CBL_status epilepticus Flashcards
What’s the usual definition for status epilepticus?
A seizure lasting more than 30 minutes or repeated seizures between which the consciousness is not fully regained
When do we need to think about the treatment as per status epilepticus?
If a seizure lasts for more than 5 minutes -> as any seizure of that duration is unlikely to cease on its own
Initial management of status epilepticus
Status epilepticus - initial management
- ABC
- check glucose level
- give glucose and thiamine
What’s first line treatment for status epilepticus?
IV lorazepam
2nd line treatment of status epilepticus
3rd line treatment of status epilepticus
Treatment for *status epilepticus*
- 1st line: IV Lorazepam
- 2nd line: IV anti-epileptic drugs (eg, fosphenytoin, phenytoin, valproate)
- third-line: general anesthesia (ie.g. propofol, thiopental)
What is the peak age (2) for the incidence of status epilepticus?
- infants younger than 1
- persons older than 65
Causes of status epilepticus
- infections complicated by fever (children)
- infections of CNS
- stroke (both, ischaemic and hemorrhagic)
- metabolic derangements
- hypoxia
- eclampsia
- alcohol intoxication or withdrawal
- withdrawal of anti-epileptic drugs (in patients with pre-existing epilepsy)
What to treat a seizure of unknown origin with?
Seizures of unknown origin - management:
- evaluate glucose
- treat with: glucose (in case hypoglycaemia is a cause) and also thiamine (in case if Wernicke’s encephalopathy is present; also to prevent iatrogenic from glucose Rx)
Diagnosis of convulsive status epilepticus vs non-convulsive status epilepticus
- Convulsive clinical diagnosis
- Non- convulsive: depends on EEG findings and response to treatment
The difference between convulsive and non-convulsive status epilepticus
- Conclusive - diagnosed clinically, the patient has prolonged clonic seizure -> it is a medical emergency
- Non - convulsive - episode when the patient has prolonged absence and atypical absence events (may last for half an hour, hours or even days) -> it is not life-threatening or damaging to the brain but should be treated
Typical EEG pattern for non-convulsive status epilepticus
Typical EEG pattern of:
- continuous or recurrent
- generalized or focal,
- epileptiform activity,
- wide-ranging alterations in mental state
Psychogenic nonepileptic seizures (PNES) - what happens in it
Psychogenic non-epileptic seizures
What happens:
- paroxysmal events -> involuntary movements
- alterations in consciousness
- no associated EEG changes
- caused by psychological factors
Psychogenic non-epileptic seizure - causes
- high level of stress, other psychologically disturbing problems
- in a patient with difficulty of understanding, recognizing and processing their emotions
- most of them happen without the patient’s control
What’s Nonepileptic psychogenic status epilepticus (NEPS)
It is a prolonged episode of psychogenic non-epileptic seizure
- the majority consider the threshold of seizure lasting >20 min
- it may be called ‘ pseudo status epilepticus’
What characteristic of seizure would indicate its possible association with intracranial lesion?
- focal onset
- new, persisting focal deficit
*intracranial lesion: tumour, stroke, abscess, vascular malformation
What should be included in history in the initial assessment of a patient with a seizure?
Initial assessment -> to identify the cause
History taken from a caregiver, family:
- previously unrecognized seizure activity
- withdrawal of anti-epileptic drugs (or reduced dose) and if they adhere to treatment
- alcohol or drug use
- PMH
What examinations should be done in a patient presenting with seizure
- full neurological examination
- developmental assessment -> in children
Psychogenic non-convulsive seizure - typical population
female, young adults, adolescent
What may be seen during a psychogenic non-convulsive seizure?
Psychogenic non-convulsive seizure - atypical seizure characteristics:
- eyes closure
- back arching
- side-to-side head shaking (‘no-no’)
- wild, asymmetric flailing /wymachujacy/ movements of the arms and pelvis
Bloods: in seizure assessments
*Give glucose and thiamine
- FBC
- complete metabolic profile
- CRP
- coagulation studies
- magnesium, B12 and folate levels
- toxicology
- blood cultures
- ABG
Other/ bedside tests in a patient with a seizure and further investigations
Bedside:
- urinalysis
- pregnancy test -> to exclude eclampsia as a cause and to guide anti-convulsant choices
Further tests:
- neuroimaging
- LP -> especially in immuno-compromised patient
- EEG
What do elevated serum protein levels may be suggestive of?
- They may aid the diagnosis of seizures (but not fully sensitive and reliable)
- Two-folds elevated serum protein 10-20 minutes after the seizure
*it does not differentiate seizure from syncope or status epilepticus
What are the risks of status epilepticus?
- airway compromise
- injury
- neuronal damage
What’s better to use in the treatment of status epilepticus: IV lorazepam or IV diazepam?
IV Lorazepam is better
Administration of Lorazepam IV in status epilepticus
- how
- dose
IV Lorazepam
- slow bolus
- 0.1 mg/kg -> usually 4mg
IV diazepam in status epilepticus
- dose
*1st try IV lorazepam (better clinical evidence)
IV diazepam
0.15 mg / kg -> usually 10mg
When administrated rectally, which one is more effective: lorazepam or diazepam?
Limited evidence that Lorazepam is more effective
What is an alternative to rectal treatment with Lorazepam or Diazepam?
Midazolam :
- buccal
- nasal
- IM
Side effects of therapy with benzodiazepines
- hypotension
- respiratory depression
*monitor patients for those signs
What’s more effective 2nd line Rx for status epilepticus: Valproate or Phenytoin?
Valproate is more effective
What’s the aim and mode of treatment for absence and focal non-convulsive status epilepticus?
