Eclamptic Seizure

Question 1

What do you suspect has happened in this scenario ?

Answer 1

Eclamptic seizure

Question 2

What factors led you to this conclusion ?

Answer 2

Sore head and disturbed Vision
Upper abdominal pain
Shaking

Question 3

How would you manage this situation ?

Answer 3

Emergency buzzer - summon help

Request : obstetric emergency for eclamptic seizure
Emergency trolley

Emergency call - 2222
Obstetrician
Anaesthetist
Senior charge midwife
Any other available staff

Remain with woman and reassure her.

Recovery position

Question 4

SBAR

Answer 4

Situation: Louise, had/having a suspected eclamptic seizure.

Background: prim, ventouse delivery 6 hours ago.
Hypertension in antenatal period- attended daycare.

Assessment: asked to check Louise as complaining of severe headache, visual disturbances and upper abdominal pain.
Went to assist - suffering seizure on bed.

Recommendation: stabilise Louise and stop seizure.
ABCDE/ AVPU
Cannulate
Catheterise
Commence observations documenting on MEWS chart

Question 5

ABCDE

Answer 5

Safe approach to assess for any dangers to Louise, myself or others. Assess situation and provide appropriate care and treatment.

Move bed out from wall and remove headboard - allowing more access for airway to be maintained.

Question 6

Airway

Answer 6

Check for signs of obstruction. Must ensure she is maintaining own airway.

If not :
Head tilt, chin lift - prevent tongue obstructing airway
Tongue sweep - check it anything in mouth.
Guedel airway- helps maintain airway
Measure from jaw to corner of mouth, use as tongue depressed and rotate 180 degrees.

Question 7

Breathing

Answer 7

Check breathing - look, listen, feel.

Chest wall movement, rising and falling.
Any noise eg strider or wheezing may suggest obstruction.
Feeling for breathe against cheek.

Respiration rate: 12-20

Oxygen saturation: check with saturation probe >95%
Commence facial oxygen via trauma mast at 15L/min.
If not breathing - two person bag and mask.

Question 8

Circulation

Answer 8

Assess for circulation problems - checking pulse, peripheral perfusion and blood pressure.

Pulse - rate, rhythm and regularity.
Peripheral perfusion - capillary refill time less than 2 seconds.
Blood pressure - especially important due to suffering eclamptic seizure so must get blood pressure under control.

Commence MEWS chart to visualise trends , worsening or improving condition.

Question 9

Disability

Answer 9

AVPU - assess responsiveness

Alert - able to speak
Vocal stimuli - responsive to voice
Pain stimuli - responsive to pain
Unresponsive - unresponsive to all.

Question 10

Exposure

Answer 10

Thorough examination while maintaining privacy and dignity.

Check temperature - thermometer
Limb temperature - hot, cold, clammy ?
Colour - pallor, cyanosis
Oedema.

Question 11

Observations

Answer 11

5 minutely observations until condition stabilise

Documented on MEWS Chart to observe for trends.
ECG - if available, could be used to monitor heart.

Question 12

Canulation

Answer 12

Gain venous access to obtain bloods and administer fluids, drugs and replacement blood if required.

2x wide bore cannulas (14 or 16 gauge)
Aseptic non touch technique with consent
Sterile dressing applied with date
Flushed by someone IV trained

Bloods

FB
GROUP AND SAVE
LFTS
U&E’s
COAG

Question 13

Anti convulsant therapy

Answer 13

Drugs administer to prevent further seizures.

Now that I have cannulated I would administer:

Magnesium sulphate:
Loading dose - 4g IV bolus over 5-15 min
Maintenance dose - 1g/hour IV via syringe driver.

If seizure continues:
Further 2g Bolus of MgSO or
Maintenance dose increased to 1.5-2g/ hour.

Can be given for no longer than 24 hours past last seizure.

Drugs should be checked and verified by two staff members prior to administration. - check drug, dose, route and expiry date.
Should be prescribed by doctor.

Question 14

Magnesium sulphate toxicity

Answer 14

Magnesium sulphate is a very potent drug - one to one care provided must closely monitor women and be aware of signs of magnesium toxicity.

Side effects :
Feeling of impending doom
Facial flushing / heat going up arm;
Metalic taste
NASUEA or vomiting.

Signs of toxicity:
Respiratory depression less than 10pm
Oliguria - less than 20mls / hour
Loss of deep tendon reflexes - check using reflex hammer on knee joint.

If any signs MgSO stop infusing immediately and administer calcium gluconate 1G IV 3-5 mins bolus.

Question 15

Anti hypertensives

Answer 15

Anti hypertensives can be given to reduce/control blood pressure.

Labetolol :
IV Bolus - 50mg (5 mins) repeat after 5 minutes if no lowering bp.
Infusion - 50mg per hour IV infusion.

Alternatively;
Hydralazine IV bolus - 5mg slow bolus repeated after 20 minutes.
Nifedipine oral - 10mg, repeated after 30 minutes.

Have drugs checked and verified by two staff members prior to administration.
Prescribed by doctor

Question 16

Fluid restriction

Answer 16

Fluid intake should be restricted to prevent overload and pulmonary oedema
Maximum volume 1ml/kg hour up to max or 85kg.

Hartman’s solution:
Carefully administered - preferably via an infusion pump to ensure the correct volume of fluid is given.

Remember:
Check expiry date and ensure solution is not contaminated.
Document batch number and expiry date.
Run through and attached by somebody IV trained.
Should be infused as rapidly as possible - use a pressure cuff/ bag if available.

Question 17

Catheterisation

Answer 17

Want to prevent fluid overload whilst still maintaining organ perfusion
Vital to correctly manage and closely monitor fluid balance
Observe fluid output as can indicate renal function

Size 12 indwelling foleys catheter with urometer attached - aseptic non touch technique.

Monitor fluids
Strict fluid restriction
Measure fluid output can help indicate renal function

Question 18

Transfer to HDU

Answer 18

MOVE acronym

Once stable transfer to HDU for close monitoring until blood pressure under control.

Mode of transfer on bed ensure stable for transfer

Oxygen - currently being administered, if still required portable oxygen.

Venous access already gained

Expertise awaiting in HDU, to be cared for by qualified and experienced midwife and have the department informed of transfer in advance.

Question 19

Documentation

Answer 19

Accurate documentation once woman is stabilised is crucial.

Date and time of incident
Management
Time help was summoning and arrived
Key times of actions taken
Record of vital signs
Time of drugs administered- name, dose, drug, route and effect
IV administered
Fluid output recorded
Oxygen administration
Maternal outcome
Follow up and future care

Question 20

Debrief

Answer 20

Debrief woman and birthing partner.