Seizure Flashcards
You are the IMT 1 on the ward. The nurses call you to go and see a 45 year old man who has been having a seizure for 2 minutes. They have been admitted under the Stroke team after presenting with a sub arachnoid haemorrhage due to a ruptured ACOM aneurysm which has been coiled. Their admission has been complicated by recurrent chest infections.
How would you assess this patient?
The interviewers will want you to take them through a structured approach to your assessment. Think about your ABCDE approach, but also what key things they will want you to be aware of for someone having a seizure. For example, oxygen, IV access, checking BMs any history of seizures etc.
Approach
* Once called, assess straight away
* