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CBL_status epilepticus Flashcards

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1
Q

What’s the usual definition for status epilepticus?

A

A seizure lasting more than 30 minutes or repeated seizures between which the consciousness is not fully regained

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2
Q

When do we need to think about the treatment as per status epilepticus?

A

If a seizure lasts for more than 5 minutes -> as any seizure of that duration is unlikely to cease on its own

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3
Q

Initial management of status epilepticus

A

Status epilepticus - initial management

  • ABC
  • check glucose level
  • give glucose and thiamine
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4
Q

What’s first line treatment for status epilepticus?

A

IV lorazepam

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5
Q

2nd line treatment of status epilepticus

3rd line treatment of status epilepticus

A

Treatment for *status epilepticus*

  • 1st line: IV Lorazepam
  • 2nd line: IV anti-epileptic drugs (eg, fosphenytoin, phenytoin, valproate)
  • third-line: general anesthesia (ie.g. propofol, thiopental)
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6
Q

What is the peak age (2) for the incidence of status epilepticus?

A
  • infants younger than 1
  • persons older than 65
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7
Q

Causes of status epilepticus

A
  • infections complicated by fever (children)
  • infections of CNS
  • stroke (both, ischaemic and hemorrhagic)
  • metabolic derangements
  • hypoxia
  • eclampsia
  • alcohol intoxication or withdrawal
  • withdrawal of anti-epileptic drugs (in patients with pre-existing epilepsy)
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8
Q

What to treat a seizure of unknown origin with?

A

Seizures of unknown origin - management:

  • evaluate glucose
  • treat with: glucose (in case hypoglycaemia is a cause) and also thiamine (in case if Wernicke’s encephalopathy is present; also to prevent iatrogenic from glucose Rx)
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9
Q

Diagnosis of convulsive status epilepticus vs non-convulsive status epilepticus

A
  • Convulsive clinical diagnosis
  • Non- convulsive: depends on EEG findings and response to treatment
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10
Q

The difference between convulsive and non-convulsive status epilepticus

A
  • Conclusive - diagnosed clinically, the patient has prolonged clonic seizure -> it is a medical emergency
  • Non - convulsive - episode when the patient has prolonged absence and atypical absence events (may last for half an hour, hours or even days) -> it is not life-threatening or damaging to the brain but should be treated
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11
Q

Typical EEG pattern for non-convulsive status epilepticus

A

Typical EEG pattern of:

  • continuous or recurrent
  • generalized or focal,
  • epileptiform activity,
  • wide-ranging alterations in mental state
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12
Q

Psychogenic nonepileptic seizures (PNES) - what happens in it

A

Psychogenic non-epileptic seizures

What happens:

  • paroxysmal events -> involuntary movements
  • alterations in consciousness
  • no associated EEG changes
  • caused by psychological factors
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13
Q

Psychogenic non-epileptic seizure - causes

A
  • high level of stress, other psychologically disturbing problems
  • in a patient with difficulty of understanding, recognizing and processing their emotions
  • most of them happen without the patient’s control
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14
Q

What’s Nonepileptic psychogenic status epilepticus (NEPS)

A

It is a prolonged episode of psychogenic non-epileptic seizure

  • the majority consider the threshold of seizure lasting >20 min
  • it may be called ‘ pseudo status epilepticus’
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15
Q

What characteristic of seizure would indicate its possible association with intracranial lesion?

A
  • focal onset
  • new, persisting focal deficit

*intracranial lesion: tumour, stroke, abscess, vascular malformation

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16
Q

What should be included in history in the initial assessment of a patient with a seizure?

A

Initial assessment -> to identify the cause

History taken from a caregiver, family:

  • previously unrecognized seizure activity
  • withdrawal of anti-epileptic drugs (or reduced dose) and if they adhere to treatment
  • alcohol or drug use
  • PMH
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17
Q

What examinations should be done in a patient presenting with seizure

A
  • full neurological examination
  • developmental assessment -> in children
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18
Q

Psychogenic non-convulsive seizure - typical population

A

female, young adults, adolescent

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19
Q

What may be seen during a psychogenic non-convulsive seizure?

