Fitting

Question 1

Someone is coming in to hospital with prolonged fitting - how do you prepare for their arrival?

Answer 1

Ensure a resus/acute bed is available – with anaesthetic machine

Gather team - doctor to do primary survey, 2x nurses -monitoring, medication, clinical tech, student doc!

Prepare drugs for managing status

Let anaesthetics know – just in case she requires intubation etc

Question 2

What are the first things you do upon their arrival to hospital?

Answer 2

Handover from paramedics

Airway – ensure is patent, Gidel/oropharngeal/nasopharyngeal** (because clenched teeth), suction (vomit, blood, saliva); lie in recovery position

Breathing – ensure she is breathing, supply high flow oxygen

Circulation - cannulate, get bloods - glucose!!

Protect them - hold gently, bolster with pillows

Question 3

If you do not have IV access what drugs to you give?

Answer 3

Buccal midazolam (often prehospital)

Rectal diazepam - 10mg - solution or suppository

Question 4

What drug do you give if you do have IV access? What side effect are you most concerned about?

Answer 4

IV lorazepam - 1st line - 4mg in average adult but titrate 1mg at a time until seizure stops

Respiratory depression - though if airway secure and ventilator on hand are less concerned

Loraz = longer half-life but quicker or equivalent onset for same dose, also more predictable because more CNS active
Diaz = longer recovery time as more lipid soluble

Question 5

What is the second line drug if there is no success with IV lorazepam?

Answer 5

Phenytoin (IV 15-18mg/kg =c.1g for average 70kg man)

NEED TO KNOW:
ECG – cardiac conditions – 2nd degree heart block, sinus bradyc. = contraindications
What drugs already on - don’t want to give too much as may push them into toxicity and may need to know if they are under treating
Allergy?
Pregnancy? Are they eclamptic? Teratogenic

Also needs cardiac monitoring as can cause arrythmias

OR kepra/levetriacetam* (not on guidelines but becoming preferred)

Question 6

What can you give if the patient is already on phenytoin?

Answer 6

Phenobarbital

Question 7

What is the medication escalation in rough?

Answer 7

Benzo 10 mins benzo 10 mins phenytoin/kepra Thiopental

Question 8

What is the role of an anaesthetist?

Answer 8

If uncontrolled after full escalation, rapid sequence induction will be required to stop seizure:

Thiopental + suxmethonium + mechanical ventilation

Question 9

What are the possible causes of status epilepticus?

Answer 9

Generalised epilepsy undertreated/undiagnosed

SOL/mass effect – Ca (primary, secondary - Hx of malignancy needs to think about mets, they also don’t actively show up on CT - MRI), blood

Brain bleeds – SAH, SDH, EDH; CVA

Infection – meningitis, encephalitis, brain abscess; sepsis

Hypoglycaemia

Hepatic encephalopathy

Hyponatraemia, hypercalcaemia, uraemia

Alcohol/drugs in excess or withdrawal - Alcohol withdrawal

Febrile status

Non-epileptic seizures

Eclampsia - (4g MgSO4 + labetalol)

Question 10

What are the medical complications of status epilepticus?

Answer 10

Cerebral oedema
Long-term neurological deficits
Hypoxia - airway occlusion
Injury - head hit? Broken bones?
(Tachy) arrythmias
Aspiration pneumonia/chemical pneumonitis
Pulmonary oedema
Hypoglycaemia, (mixed) metabolic lactic acidosis
Muscle breakdown -CK release, deposition in proximal tubules renal failure; hyperkalaemia
Coning, death