Aim: to stabilize vital signs
Treatment: Oral benzodiazepines
Do we hospitalise patient with status epilepticus
Yes, all status epilepticus patients should be hospitalized -> ideally after they are stabilized and IV benzodiazepines are given
NICE algorithm to the approach of initial management of status epilepticus
Difference between the seizure and epilepsy
- Seizure -> can be one off thing
- Epilepsy -> recurrent seizures due to chronic process
Possible triggers for seizure
- Sleep depravation
- Drugs (antibiotics, withdrawal from antibiotics, benzodiazepines)
- Alcohol withdrawal
- Fever
- Hypoglycaemia -> check glucose immediately
- Space-occupying lesion
- Trauma / head injury
- Stroke
- Infections: meningitis, encephalitis
- Neurodegenerative causes (e.g. severe dementia -> brain atrophies -> predisposition to neuronal excitability)
- Congenital/ genetic problems
Electrolyte disturbance/ metabolic (sodium, thymine levels abnormalities)
Investigations for seizures at A&E
Investigations:
- Glucose
- FBC, U+E
- Toxicology -> drugs, alcohol
- *LP -> if infection (meningitis/encephalitis) is suspected e.g. pt has high fever
- CT head
If a person is known to have epilepsy and come to A&E
- Check antiepileptic drug levels -> if they take their medication
Management of status epilepticus (stepwise)
Management:
- ABCDE
- Drug treatment: rectal diazepam OR buccal midazolam (community), 4mg Lorazepam IV (repeat twice after 5 minutes) -> then give Phenytoin / sodium valproate/Levetiracetam (Keppra) -> call ITU
*Phenobarbital -> given by ITU and propofol/midazolam infusion
What’s dissociative seizure?
Dissociative seizures -> non-epileptic -> happens due to psychological causes rather than physical
How much Lorazepam IV do we give at A&E to an adult?
(status epilepticus, febrile seizures, convulsions caused by poisons)
4 mg for 1 dose, then 4 mg after 10 minutes if required for 1 dose, to be administered into a large vein
How much Lorazepam IV do we give at A&E to a child 1 month - 11 years?
100 micrograms/kg (max. per dose 4 mg) for 1 dose, then 100 micrograms/kg after 10 minutes (max. per dose 4 mg) if required for 1 dose, to be administered into a large vein.
How much Lorazepam IV do we give to a child 12 - 17 y?
4 mg for 1 dose, then 4 mg after 10 minutes if required for 1 dose, to be administered into a large vein.
Dissociative (non-epileptic) vs Epileptic seizure
(compare/how to distinguish)
Dissociative (non-epileptic)
Epileptic
- Cardio-respiratory not usually involved
- Cardio-respiratory involved
- Non- rhythmic movements (higher amplitude)
- Rhythmic movements
- Eyes are closed
- Eyes open
- Distractible (e.g. if you talk to the patient they may respond)
- Non- distractible
- Onset is slow
- Sudden onset
- Biting inside the mouth
- Biting inside the mouth
- Posterior-lateral tongue biting not present
- Posterior – lateral tongue biting
- Incontinence may be present
- Incontinence may be present
- Pelvic trust
- No pelvic trust
Recovery time/ after seizure:
- Pt may be able to recall some events (e.g. going to CT scan); can make quick recovery; tend to cry after the seizures
Recovery time/after seizure:
- confused, do not remember seizure, tired à slower recovery; do not tend to cry after the seizures
What is postero-lateral tongue biting suggestive of?
If posterior and lateral tongue biting -> epilepsy
*lateral tongue biting is specific to generalized tonic-clonic seizures = grand mal seizures)
Differentials for seizures
Differentials for seizures
- Syncope:
- cardiac -> during exercise, chest pain, light headedness, drug on, palpitations, no aura
- vasovagal
- Sleep disorders -> narcolepsy, cataplexy
- TIA -> and any other neurological conditions may be suspective of seizures
- Children -> breath holding, night terrors
What questions to ask in a Hx of an adult with a first fit (e.g. seen in 1st fit clinic)
First clinic at fit clinic -> ask
Adult and 1st fit:
- Any previous seizures (e.g. febrile seizures as child ->increased likelihood)
- What they were doing at the time
- What they were doing
- Do they recall events during/after the seizure
- Length of time
- Incontinence/ tongue biting
- Anyone saw it happening -> collateral history (maybe they have recorded it)
- PMH
- Auras
- Trauma, head injuries (any HI can reduce seizure threshold)
- Triggers (psychological, lack of sleep, alcohol)
- Medication history
- Drug use
- What happened after -> length of recovery, confusion etc
- Injuries -> tongue biting, bruises on the limbs, burns, shoulder dislocations
In paediatrics/young adults:
- Developmental history
- Birth history
- Family history
What type of epilepsy/seizure is more common in adult and what type in children?
Classification of epilepsy
- Focal onset epilepsy ->most common in adults (brain tumour, trauma, infection)
- Generalised -> children/congenital
What in below scenario can indicate the type of seizure?
39 y old woman brought to A&E by husband. Have has seizures on and off for 30-40 mins. Large amplitude of movements in her limbs
39 y old woman brought to A&E by husband. Have has seizures on and off for 30-40 mins. Large amplitude of movements in her limbs
- Large amplitude of movements -> non- epileptic attack (dissociative seizure)
- On and off/ fluctuating nature -> dissociative seizure
What in below scenario can indicate the type of seizure?
24 y old man brought to A&E by friends. Convulsing for 20 mins. He is cyanosed with rhythmic clonic movements in all four limbs.
24 y old man brought to A&E by friends. Convulsing for 20 mins. He is cyanosed with rhythmic clonic movements in all four limbs.
Status epilepticus:
- Respiratory involvement
- Rhythmic movement
What are two the most important causes to role out first in status epilepticus?
hypoxia and hypoglycaemia
