Neurology - Epileptic emergencies

Question 1

Definition of status epilepticus

Answer 1

Seizure lasting >30min or

Repeated seizures without intervening consciousness

Question 2

Key investigations for status

Answer 2

BM
Bloods - glucose, ABG, U&Es, FBC, Ca++
ECG
Consider: Alcohol levels, tox screen, LP, beta hCG, CT

Question 3

What is the acute management of status?

Answer 3

1) ABC - airway (adjuncts), suction, 100% oxygen, cap glucose
2) IV Access + Bloods

3) Reverse potential causes
- Thiamine 250mg IV if EtOH
- 100ml 20% glucose unless glucose is normal

4) Slow IV bolus phase
- Lorazepam 2-4mg IV
- 2nd dose if no response within 2 minutes

5) IV infusion phase
- Phenytoin 15mg/kg
- Diazepam

6) ITU

Question 4

How long should seizure activity be treated during status before calling an anaesthetist?

Answer 4

Never spend longer than 20 minutes with someone in status without calling an anaesthetist

Question 5

Why is lorazepam a first line BDZ in status over diazepam?

Answer 5

Both are equally effective in stopping seizures

But lorazepam has a much longer duration of anti-seizure effect than diazepam

Question 6

How should a phenytoin loading dose be prepared before starting an infusion?

Answer 6

Phenytoin should be reconstituted with 0.9% saline (it should not be stored in this form though)
Should be infused at a rate no greater than 50mg/min

Question 7

Drugs used if patient still seizing following phenytoin infusion

Answer 7

Phenobarbital - causes respiratory depression, reduced GCS and hypotension

Refractory status - infusion of anaesthetic doses of midazolam + ventilatory support

Question 8

Should long term maintenance anticonvulsants still be administered in status?

Answer 8

Yes
Should be administered along with any treatment for status - includes anticonvulsant medication prescribed before admission

Phenytoin should be administered as a maintenance dose following any IV loading dose

Anticonvulsants can be administered via nasogastric tube