Neurology
Question 49 of 180
A 45 year old man is witnessed to have a tonic-clonic seizure lasting more than 5 minutes in the Emergency Department. He is known to have epilepsy. Which of the following is the optimal first line treatment?
Answer:
- If the person with convulsive status epilepticus does not have an individualised emergency management plan immediately available:
- give a benzodiazepine (buccal midazolam or rectal diazepam) immediately as first-line treatment in the community or
- use intravenous lorazepam if intravenous access and resuscitation facilities are immediately available.
Status Epilepticus
Neurology
Last Updated: 21st March 2023
Provide resuscitation and immediate emergency treatment for children, young people and adults who have convulsive status epilepticus (seizures lasting 5 minutes or more).
Resuscitation
General measures to manage status epilepticus include:
- Positioning the patient to avoid injury
- Securing the airway
- Supporting respiration including the provision of oxygen
- Assessing cardiorespiratory function
- Establishing intravenous access
- Obtaining BM and correcting any hypoglycaemia
- Instituting regular monitoring
- Emergency antiepileptic drug therapy
- Emergency investigations
- Administering glucose and/or intravenous thiamine as high potency intravenous Pabrinex if any suggestion of alcohol abuse or impaired nutrition
- Treating acidosis if severe (discuss with critical care)
- Maintaining blood pressure (with pressor therapy where appropriate)
- Considering and treating underlying cause e.g.
- Medication related (poor compliance, poor absorption, recent antiepileptic drug changes, medication interactions or subtherapeutic levels)
- Infection
- Electrolyte disturbance
- Toxicity or drug withdrawal (including alcohol withdrawal)
- CNS pathology (tumour, stroke, encephalitis, PRES, neurodegenerative diseases etc.)
Emergency antiepileptic drug therapy
- Initial management:
- If the person with convulsive status epilepticus has an individualised emergency management plan that is immediately available, administer medication as detailed in the plan.
- If the person with convulsive status epilepticus does not have an individualised emergency management plan immediately available:
- give a benzodiazepine (buccal midazolam or rectal diazepam) immediately as first-line treatment in the community or
- use intravenous lorazepam if intravenous access and resuscitation facilities are immediately available.
- If convulsive status epilepticus does not respond to the first dose of benzodiazepine:
- Continue to follow the person's individualised emergency management plan, if this is immediately available, or give a second dose of benzodiazepine if the seizure does not stop within 5 to 10 minutes of the first dose.
- If convulsive status epilepticus does not respond to 2 doses of a benzodiazepine, give any of the following medicines intravenously as a second-line treatment:
- levetiracetam (take into account that levetiracetam may be quicker to administer and have fewer adverse effects than the alternative options, although this is an off licence use)
- phenytoin
- sodium valproate
- If convulsive status epilepticus does not respond to a second-line treatment, consider trying an alternative second-line treatment option under expert guidance.
- If convulsive status epilepticus does not respond to the second-line treatment options tried, consider the following third-line options under expert guidance:
- phenobarbital or
- general anaesthesia.
Emergency investigations
- Blood should be taken for blood gases, glucose, renal and liver function, calcium and magnesium, full blood count (including platelets), blood clotting, AED drug levels; 5 ml of serum and 50 ml of urine samples should be saved for future analysis, including toxicology, especially if the cause of the convulsive status epilepticus is uncertain.
- 12 lead ECG.
- Chest radiograph to evaluate possibility of aspiration.
- Other investigations depend on the clinical circumstances and may include brain imaging, lumbar puncture, and EEG.
Monitoring
- Regular neurological observations and measurements of pulse, blood pressure, temperature.
- ECG, biochemistry, blood gases, clotting, blood count, drug levels.
- Patients require the full range of ITU facilities and care should be shared between anaesthetist and neurologist.
- EEG monitoring is necessary for refractory status. Consider the possibility of non-epileptic status. In refractory convulsive status epilepticus, the primary end-point is suppression of epileptic activity on the EEG, with a secondary end-point of burst-suppression pattern (that is, short intervals of up to 1 second between bursts of background rhythm).
Report A Problem
Is there something wrong with this question? Let us know and we’ll fix it as soon as possible.
Loading Form...
- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
