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CBL_status epilepticus Flashcards

1
Q

What’s the usual definition for status epilepticus?

A

A seizure lasting more than 30 minutes or repeated seizures between which the consciousness is not fully regained

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2
Q

When do we need to think about the treatment as per status epilepticus?

A

If a seizure lasts for more than 5 minutes -> as any seizure of that duration is unlikely to cease on its own

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3
Q

Initial management of status epilepticus

A

Status epilepticus - initial management

  • ABC
  • check glucose level
  • give glucose and thiamine
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4
Q

What’s first line treatment for status epilepticus?

A

IV lorazepam

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5
Q

2nd line treatment of status epilepticus

3rd line treatment of status epilepticus

A

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)
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6
Q

What is the peak age (2) for the incidence of status epilepticus?

A
  • infants younger than 1
  • persons older than 65
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7
Q

Causes of status epilepticus

A
  • 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)
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8
Q

What to treat a seizure of unknown origin with?

A

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)
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9
Q

Diagnosis of convulsive status epilepticus vs non-convulsive status epilepticus

A
  • Convulsive clinical diagnosis
  • Non- convulsive: depends on EEG findings and response to treatment
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10
Q

The difference between convulsive and non-convulsive status epilepticus

A
  • 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
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11
Q

Typical EEG pattern for non-convulsive status epilepticus

A

Typical EEG pattern of:

  • continuous or recurrent
  • generalized or focal,
  • epileptiform activity,
  • wide-ranging alterations in mental state
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12
Q

Psychogenic nonepileptic seizures (PNES) - what happens in it

A

Psychogenic non-epileptic seizures

What happens:

  • paroxysmal events -> involuntary movements
  • alterations in consciousness
  • no associated EEG changes
  • caused by psychological factors
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13
Q

Psychogenic non-epileptic seizure - causes

A
  • 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
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14
Q

What’s Nonepileptic psychogenic status epilepticus (NEPS)

A

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’
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15
Q

What characteristic of seizure would indicate its possible association with intracranial lesion?

A
  • focal onset
  • new, persisting focal deficit

*intracranial lesion: tumour, stroke, abscess, vascular malformation

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16
Q

What should be included in history in the initial assessment of a patient with a seizure?

A

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
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17
Q

What examinations should be done in a patient presenting with seizure

A
  • full neurological examination
  • developmental assessment -> in children
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18
Q

Psychogenic non-convulsive seizure - typical population

A

female, young adults, adolescent

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19
Q

What may be seen during a psychogenic non-convulsive seizure?

A

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
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20
Q

Bloods: in seizure assessments

A

*Give glucose and thiamine

  • FBC
  • complete metabolic profile
  • CRP
  • coagulation studies
  • magnesium, B12 and folate levels
  • toxicology
  • blood cultures
  • ABG
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21
Q

Other/ bedside tests in a patient with a seizure and further investigations

A

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
22
Q

What do elevated serum protein levels may be suggestive of?

A
  • 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

23
Q

What are the risks of status epilepticus?

A
  • airway compromise
  • injury
  • neuronal damage
24
Q

What’s better to use in the treatment of status epilepticus: IV lorazepam or IV diazepam?

A

IV Lorazepam is better

25
Q

Administration of Lorazepam IV in status epilepticus

  • how
  • dose
A

IV Lorazepam

  • slow bolus
  • 0.1 mg/kg -> usually 4mg
26
Q

IV diazepam in status epilepticus

  • dose
A

*1st try IV lorazepam (better clinical evidence)

IV diazepam

0.15 mg / kg -> usually 10mg

27
Q

When administrated rectally, which one is more effective: lorazepam or diazepam?

A

Limited evidence that Lorazepam is more effective

28
Q

What is an alternative to rectal treatment with Lorazepam or Diazepam?

A

Midazolam :

- buccal

  • nasal
  • IM
29
Q

Side effects of therapy with benzodiazepines

A
  • hypotension
  • respiratory depression

*monitor patients for those signs

30
Q

What’s more effective 2nd line Rx for status epilepticus: Valproate or Phenytoin?

A

Valproate is more effective

31
Q

What’s the aim and mode of treatment for absence and focal non-convulsive status epilepticus?

A

Aim: to stabilize vital signs

Treatment: Oral benzodiazepines

32
Q

Do we hospitalise patient with status epilepticus

A

Yes, all status epilepticus patients should be hospitalized -> ideally after they are stabilized and IV benzodiazepines are given

33
Q

NICE algorithm to the approach of initial management of status epilepticus

A
34
Q
A
35
Q

Difference between the seizure and epilepsy

A
  • Seizure -> can be one off thing
  • Epilepsy -> recurrent seizures due to chronic process
36
Q

Possible triggers for seizure

A
  • 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)

37
Q

Investigations for seizures at A&E

A

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
38
Q

Management of status epilepticus (stepwise)

A

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

39
Q

What’s dissociative seizure?

A

Dissociative seizures -> non-epileptic -> happens due to psychological causes rather than physical

40
Q

How much Lorazepam IV do we give at A&E to an adult?

(status epilepticus, febrile seizures, convulsions caused by poisons)

A

4 mg for 1 dose, then 4 mg after 10 minutes if required for 1 dose, to be administered into a large vein

41
Q

How much Lorazepam IV do we give at A&E to a child 1 month - 11 years?

A

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.

42
Q

How much Lorazepam IV do we give to a child 12 - 17 y?

A

4 mg for 1 dose, then 4 mg after 10 minutes if required for 1 dose, to be administered into a large vein.

43
Q

Dissociative (non-epileptic) vs Epileptic seizure

(compare/how to distinguish)

A

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
44
Q

What is postero-lateral tongue biting suggestive of?

A

If posterior and lateral tongue biting -> epilepsy

*lateral tongue biting is specific to generalized tonic-clonic seizures = grand mal seizures)

45
Q

Differentials for seizures

A

Differentials for seizures

  1. Syncope:
  • cardiac -> during exercise, chest pain, light headedness, drug on, palpitations, no aura
  • vasovagal
  1. Sleep disorders -> narcolepsy, cataplexy
  2. TIA -> and any other neurological conditions may be suspective of seizures
  3. Children -> breath holding, night terrors
46
Q

What questions to ask in a Hx of an adult with a first fit (e.g. seen in 1st fit clinic)

A

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
47
Q

What type of epilepsy/seizure is more common in adult and what type in children?

A

Classification of epilepsy

  • Focal onset epilepsy ->most common in adults (brain tumour, trauma, infection)
  • Generalised -> children/congenital
48
Q

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

A

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

  1. Large amplitude of movements -> non- epileptic attack (dissociative seizure)
  2. On and off/ fluctuating nature -> dissociative seizure
49
Q

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.

A

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
50
Q

What are two the most important causes to role out first in status epilepticus?

A

hypoxia and hypoglycaemia

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