What is the definition of status epilepticus?
Continuous seizures for 30 minutes or longer (or two or more seizures without recovery of consciousness between them over a similar period)
What is the risk of brain damage in someone having status epilepticus for the first time?
Do all those in status epilepticus have tonic-clonic seizures?
Primarily, but can also have absence status (continous, stuporous state), focal status and epilepsia patiralis continua (seizure activity in one part fo the body e.g. finger or limb)
If a patient was in status epilepticus and was pregnant, what might you consider as your differentials?
- Eclampsia - following pre-eclampsia
- Epilepsy - previously diagnosed or undiagnosed
If a patient was in status epilepticus and was pregnant, what investigations might you consider?
- Urine dipstick - protein
How would you initially manage someone in status epilepticus?
- A - open, remove false teeth
- B - 100% O2 + suction
- C - IV access, BP, fluids
- D - consider blood glucose
- E - head injury?
When gaining IV access in someone in status epilepticus, what bloods would you want to take?
- Toxicology screen
- Anticonvulsant levels
- Consider CO levels
What initial investigations would you do in someone in status epilepticus?
- Cap glucose
- Bloods - FBC, U+E's, Ca2+, VBG, Anticonvulsant levels, clotting
- Consider LP, BCs - infection
- If cause unkown - Consider CT/MRI head/EEG
What would you give in the first 10 minutes to attempt to terminate status epilepticus?
IV Lorazepam - 4mg; or IV Diazepam - 10 mg
If you were uable to gain IV access to give medications, how would you administer benzodiazepines in an attempt to terminate status epilepticus?
- Buccal Midazolam - 10 mg adult, 7.5 mg age 5-10, 5mg age 1-5
- Diazepam PR - 10-20mg
What dose of lorazepam would you initially give someone IV if they were in status epilepticus?
What dose would you initially consider giving someone of IV diazepam if they were in status epilpeticus?
10 mg IV diazepam
If there was no response to an initial dose of benzodiazepines (lorazepam/diazepam) after 10-20 minutes, what would you consider doing?
Give second dose of benzodiuazepines
If someone, after repeated benzodiazepine doses, was still in status epilepticus after 30 minutes, what would you consider giving them?
What dose of phenytoin would you consider giving to someone in status epilepticus?
15-18 mg/kg IV
What rate would you give IV phenytoin at in someone in status epilepticus?
What monitoring would you do whilst giving someone in status epilpeticus phenytoin infusion?
If, after 60-90 minutes, someone is still in status epilepticus following treatment with phenytoin and benzodiazepines, what would you consider doing?
Call anaesthetist/ITU physician - General anaesthesia (propofol) in ITU, intubation
What is the general rule for when to call an anaesthatist when managing someone in status epilepticus?
Never spend longer than 20 mins on someone in status without help from anaesthatist
When would you not use phenytoin to treat status epilepticus?
- Heart block
When would you be cautious using phenytoin in someone in status epilepticus?
What should you be wary of when giving someone IV benzodiazepines?
Respiratory arrest - during last part of injection
What monitoring would you perform in someone in status epilepticus?
- Pulse oximetry
- Cardiac Monitor
If you suspected a seizure was due to hypoglycaemia, what might you give in addition to standard treatment for status epilepticus?
50ml 50% glucose
What would you give in addition to standard treatment for status epilepticus in someone where you think alcohol abuse may be an issue/the cause?
How would you correct hypotension in someone in status epilepticus?
How long can the post-ictal period last following status epilepticus?
A few hours
What would you want to do once you have managed to terminate a status epilepticus?
- Switch to oral drugs when possible
- Find cause - History, mutli-system exam, investigations
- Treat cause
- Refer to neurology
- Advise regarding driving and DVLA
What are common neurological causes of seizures?
- Brain tumour
- Head Trauma
- Congenital abnormalities/hypoxic injury
What are metabolic causes of seizures?
What drugs can cause seizures?
- Illicit drugs of abuse
- Alcohol withdrawal
What are respiratory complications of status epilepticus?
- Aspiration pneumonitis
- Respiratory acidosis
What are cardiovascular complications of status epilepticus?
What are neurological complications of status epilepticus?
- Primary brain injury - excitotoxic neuronal brain injury
- Secondary brain injury - hypotension, hypoperfusion, hypoxia
What should you give immediately as someone starts seizing?
15L/min O2 therapy - non-rebreath mask
Why might you take a VBG in someone with acute seizure?
Assess lactate levels and acidosis
Why might you look at U+E's and Ca2+ in someone with acute seizure?
Look for electrolyte abnormalities
Why might you do an ECG in someone with acute seizure?
Look for features of prolonged QT interval