Successful management of a kitten with chlorpyrifos and cypermethrin toxicosis with pralidoxime and atropine

Case summary Organophosphates and pyrethroids have been widely used as agricultural and domestic insecticides. This case report describes a 3-month-old free-roaming female kitten, weighing 930 g, that developed hypersalivation, hypothermia, dyspnoea due to increased bronchial secretion, bradycardia, miosis and neurological signs, including restlessness, ataxia, disorientation, apparent hallucination, muscle twitching and seizures within 6 h of accidental ingestion of an insecticide containing chlorpyrifos (500 g/l) and cypermethrin (50 g/l). The kitten was treated empirically with intramuscular atropine and dexamethasone, and rectal diazepam. The history of insecticide exposure was obtained after 6 h of treatment and intramuscular 2-pyridine aldoxime methochloride (pralidoxime [2-PAM]) and atropine therapy was started 2 h later. Recovery was complicated by suspected aspiration, but there were no sequelae from the insecticide exposure and by 7 days post-ingestion the kitten was normal and playful. Relevance and novel information To the best of our knowledge, this is the first report of successful management of chlorpyrifos and cypermethrin toxicosis in a cat in Bangladesh. This case report suggests that 2-PAM followed by atropine and other supportive therapy may be an effective strategy to manage a cat poisoned by chlorpyrifos and cypermethrin; however, expanded clinical trials are needed.

Factors Predicting the Recurrence of Febrile Seizure in Siloam General Hospital: A Descriptive Analysis

Febrile seizure (FS) is one of the most common pediatric neurologic disorders, affecting 2 to 5% of children between 6 months and 5 years. In 2008 to 2010, almost half of children with FS in Indonesia experienced recurrences. Various factors have been related to potential predictors for FS recurrence. However, available data reported inconsistent results. Considering its high recurrence rate, this study aimed to determine and assess the factors predicting the recurrence of FS. A cross-sectional study was done in Siloam General Hospital, Lippo Village. The study period was from December 2018 to December 2019, and data were obtained through medical records. Out of 60 participants, 41.7% had recurrent FS. No administration of rectal diazepam before admission (odds ratio [OR] = 6.42; 95% confidence interval [CI]: 1.20–34.2, p = 0.027) was a predictive factor of recurrent FS, while female sex (OR = 0.23; 95% CI: 0.64–0.80, p = 0.025) and shorter duration of the first FS (OR = 0.21; 95% CI 0.06–0.69, p = 0.008) were protective factors of recurrent FS. Identification of factors predicting the recurrence of FS is a powerful tool for clinicians. This study showed that no administration of rectal diazepam before admission was correlated with the risk of FS recurrence, while shorter duration of FS and female sex were protective factors of recurrent FS.

Epilepsy: recognition and management of seizures in children and young people

A seizure describes the signs and symptoms associated with a sudden surge in brain activity. It is a symptom of either acute brain disturbance, or may indicate a diagnosis of epilepsy, which describes an underlying tendency to have seizures. There are many different seizure types, which account for the wide variation in seizure symptoms. The principles of management remain constant for all seizure types: maintain child safety, ABC support, and arrange emergency assistance and hospital transfer for prolonged episodes. In addition to this, tonic-clonic seizures lasting for more than 5 minutes require treatment with benzodiazepines. Buccal midazolam or rectal diazepam are first-line options when intravenous or intraosseous access is not available. Children and young people with epilepsy should have individualised treatment plans which, if available, further simplify emergency treatment decisions.