A

Psychogenic non-convulsive seizure - atypical seizure characteristics:

  • eyes closure
  • back arching
  • side-to-side head shaking (‘no-no’)
  • wild, asymmetric flailing /wymachujacy/ movements of the arms and pelvis
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20
Q

Bloods: in seizure assessments

A

*Give glucose and thiamine

  • FBC
  • complete metabolic profile
  • CRP
  • coagulation studies
  • magnesium, B12 and folate levels
  • toxicology
  • blood cultures
  • ABG
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21
Q

Other/ bedside tests in a patient with a seizure and further investigations

Study These Flashcards
A

Bedside:

  • urinalysis
  • pregnancy test -> to exclude eclampsia as a cause and to guide anti-convulsant choices

Further tests:

  • neuroimaging
  • LP -> especially in immuno-compromised patient
  • EEG
22
Q

What do elevated serum protein levels may be suggestive of?

Study These Flashcards
A
  • They may aid the diagnosis of seizures (but not fully sensitive and reliable)
  • Two-folds elevated serum protein 10-20 minutes after the seizure

*it does not differentiate seizure from syncope or status epilepticus

23
Q

What are the risks of status epilepticus?

Study These Flashcards
A
  • airway compromise
  • injury
  • neuronal damage
24
Q

What’s better to use in the treatment of status epilepticus: IV lorazepam or IV diazepam?

