997) found 29 pediatric cases reported. There are ongoing clinical trials currently. PEMsource’s algorithm can be found here http://pemsource.org/wp-content/uploads/2016/04/Status-Epilepticus.pdf