CBD 1: Status epilepticus Flashcards
Status epilepticus.
a) Define
b) 2 types - which is more worrying?
c) Risk factors/ triggers
a) Status is…
- Seizures > 5 mins, or
- Consecutive seizures with no recovery in between
- Also treat if > 3 seizures in one hour
b) Convulsive (medical emergency) and non-convulsive
c) Predisposing factors.
- Extremes of age
- Structural brain pathology
- Intellectual disability
Triggers.
- First presentation
- Anti-epileptic drug withdrawal/ non-compliance
- Alcohol intoxication or withdrawal; drug overdose
- Intercurrent illness (eg. infection, MI)
- Metabolic disturbance (eg, hypoglycaemia, Na+, Ca2+)
- Head injury/ SOL/ stroke
Status: initial management (A - E)
- Move away from danger and ensure head is protected
- 1st line: buccal midazolam or rectal diazepam
Airway.
- Loosen any tight-fitting neckwear
- Secure airway: head tilt, chin lift; NPA, suction, etc.
(avoid OP airway/iGel as will not tolerate)
Breathing.
- high-flow oxygen
- SpO2 monitoring in hospital
- ABG (risk of hypoxia)
Circulation.
- IV access
- Take BM, take bloods
- Administer IV lorazepam and fluids as necessary
- ECG/ cardiac monitoring
Disability.
- GCS, pupils, focal neurology, glucose
- Consider CT head
Exposure.
- Temperature (?infection, hypothermia)
- Rashes, abdomen, calves, etc.
- Signs of drug/ alcohol abuse (jaundice, track marks, etc.)
Status: treatment algorithm
- 1st line
- 2nd line
- 3rd line
- Refractory
- Adjuvant treatments
1st line:
- Hospital: lorazepam (if IV access)
- Community: buccal midazolam or rectal diazepam
2nd line (after 10 mins): - 2nd dose of benzo
3rd line (after another 10 mins) - Antiepileptic drug: IV phenytoin or phenobarbital
Refractory status
- Ring anaesthetics
- RSI: sodium thiopental or propofol
Adjuvant treatments.
- Oxygen, fluids, etc.
- Glucose (if hypoglycaemic)
- Correct any other electrolyte abnormalities
- Thiamine if alcoholic (WKS)
Status: further management
Identify and treat complications.
- CXR for ?aspiration
- CT head for ?head injury
- XR shoulder for ?dislocation
Explore reasons for status
Secondary prevention.
- Action plan and patient/ carer/ family education
- Stabilise on regular AEDs
- Remove / reduce triggers
- Prescribe buccal midazolam for any future episodes
Phenytoin: cautions
- Already taking phenytoin (risk of toxicity)
- Pregnancy (teratogenic)
- LFTs
Status: differentials
- NES
- Eclampsia - treat with 4g IV MgSO4 + Labetalol
Status: complications
Traumatic.
- Posterior shoulder dislocation
- Head injury
Neurological.
- Cerebral oedema
- Encephalopathy
Metabolic.
- Lactic acidosis (due to hypoxia and anaerobic resp)
- Hyperkalaemia (due to muscle cell breakdown)
- Rhabdomyolysis - CK release, deposits in PCT and leads to AKI
Respiratory.
- Aspiration/airway obstruction
Why lorazepam preferred over diazepam?
Quicker onset, higher and more predictable efficacy, more CNS-specific
Alcohol withdrawal: presentation
a) Early
b) Later
a) Early - sweating, agitation, tremor, nausea, vomiting, insomnia, alcohol cravings, palpitations
b) Later:
- 12-24 hours: visual, auditory or tactile hallucinations (formication, Lilluputian)
- 24-72 hours: withdrawal seizures and DTs (seizures, tachycardic, hypertensive, confusion)
Note: may present in acute withdrawal or may be admitted for another reason and develop acute withdrawal symptoms
Alcohol withdrawal: management
a) Non-drug
b) Drug - main one and contraindication (alternative?)
c) When should treatment be stopped?
Adjuvant treatments
d) Screening patients: prophylactic treatment
a) - Calm and well-lit environment
- Continuity of nurses and environment
- Orientate the patient
- Treat any precipitants
b) Benzos:
- 1st line: oral chlordiazepoxide reducing regime over ~ 5 to 7 days (start at ~ 20 mg QDS on day 1, then reduce)
- Alternative: except in liver failure - give IV lorazepam/diazepam
- Monitor daily (breathalyse if necessary to confirm abstinence)
c) - Stop treatment after 5 - 7 days or when detox complete (may need longer if seizures)
- Also stop if patient relapses in this period
c) - IV thiamine (Pabrinex)
d) - Alcohol volume: > 10 - 15 units/day
- Previous withdrawal symptoms/ DTs (or need to keep drinking to prevent these)
- Previous DTs
Wernicke’s vs. Korsakoff’s
Wernicke’s.
- ACE: Ataxia, Confusion, Eye signs (CN VI palsy: ophthalmoplegia, nystagmus)
Korsakoff’s.
- irreversible
- anterograde and retrograde amnesia, confabulation
Wernicke-Korsakoff syndrome.
a) Why alcoholics become thiamine deficient
b) Management
a) - Gastritis and malabsorption
- Poor diet
- Thiamine is an enzyme in alcohol metabolism
b) - IV or IM thiamine (Pabrinex)
- Note: can be given orally, but generally not well-absorbed in heavy drinkers
Relapse prevention in alcoholics.
a) Non-drug measures
b) Drugs and their modus operandi
c) Who must be admitted for relapse prevention?
a) - Counselling, CBT, group therapy (eg. AA)
b) Drugs.
- Acamprosate - GABA and NMDA receptor antagonist; reduces cravings
- Naltrexone - competitive opioid antagonist; prevents pleasurable effect of alcohol
- Disulfiram - acetaldehyde dehydrogenase (ADH) inhibitor - causes hangover symptoms on ingestion (headache, nausea, vomiting, flushing, etc.)
c) Inpatient care is recommended for:
- Patients at risk of suicide.
- Those without social support.
- Patients who have a history of severe withdrawal reactions.
Smoking cessation drugs.
best when combined with psychological support
NRT
Varenicline - reduces cravings and pleasurable effects
Buproprion - reduces cravings
For a patient in whom a seizure needs to be excluded, and may not have been witnessed, what biochemical test may be useful?
Serum lactate
- do an ABG or VBG
- raised lactate would be consistent with generalised tonic-clonic (GTC) seizure activity
