Adult Seizures

Question 1

Status Epilepticus (SE) Definition

Answer 1

≥ 5 minutes of continuous seizure activity OR multiple seizures without full recovery of consciousness (i.e. back to baseline) between seizures.

Question 2

Generalised Convulsive Status Epilepticus (GCSE) Definition

Answer 2

Generalised tonic-clonic movements of the extremities with altered conscious state.

Question 3

Subtle SE Definition

Answer 3

May develop from prolonged or uncontrolled GCSE and is characterised by coma and ongoing electrographical seizure activity with or without subtle convulsive movements.

Subtle SE is difficult to diagnose in the pre-hospital
environment but should be considered in patients who are witnessed to have generalised tonic-clonic convulsions initially and present with ongoing coma and no improvement in conscious state

Question 4

Seizures other than GCSE

Answer 4

Midazolam may only be administered following consultation via the Clinician

Question 5

What can Midazolam effect in pt presentation

Answer 5

Midazolam can have pronounced effects on BP, conscious state, ventilations and airway tone

Question 6

Use of Midazolam during pregnancy

Answer 6

Midazolam crosses the placenta and administration in pregnant patients may cause adverse effects
to the baby. However GCSE is life-threatening to both mother and baby and Midazolam is therefore still indicated in this situation.

Question 7

Seizures Mgx SD3

Answer 7

1. R+R
2. Position - Supine/Lateral + MICA UNWELL PT
3. O2 therapy - Critical Illness - Status Epilepticus 15L NRB
4. Consider airway support if req. eg NPA if trismus
5. IM Midazolam - 5mg/1mL. 10mg/10min/10mg or frail 5mg/5min/5mg to large muscle mass
6. IV Access
7. MICA - Up/Downgrade/Cancel/Sitrep
8. Extrication - Combi Carrier to Stretcher ? Extra Crew for Extrication
9. Reassess VSS 5/60
10. Load Signal? MICA?

Question 8

Seizures Differential Diagnosis

Answer 8

Status Epilepticus - Epilepsy
Hypoglycaemia
Alcohol
Heat/Cold
Fever/Sepsis
Pregnancy/Eclampsia
Infarction
Overdose
Head Injury
Hypoxia/Drowning
Poor Med Compliance
Neurological/CVA

Question 9

Why do we use Midazolam in seizures?

Answer 9

• Seizures can cause diaphragmatic spasm which causes poor ventilation
• Midazolam controls this and allows for normal ventilation
• Midazolam can cause resp depression and loss of airway control therefore assisted ventilation may be required

Question 10

Seizures Pathophysiology

Answer 10

Trigger
↓
Abnormal neuronal depolarisation
↓
Glutamate release activates NMDA receptors (amino acid)
↓
Na+ and Ca+ influx
↓
Prolonged neuronal depolarisation
↓
GABA inhibits normal action potential regulation
↓
Imbalance between glutamate and GABA = seizure action potential
↓
Tonic phase = prolonged muscle contraction (10-30 sec), loss of postural control
↓
Action potential spreads to spinal cord
↓
Clonic phase = alternating contracting and relaxation (30-60sec, jerking)
↓
Action potential neurons become exhausted and membranes hypo polarise

Question 11

Describe the difference between generalised and partial seizures in terms of: Brain involvement, Type of seizures and the AV adult non-frail treatment?

Answer 11

Generalised Seizures
Brain Involvement Both lobes
Types of seizures Tonic-Clonic, absent

Partial Seizures
Brain Involvement Single lobe
Types of seizures Complex partial, simple partial

AV Adult non-frail treatment
- 10mg IM Midazolam repeat 10mg at 10/60 if required, consult for management if subtle status is suspected

Question 12

List two of the four specific side effects listed for Midazolam and how would you prepare to manage them?

Answer 12

1) Hypotension - IV access, consult with clinician for
possible IV fluid administration
2) Respiratory Depression - High flow O2 as per critical illness. Prepare airway equipment consider IPPV if inadequate ventilation
3) Depressed level of consciousness - Consider airway support and MICA
4) Loss of airway control - Consider airway support and MICA

Question 13

Midazolam Presentation

Answer 13

5 mg in 1 mL glass ampoule
15 mg in 3 mL glass ampoule

Question 14

Midazolam Pharmacology

Answer 14

Short acting CNS depressant
Actions:
Anxiolytic
Sedative
Anti-convulsant

Question 15

Midazolam Indications

Answer 15

1. Status epilepticus
2. Sedation to maintain intubation
3. Sedation to facilitate intubation (RSI - modified or Paediatric IFS)
4. Sedation to facilitate synchronised cardioversion
5. Sedation to facilitate transthoracic pacing
6. Sedation in the agitated patient (including patients under the Mental Health Act 2014)
7. Sedation in psychostimulant OD

Question 16

Midazolam Contraindications

Answer 16

Known hypersensitivity to benzodiazepines

Question 17

Midazolam Precautions

Answer 17

1. Reduced doses may be required for the elderly/frail, patients with chronic renal failure, CCF, or shock
2. The CNS depressant effects of benzodiazepines are enhanced in the presence of narcotics and other tranquillisers including alcohol
3. Can cause severe respiratory depression in patients with COPD
4. Patients with myasthenia gravis

Question 18

Midazolam Side Effects

Answer 18

Depressed level of consciousness
Respiratory depression
Loss of airway control
Hypotension

Question 19

Name 5 conditions that may cause a seizure

Answer 19

□ Hypoglycaemia
□ Hypoxia
□ Head Trauma
□ Stroke
□ Electrolyte disturbances
□ Meningitis
□ Encephalitis