Study These Flashcards
A

IV Lorazepam is better

25
Administration of ***Lorazepam IV*** in status epilepticus - how - dose
***IV Lorazepam*** - slow bolus - **0.1 mg/kg** -\> usually **4mg**
26
***IV diazepam*** in status epilepticus - dose
\*1st try IV lorazepam (better clinical evidence) ***IV diazepam*** **0.15 mg / kg** -\> usually **10mg**
27
When administrated rectally, which one is more effective: ***lorazepam*** or ***diazepam***?
Limited evidence that ***Lorazepam*** is more effective
28
What is an alternative to rectal treatment with ***Lorazepam*** or ***Diazepam***?
***Midazolam :*** ***-*** buccal - nasal - IM
29
Side effects of therapy with ***benzodiazepines***
- hypotension - respiratory depression \*monitor patients for those signs
30
What's more effective 2nd line Rx for status epilepticus: ***Valproate*** or ***Phenytoin***?
Valproate is more effective
31
What's the aim and mode of treatment for absence and focal non-convulsive status epilepticus?
**Aim**: to stabilize vital signs **Treatment**: Oral ***benzodiazepines***
32
Do we hospitalise patient with status epilepticus
Yes, all status epilepticus patients should be hospitalized -\> ideally after they are stabilized and IV benzodiazepines are given
33
NICE algorithm to the approach of **initial management of status epilepticus**
34
35
Difference between the seizure and epilepsy
* **Seizure** -\> can be one off thing * **Epilepsy** -\> recurrent seizures due to chronic process
36
Possible triggers for seizure
* Sleep depravation * Drugs (antibiotics, withdrawal from antibiotics, benzodiazepines) * Alcohol withdrawal * Fever * Hypoglycaemia -\> check glucose immediately * Space-occupying lesion * Trauma / head injury * Stroke * Infections: meningitis, encephalitis * Neurodegenerative causes (e.g. severe dementia -\> brain atrophies -\> predisposition to neuronal excitability) * Congenital/ genetic problems Electrolyte disturbance/ metabolic (sodium, thymine levels abnormalities)
37
Investigations for seizures at A&E
**Investigations:** * Glucose * FBC, U+E * Toxicology -\> drugs, alcohol * \*LP -\> if infection (meningitis/encephalitis) is suspected e.g. pt has high fever * CT head If a person is known to have epilepsy and come to A&E * Check antiepileptic drug levels -\> if they take their medication
38
Management of status epilepticus (stepwise)
**_Management:_** * ABCDE * Drug treatment: rectal ***diazepam*** OR buccal ***midazolam*** (community), ***4mg Lorazepam IV*** (repeat twice after 5 minutes) -\> then give ***Phenytoin / sodium*** ***valproate/Levetiracetam (Keppra)*** -\> call ITU \****Phenobarbital*** -\> given by ITU and ***propofol/midazolam*** infusion
39
What's dissociative seizure?
Dissociative seizures -\> non-epileptic -\> happens due to psychological causes rather than physical
40
How much Lorazepam IV do we give at A&E to an adult? (status epilepticus, febrile seizures, convulsions caused by poisons)
**4 mg for 1 dose**, **then 4 mg** after 10 minutes if required for 1 dose, to be administered into a large vein
41
How much **Lorazepam IV** do we give at A&E to a child 1 month - 11 years?
**100 micrograms/kg** (**max. per dose 4 mg**) for 1 dose, then 100 micrograms/kg after 10 minutes (max. per dose 4 mg) if required for 1 dose, to be administered into a large vein.
42
How much Lorazepam IV do we give to a child 12 - 17 y?
**4 mg for 1 dose**, then **4 mg after 10 minutes** if required for 1 dose, to be administered into a large vein.
43
**Dissociative** (non-epileptic) vs **Epileptic** seizure (compare/how to distinguish)
**Dissociative (non-epileptic)** **Epileptic** * Cardio-respiratory not usually involved * Cardio-respiratory involved * Non- rhythmic movements (higher amplitude) * Rhythmic movements * Eyes are closed * Eyes open * Distractible (e.g. if you talk to the patient they may respond) * Non- distractible * Onset is slow * Sudden onset * Biting inside the mouth * Biting inside the mouth * Posterior-lateral tongue biting not present * Posterior – lateral tongue biting * Incontinence may be present * Incontinence may be present * Pelvic trust * No pelvic trust _Recovery time/ after seizure:_ * Pt may be able to recall some events (e.g. going to CT scan); can make quick recovery; tend to cry after the seizures _Recovery time/after seizure_: * confused, do not remember seizure, tired à slower recovery; do not tend to cry after the seizures
44
What is **postero-lateral** tongue biting suggestive of?
If posterior and lateral tongue biting -\> epilepsy \*lateral tongue biting is specific to generalized tonic-clonic seizures = grand mal seizures)
45
Differentials for seizures
**Differentials for seizures** 1. _Syncope:_ * cardiac -\> during exercise, chest pain, light headedness, drug on, palpitations, no aura * vasovagal 1. _Sleep disorders_ -\> narcolepsy, cataplexy 1. _TIA_ -\> and any other neurological conditions may be suspective of seizures 1. _Children_ _-\>_ breath holding, night terrors
46
What questions to ask in a Hx of an adult with a first fit (e.g. seen in 1st fit clinic)
**First clinic at fit clinic** **-\> ask** Adult and 1st fit: * Any previous seizures (e.g. febrile seizures as child **-\>**increased likelihood) * What they were doing at the time * What they were doing * Do they recall events during/after the seizure * Length of time * Incontinence/ tongue biting * Anyone saw it happening **-\>** collateral history (maybe they have recorded it) * PMH * Auras * Trauma, head injuries (any HI can reduce seizure threshold) * Triggers (psychological, lack of sleep, alcohol) * Medication history * Drug use * What happened after **-\>** length of recovery, confusion etc * Injuries **-\>** tongue biting, bruises on the limbs, burns, shoulder dislocations _In paediatrics/young adults:_ * Developmental history * Birth history * Family history
47
What type of epilepsy/seizure is more common in adult and what type in children?
**Classification of epilepsy** * **Focal onset** epilepsy -\>most common in adults (brain tumour, trauma, infection) * **Generalised** -\> children/congenital
48
What in below scenario can indicate the type of seizure? 39 y old woman brought to A&E by husband. Have has seizures on and off for 30-40 mins. Large amplitude of movements in her limbs
39 y old woman brought to A&E by husband. Have has seizures **on and off** for 30-40 mins. **Large** **amplitude of movements** in her limbs 1. Large amplitude of movements **-\>** non- epileptic attack (dissociative seizure) 2. On and off/ fluctuating nature **-\>** dissociative seizure
49
What in below scenario can indicate the type of seizure? 24 y old man brought to A&E by friends. Convulsing for 20 mins. He is cyanosed with rhythmic clonic movements in all four limbs.
24 y old man brought to A&E by friends. Convulsing for 20 mins. He is **cyanosed** with **rhythmic clonic movements** in all four limbs. Status epilepticus: * Respiratory involvement * Rhythmic movement
50
What are two the most important causes to role out first in ***status epilepticus?***
***hypoxia*** and ***hypoglycaemia***

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