Time Is Brain: Acute Control of Repetitive Seizures and Status Epilepticus Using Alternative Routes of Administration of Benzodiazepines

Time plays a major role in seizure evaluation and treatment. Acute repetitive seizures and status epilepticus are medical emergencies that require immediate assessment and treatment for optimal therapeutic response. Benzodiazepines are considered the first-line agent for rapid seizure control. Thus, various routes of administration of benzodiazepines have been studied to facilitate a quick, effective, and easy therapy administration. Choosing the right agent may vary based on the drug and route properties, patient’s environment, caregiver’s skills, and drug accessibility. The pharmacokinetic and pharmacodynamic aspects of benzodiazepines are essential in the decision-making process. Ultimately, agents and routes that give the highest bioavailability, fastest absorption, and a modest duration are preferred. In the outpatient setting, intranasal and buccal routes appear to be equally effective and more rapidly administered than rectal diazepam. On the other hand, in the inpatient setting, if available, the IV route is ideal for benzodiazepine administration to avoid any potential absorption delay. In this article, we will provide an overview and comparison of the various routes of benzodiazepine administration for acute control of repetitive seizures and status epilepticus.

VALTOCO® (Diazepam Nasal Spray) for the Acute Treatment of Intermittent Stereotypic Episodes of Frequent Seizure Activity

Valtoco® is a new FDA-approved nasal spray version of diazepam indicated for the treatment of acute, intermittent, and stereotypic episodes of frequent seizure activity in epilepsy patients six years of age and older. Although IV and rectal diazepam are already used to treat seizure clusters, Valtoco® has less variability in plasma concentration compared to rectal diazepam. Furthermore, the intranasal administration of Valtoco® is more convenient and less invasive than rectal or IV diazepam, making it ideal for self-administration outside of a hospital setting. Multiple clinical trials have taken place comparing Valtoco® to the oral, rectal, and IV forms of diazepam. Aside from mild nasal irritation and lacrimation, Valtoco® was found to have no increased safety risk in comparison to traditional forms of diazepam. This review of Valtoco® will include a history of diazepam prescribing and withdrawal treatment, Valtoco® drug information, its mechanism of action, pharmacokinetics and pharmacodynamics, and a comprehensive review of clinical studies.

A Short Review on the Intranasal Delivery of Diazepam for Treating Acute Repetitive Seizures

Benzodiazepines such as diazepam, lorazepam and midazolam remained the mainstay of treatment for acute repetitive seizures (ARS). The immediate care for ARS should often begin at home by a caregiver. This prevents the progression of ARS to prolonged seizures or status epilepticus. For a long time and despite social objections rectal diazepam gel remained only FDA-approved rescue medication. Intranasal administration of benzodiazepines is considered attractive and safe compared with rectal, buccal and sublingual routes. Intranasal delivery offers numerous advantages such as large absorptive surface area, bypass the first-pass metabolism and good patient acceptance as it is needle free and painless. Recent clinical studies have demonstrated that diazepam nasal spray (NRL-1; Valtoco®, Neurelis Inc.,San Diego, CA, USA) showed less pharmacokinetic variability and reliable bioavailability compared with the diazepam rectal gel. Diazepam nasal spray could be considered as a suitable alternative for treating seizure emergencies outside the hospital. This review summarizes the treatment options for ARS and findings from clinical studies involving intranasal diazepam for treating seizure emergencies.

Simple Febrile Seizures: A Benign Phenomena?

Febrile seizures are one of the most common neurological causes of visits to the emergency room. This article is a review of the current literature concerning the evaluation and treatment of children with febrile seizures. Longitudinal prospective studies such as the FEBSTAT study (consequences of prolonged febrile seizures in childhood) have contributed to elucidate the long-term outcome of patients with prolonged febrile seizures. Neurogenetic research also demonstrated the role of genetic mutations (mainly voltage-gated ion channels) in the etiology of febrile seizures. Most febrile seizures are self-limited events with low risk of injury or evolution into status epilepticus or sudden death. However, the use of rectal diazepam as acute abortive treatment for febrile seizures lasting 5 minutes or longer has gained acceptance as a first-line home intervention. Most patients with febrile seizures do not require extensive investigations, but the treatment involves a customized plan. Efforts should be directed to educate caregivers about prognosis and management of potential recurrences. In selected cases, appropriate use of preventive antiseizure medication may be a consideration.