Neurology
Question 88 of 92
A 25 year old homeless woman is brought to the Emergency Department by paramedics, she is unconscious and having a seizure. The paramedics estimate the seizure has been ongoing for 20 minutes. They have administered buccal midazolam 10 minutes ago. She smells of alcohol and the paramedics tell you she is well known to the ambulance service due to intoxication. Her airway is maintained and she is taking 16 breaths per minute. Her blood glucose is measured as 8.7 mmol/L. You have established IV access. What is the recommended management for this patient in the first instance?
Answer:
Seizures lasting longer than 5 minutes should be treated urgently with intravenous lorazepam 0.1 mg/kg (usually a 4 mg bolus, repeated once after 5-10 minutes if seizures recur or fail to respond). Intravenous Pabrinex (vitamin B complex) is being used in this case as there is a possibility of alcohol withdrawal which, in the presence of B1 deficiency (not unlikely in chronic alcoholism) can potentially cause Wernicke encephalopathy and then the irreversible Korsakoff syndrome.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).
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- 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 |
