11.2 Status Epilepticus

Question 1

Compare Status Epilepticus to normal epilepsy

Answer 1

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

Question 2

Describe Status Epilepticus

Answer 2

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

Question 3

Define Epilepsy and the 2 main types of seizures

Answer 3

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.

Question 4

What are the 2 ways seizures present?

Answer 4

a) a convulsion with abnormal movements (convulsive)

OR

b) a change in awareness / behaviour (non-convulsive).

Question 5

What is a convulsion and what are the 2 terms used to describe these movements

Answer 5

Convulsion - uncontrolled body movements, muscles contract then relax repeatedly

Muscles stiffen (tonic phase) then jerk (clonic phase).

Question 6

What causes convulsions?

Answer 6

Caused by a seizure affecting the motor cortex area (If it doesnt affect motor cortex, we don’t get convulsions)

Question 7

What are the 2 simple classifications of seizures?

Answer 7

1) Generalised seizures - affect both hemispheres (bilateral)
2) Focal seizures – affect one hemisphere (unilateral)

Question 8

What 2 things may cause and explain what exactly these things lead too

Answer 8

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.

Question 9

Give the clinical presentation of a Tonic-clonic (‘grand mal’) seizure

Answer 9

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

Question 10

What warning sign may be present prior to a tonic-clonic seizure?

Answer 10

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

Question 11

Describe the tonic phase

Answer 11

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

Question 12

Describe the Clonic Phase

Answer 12

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.

Question 13

How long is the Flaccid (post-ictal) phase and describe this

Answer 13

(minutes/hours) ➞ muscles relax

This is a coma followed by gradual arousal, headache, drowsiness, confusion, memory loss and antisocial behaviour.

Question 14

Give some systemic clinical signs of a Tonic-clonic seizure

Answer 14

Question 15

What are the 2 causes of seizures?

Answer 15

1) Idiopathic: repeated episodes in a known epileptic
2) symptomatic: due to a new secondary cause

Question 16

Give 4 causes of a symptomatic aetiology

Answer 16

Question 17

What is the highest cause of Status Epilepticus?

Answer 17

Pre-existing epilepsy!! Often associated with a change or omission of medication resulting in a low blood level of anticonvulsant

Question 18

Aside from epilepsy give 2 common triggers for seizures in children and adults

Answer 18

Children ➞ Infection and fever

Adults ➞

• a new secondary cause is likely…. such as a cerebral event (stroke, tumour, 2^o metastases) esp is > 60
• could also be caused by alcohol excess or withdrawal

Question 19

Give 4 important dangers of Severe Epilepsy

Answer 19

Question 20

How would you manage an epilepsy OUTSIDE hospital?

Answer 20

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

Question 21

Give 4 1st line anti-epileptic drugs

Answer 21

Benzodiazepine (1st line)

Midazolam 10mg by buccal syringe (Epistatus / Buccolam)

Diazepam 10-20mg by rectal tube

Lorazepam 4mg IV if IV route available

Question 22

How would you manage an epilepsy IN hospital?

Answer 22

1) Secure airway, especially if cyanosed (ie. oral airway/early tracheal intubation and ventilation)
2) Terminate the seizure with medication

Question 23

Give a second and third line anti-epileptic drugs (if 1st line fails)

Answer 23

Question 24

What Investigations would we do

Answer 24

Blood Glucose, FBC, U&E, ABG, AED levels

Question 25

What does ABC then DEFG mean?

Answer 25

Airways, breathing, circulation ➞ “Don’t Ever Forget Glucose”

Question 26

Describe the Recovery position

Answer 26

RELISTEN

Question 27

Give 3 OTHER types of convulsions

Answer 27

1) Febrile convulsions – common in children
2) Eclampsia – in later pregnancy
3) Local anaesthetics (Lidocaine) or street drugs

Question 28

Who is commonly affected by febrile convulsions and give 4 things it may be a/w

Answer 28

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

Question 29

Describe a Febrile convulsion

Answer 29

Fever raises cerebral neurone excitability and lowers threshold for seizure. In child, seizure usually one-off, self-limiting, and with early recovery

Question 30

Pre-eclampsia is associated with what type of convulsion and how would we treat?

Answer 30

Tonic ~Clonic (grand mal) convulsions

Treat by anticonvulsant magnesium sulphate and antihypertensive medications.

Question 31

Give the triad seen in pre-eclampsia

Answer 31

hypertension, proteinuria, +/- oedema

Question 32

Give 4 examples of how convulsions may occur due to
‘Local Anaesthetics’

Answer 32

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

Question 33

What MUST we consider when giving an anti-epileptic drug?

Answer 33

All anti-epileptic drugs have teratogenic potential

Question 34

What is Foetal Valproate Syndrome?

Answer 34

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)

Question 35

During pregnancy how do we manage giving anti-epileptic drugs and risk drug teratogenicity and foetal malformations

Answer 35

1) mild disease – consider stopping medication
2) status epilepticus or severe disease – in most cases preferable to continue treatment using the least toxic medication

Question 36

What is the preffered anti-epileptic drug given during pregnancy in the NHS

Answer 36

Lamotrigine