Case-based discussion: 1 History You are the clinician working on a busy ward and haven’t had a break for 8 hours. On your way to the toilet, the emergency buzzer goes off. A 62-year-old 00:57 man is having a tonic-clonic seizure. You are the first clinician on the scene. Observations HR 95, BP 130/45 mmHg, RR 15, SpO2 95%, Temp 37.2 2
Question: 1 3
Question: 2 4
Case-based discussion: 1 History You are the clinician working on a busy ward and haven’t had a break for 8 hours. On your way to the toilet, the emergency buzzer goes off. A 62-year-old 00:57 man is having a tonic-clonic seizure. You are the first clinician on the scene. Observations HR 95, BP 130/45 mmHg, RR 15, SpO2 95%, Temp 37.2 5
Introduction Definition Seizure > five minutes or • Recurrent seizures without regaining consciousness in • between Convulsive vs non-convulsive • Epidemiology Mortality • Adults: 15-20% • Children: 3-15% • Longer duration associated with poorer prognosis • Most common neurological emergency in children • 6
Aetiology Causes Epilepsy: poor medication compliance • Febrile convulsion • Infection • Stroke • Cerebral haemorrhage • Alcohol abuse • Recreational drug use • Electrolyte imbalance: hyponatraemia and hypocalcaemia • 7
Aetiology 8
Aetiology 9
Aetiology Generalised Focal (Impaired or retained consciousness) Motor Tonic-clonic Automatisms Tonic Tonic Clonic Clonic Myoclonic Myoclonic Atonic Atonic Non-motor Absence Autonomic Emotional Sensory Cognitive 10
Aetiology 11
Pathophysiology • Mechanisms required for seizure termination fail • Imbalance between excitation and inhibition • Cerebral damage occurs after ~ 30 mins of convulsive status epilepticus 12
Clinical features Symptoms Signs Limb jerking Loss of consciousness Limb stiffness Post ictal: confusion and reduced GCS Tongue biting Urinary incontinence 13
Investigations Bedside ECG: arrhythmia • Blood glucose: hypoglycaemia • Bloods Venous blood gas: lactic acidosis • FBC and CRP: possible infection • Electrolytes: in particular, hyponatraemia and hypocalcaemia • Anti-epileptic drug levels • Imaging CT head: structural brain lesion • Specialist tests Lumbar puncture (LP): CNS infection • EEG • 14
Question: 3 History You are the clinician working on a busy ward and haven’t had a break for 8 hours. On your way to the toilet, the emergency buzzer goes off. A 62-year-old 00:57 man is having a tonic-clonic seizure. You are the first clinician on the scene. Observations HR 95, BP 130/45 mmHg, RR 15, SpO2 95%, Temp 37.2 15
Management Airway Start timing • Position: semi-prone with head facing down • Suction • Airway adjuncts • 1 Breathing 1. Observations: RR 15, SpO2 95% 2. Peripheral exam: not cyanosed 3. Central exam: trachea central, equal air entry 4. Urgent investigations: CXR 5. Management: High flow oxygen 2 16
Management Circulation 1. Observations: HR 95, BP 130/45 2. Peripheral exam: CRT 2s, regular pulse, well perfused 3. Central exam: normal heart sounds 4. Urgent investigations: IV access and bloods 5. Management: commence AEDs Disability DEFG: don’t ever forget glucose! • GCS: E V M • Exposure Evidence of underlying cause • Trauma • 17
Question: 4 History You have now inserted an oropharyngeal airway which your patient tolerates. You have commenced high flow oxygen and inserted a cannula. The patient 5:07 is in status epilepticus. No help has arrived. Observations HR 95, BP 130/45 mmHg, RR 15, SpO2 100%, Temp 37.2 18
Question: 5 History The patient is continuing to fit. The anaesthetist has appeared and asks you what you would like to do next. 15:30 Observations HR 105, BP 110/45 mmHg, RR 19, SpO2 96%, Temp 38.4 19
Management: convulsive status epilepticus Time Treatment Early: <10 minutes Rectal diazepam 10-20mg or buccal midazolam 10mg • First line: IV lorazepam 4mg • Repeat once after 10 - 20 minutes • 20
Question: 6 History The patient is continuing to fit. 24:07 Observations HR 115, BP 100/45 mmHg, RR 19, SpO2 94%, Temp 39.0 21
