Epilepsy Flashcards
An 18 year old girl presents to A+E with a seizure. You have been asked to see her on the take by the medical registrar. She has a known history of epilepsy and is under the neurology team at the hospital. You have been told that she was last in hospital with seizures one month ago. On your way to A+E you are bleeped to tell you that she has started having seizures again and you are asked to see her urgently.
How will you assess this patient?
ABCDE approach
Safe to approach?
A
- Open the airway by laying the pt on her side in a semiprone position
- Nasopharyngeal airway or, if possible, Guedel airway
B
- Continuous SpO2 monitoring
- High flow oxygen via NRB (hypoxaemia can be the both cause and consequence of seizures)
C
- HR, BP
- 2 x IV access (large bore)
- IV fluids
D
- Blood sugar, temperature
- Record GCS
E
- Appropriately expose and examine full body
- Any external signs of head injury?
What could be the cause for this current seizure?
The pt has a diagnosis of epilepsy
Causes of this seizure
* Her usual presentation
* Anti-epileptic non-compliance
* Withdrawal of medications
Others
- Infection: meningitis
- Neoplastic: Tumour
- Vascular: post-stroke, hypertensive encephalopathy
- Inflammatory: vasculitis
- Trauma: head injury - subdural / epidural haematoma
- Electrolyte/Endocrine: hypo and hyper G/Ca/Na/T, hypoMg,
How will you further investigate this patient?
Bedside
* Monitor SpO2, HR, BP, Temperature
* 12-lead ECG if possible
* VBG/ABG for prompt identification of electrolyte imbalances/acidosis
Bloods
* FBC, CRP, U&E, TFTs, LFTs
* If infection likely, blood cultures, urine MC&S
Imaging
* Urgent CT head if head injury suspected
* LP will be necessary to exclude CNS infection
* MRI once pt more stable (structural abnormalities)
* EEG to determine seizure type and epilepsy syndrome
How will you manage this patient?
First pritority is to stabilise the patient.
Would give supportive Rx
* High flow oxygen
* IV fluids
* If hypoG > IV glucose
Medical Rx
1st-line: Benzodiazepines
- Buccal midazolam, rectal diazepam, IV lorazepam
2nd-line: (d/w senior)
* Levetiracetam
* Phenytoin
* Sodium valproate
What do you understand by status epilepticus?
Sustained epileptic seizure lasting > 5 minutes
or
2 or more seizures within 5 min period, without the person returning to their normal in between them
Status epilepticus can be divided into both convulsive and non-convulsive
How should refractory status be managed?
If medical management does not terminate the seizure beyond 60 minutes, **general anaesthesia **will be needed
* Propofol
* Thiopental
EEG monitoring should be commenced
What complications of status epilepticus are you aware of?
Many, but key ones are:
* Hyperthermia
* Acidosis (2nd to raised lactate)
* Hypotension
* Respiratory failure
* Rhabdomyolysis
* Aspiration
What is important to tell a patient presenting with seizures for the first time?
- Warn them about non-compliance with anti-epileptic medications
- Must stop driving and inform DVLA
Private car / motorcycle drives
* Stop driving for 6 months
LGV drivers
* Cannot drive for 5 years after the date of the seizure
* To return, must undergo recent assessment by a neurologist
* Risk must be <2% per annum
Advise against swimming alone
LGV - Large Good Vehicle
Do you as the doctor need to inform the DVLA of this patient following a seizure?
No, the responsibility lies with patient
If a pt poses a risk of serious harm to the public by continuing driving and refusing to inform the DVLA, the doctor should contact the DVLA even if they do not have the pt’s consent to do so. (last resort though)
Should a pt be started on anti-epileptic drugs following a first seizure?
Rx usually not recommended until after a second epileptic seizure.
But it may be indicated after a first seizure if the individual has
* Neurological deficit
* Brain imaging shows structural abnormality
* EEG shows unequivocal epileptic activity
You now have one minute to handover the patient in this scenario to your registrar/consultant as if you were at the Acute Medical Handover.
Situation: I am handing over an 18 year old woman who has presented with seizures.
Background: She has a history of epilepsy and is known to the Neurology team here at the hospital.
Assessment: Following my initial assessment I have located a nasopharyngeal airway and started high flow oxygen. IV access has been secured. Bloods and a VBG have been sent to look for common causes of a seizure including hypoglycaemia.
Recommendations: If the seizure continues beyond five minutes I would recommend treatment with a benzodiazepine (as per trust guidelines) such as IV lorazepam. I would recommend putting out a 2222 call or Medical Emergency Team call depending on the availability in the hospital. If the seizure is ongoing I will need support in managing her airway and initiating and escalating medication doses.
