11.2 Status Epilepticus Flashcards
Compare Status Epilepticus to normal epilepsy
Most seizures are short-lived (1-3 minutes) but convulsive status epilepticus is different. It presents as a prolonged epileptic convulsion ( > 5’ ) or repeated convulsions and no return to consciousness
Describe Status Epilepticus
A life threatening neurological disorder ➞ medical emergency
Involves a convulsive seizures which lasts “too long”,
OR repeated seizures without return to consciousness.
Untreated it can cause permanent brain damage (hypoxic encephalopathy)
Presents as a prolonged epileptic convulsion ( > 5’ ) or repeated convulsions and no return to consciousness
Define Epilepsy and the 2 main types of seizures
A disorder with recurrent abnormal spontaneous intermittent electrical activity in the brain leading to a seizure
Types of seizure:
- with or without convulsions
- with or without loss of consciousness.
What are the 2 ways seizures present?
a) a convulsion with abnormal movements (convulsive)
OR
b) a change in awareness / behaviour (non-convulsive).
What is a convulsion and what are the 2 terms used to describe these movements
Convulsion - uncontrolled body movements, muscles contract then relax repeatedly
Muscles stiffen (tonic phase) then jerk (clonic phase).
What causes convulsions?
Caused by a seizure affecting the motor cortex area (If it doesnt affect motor cortex, we don’t get convulsions)
What are the 2 simple classifications of seizures?
1) Generalised seizures - affect both hemispheres (bilateral)
2) Focal seizures – affect one hemisphere (unilateral)
What 2 things may cause and explain what exactly these things lead too
1) Increased excitation ↑ (via GLUTAMATE) OR
2) Decreased inhibition ↓ (via GABA)
Results in abnormal neuronal imbalance which causes
- cell membrane unstable → rapid firing of action potentials
- neurones become hyperexcitable and discharge synchronously → seizure.
Give the clinical presentation of a Tonic-clonic (‘grand mal’) seizure
Loss of consciousness + violent muscle contractions
Presents in 2 main phases, (+ pre- and post- phases)
1) Tonic phase: (10 -30 secs) - muscles contract
2) Clonic phase: (1 to 3 minutes) repeated violent muscle jerks affecting face, jaw, trunk, limbs
What warning sign may be present prior to a tonic-clonic seizure?
Aura phase: a warning sign, hours before hand.
Patient may have a strange feeling or sensation such as odd smell/taste, mood upset, visual change, confusion, tremor, tingling, headache
Describe the tonic phase
Sudden Loss of consciousness and falling down, arched back
Arms flex, legs extend, as muscles stiffen and become rigid
Involuntary cry - spasm of respiratory and larynx muscles
Temporary respiratory arrest may cause cyanosis (lips, nails)
Bleeding in mouth from biting tongue or cheek
Potential for head / limb injury during fall
Describe the Clonic Phase
Repeated violent muscle jerks or twitches affecting face, jaw, trunk, limbs
Muscle jerks due to alternating contraction and relaxation
Foaming at mouth due to saliva being lathered into a foam
Involuntary loss of control of bladder/bowel → micturition.
How long is the Flaccid (post-ictal) phase and describe this
(minutes/hours) ➞ muscles relax
This is a coma followed by gradual arousal, headache, drowsiness, confusion, memory loss and antisocial behaviour.
Give some systemic clinical signs of a Tonic-clonic seizure
What are the 2 causes of seizures?
1) Idiopathic: repeated episodes in a known epileptic
2) symptomatic: due to a new secondary cause
Give 4 causes of a symptomatic aetiology
What is the highest cause of Status Epilepticus?
Pre-existing epilepsy!! Often associated with a change or omission of medication resulting in a low blood level of anticonvulsant
Aside from epilepsy give 2 common triggers for seizures in children and adults
Children ➞ Infection and fever
Adults ➞
- a new secondary cause is likely…. such as a cerebral event (stroke, tumour, 2o metastases) esp is > 60
- could also be caused by alcohol excess or withdrawal
Give 4 important dangers of Severe Epilepsy
How would you manage an epilepsy OUTSIDE hospital?
1) Immediate first aid!! Concentrate on ABC
2) Reposition away from danger, protect from head injury, and loosen constrictive neck clothing
3) Turn to lateral RECOVERY position ➞ call ambulance
4) Give anticonvulsant drug if available to stop fit
Give 4 1st line anti-epileptic drugs
Benzodiazepine (1st line)
Midazolam 10mg by buccal syringe (Epistatus / Buccolam)
Diazepam 10-20mg by rectal tube
Lorazepam 4mg IV if IV route available
How would you manage an epilepsy IN hospital?
1) Secure airway, especially if cyanosed (ie. oral airway/early tracheal intubation and ventilation)
2) Terminate the seizure with medication
Give a second and third line anti-epileptic drugs (if 1st line fails)
What Investigations would we do
Blood Glucose, FBC, U&E, ABG, AED levels
What does ABC then DEFG mean?
Airways, breathing, circulation ➞ “Don’t Ever Forget Glucose”
Describe the Recovery position
RELISTEN
Give 3 OTHER types of convulsions
1) Febrile convulsions – common in children
2) Eclampsia – in later pregnancy
3) Local anaesthetics (Lidocaine) or street drugs
Who is commonly affected by febrile convulsions and give 4 things it may be a/w
Common in children age 6 months to 6 years who usually a fever and history of infection
Associated with common infections eg. tonsillitis, URTI, otitis media. Rarer causes incl meningitis, so must excl this first.
If it occurs multiple time there is a concern of possible underlying epilepsy
Describe a Febrile convulsion
Fever raises cerebral neurone excitability and lowers threshold for seizure. In child, seizure usually one-off, self-limiting, and with early recovery
Pre-eclampsia is associated with what type of convulsion and how would we treat?
Tonic ~Clonic (grand mal) convulsions
Treat by anticonvulsant magnesium sulphate and antihypertensive medications.
Give the triad seen in pre-eclampsia
hypertension, proteinuria, +/- oedema
Give 4 examples of how convulsions may occur due to
‘Local Anaesthetics’
1) Accidental IV overdose by drug error
2) Accidental IV dose with epidural
3) Accidental IV dose after dental injection
4) Cocaine paste en route to theatre
What MUST we consider when giving an anti-epileptic drug?
All anti-epileptic drugs have teratogenic potential
What is Foetal Valproate Syndrome?
Caused by anti-epileptic drugs during pregnancy
Can cause:
- neural tube defects e g spina bifida
- cleft palate, facial & limb deformities
- congenital heart defects
- brain damage (cognition, autism, low IQ)
During pregnancy how do we manage giving anti-epileptic drugs and risk drug teratogenicity and foetal malformations
1) mild disease – consider stopping medication
2) status epilepticus or severe disease – in most cases preferable to continue treatment using the least toxic medication
What is the preffered anti-epileptic drug given during pregnancy in the NHS
Lamotrigine
