😴 Preferred sedative post-intubation in setting of seizures? - #DrugQueryInbox
For my personal preference, it'll be important to discuss induction agents as I like to streamline my options for maximal therapeutic effect. Etomidate doesn't have anticonvulsant properties. Giving it as your induction is fine, but you have to ensure you have immediate anticonvulsant agents on board afterwards.
I'm a big fan of using propofol for induction within RSI for several reasons. Rapid onset which improves the likelihood seizure termination while making the patient unconscious. It also has a short duration of action. This comes in handy when you need to shut off the infusion post-intubation. Hypotension can be fluid responsive, but the drip off and short duration of actions allows for better information on the reasoning behind the acute drop in blood pressure.
Midazolam can be used for induction and post-intubation sedation in status epilepticus. However, the PK and PD are important to discuss. Midazolam caps the dose at 10 mg for initial seizure treatment. That is not enough to make someone unconscious. Doses for induction are weight-based at 0.2 - 0.4 mg/kg wit no cap. These larger doses often negate the cardiovascular neutral properties, and that gets you in trouble inducing hypotension. Midazolam has a much greater duration of action (~2 hours).
As a continous infusion, you aren't able to uptitrate as rapidly as propofol and with this patient population, high doses and longer therapies are associated with benzodiazepine-induced delirium.
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