Management: convulsive status epilepticus Time Treatment Early: <10 minutes Rectal diazepam 10-20mg or buccal midazolam 10mg • First line: IV lorazepam 4mg • Repeat once after 10 - 20 minutes • Established: 10-60 • Alert on call anaesthetist minutes • Phenytoin 15-18mg/kg infusion and/or • Phenobarbital 15mg/kg bolus Refractory: 60-90 minutes General anaesthesia (rapid sequence induction) with one of: Propofol • Midazolam • Thiopental • Transfer to ICU 22
Question: 8 History The patient has stopped fitting and you have saved the day! 29:33 His eyes do not open when you shout his name. When you pinch his eyebrow he opens his eyes and moves away. His speech is confused. Observations HR 100, BP 110/45 mmHg, RR 19, SpO2 95%, Temp 38.1 23
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Management: convulsive status epilepticus in children Time Treatment >5 minutes IV lorazepam • Buccal midazolam or rectal diazepam • >15 minutes • Repeat IV lorazepam >25 minutes Phenytoin or • Phenobarbital if on regular phenytoin • >45 minutes General anaesthesia (rapid sequence induction) with one of: Thiopental • Transfer to paediatric ICU 25
Management: non-convulsive status epilepticus Treatment is not as urgent compared to convulsive status epilepticus Awareness: commence or reinstate maintenance oral anti-epileptic therapy • Lack of awareness: manage as convulsive status epilepticus • Anaesthesia rarely required • Much better outcomes compared to convulsive status epilepticus • 26
Complications System Complication Acute Hyperthermia • Pulmonary oedema • Cardiac arrhythmia • Cardiovascular collapse • Chronic Epilepsy • Neurological deficit • 27
Top-decile questions 28
Top-decile question Fechtner syndrome: a variant of Alport syndrome • Riddoch syndrome: visual impairment often caused by lesions in the occipital lobe which limit the • sufferer's ability to distinguish objects Rasmussen syndrome: a rare encephalitis affecting one hemisphere in children, resulting in • seizures. The cause is not entirely understood. Seizures gradually increase in frequency, are difficult to control and, after a period of time, the child will usually develop a weakness of the side of the body that is affected by the seizures Exploding head syndrome: a condition where the person experiences unreal noises that are loud • and of short duration when falling asleep or waking up. It has an unknown cause and is benign Alex in Wonderland syndrome: also known as Todd's syndrome. People experience distortions in • visual perception of objects, such as appearing smaller or larger. Associated with epilepsy, intoxicants, infections, fevers, and brain lesions 29
Top-decile question New-onset refractory status epilepticus (NORSE) is a rare but challenging condition, characterized by • the occurrence of a prolonged period of refractory seizures with no readily identifiable cause in otherwise healthy individuals Autoimmune encephalitis is the most common cause • EBV and leptomeningeal carcinomatosis are involved in a small number of cases • The others are irrelevant • 30
Recap Status epilepticus: seizure > 5 mins or the patient does not regain consciousness between 2 • seizures Convulsive status: most often refers to a tonic-clonic seizure and requires urgent management • ABCDE management • Anti-epileptics commenced if the seizure > 5 mins • Benzodiazepines are first-line • Associated with high mortality • 31
References 1) ICUnurses / CC BY-SA (https://creativecommons.org/licenses/by-sa/4.0) 2) ICUnurses / CC BY-SA (https://creativecommons.org/licenses/by-sa/4.0) Video 1: https://www.youtube.com/watch?v=qgo6LIosP6Y&feature=emb_title Video 2: https://www.youtube.com/watch?v=OroIkCTHSek&feature=emb_title Video 3: https://www.youtube.com/watch?time_continue=1&v=Nds2U4CzvC4&feature=emb_title All other diagrams and flowcharts were made by BiteMedicine and are not suitable for redistribution 32
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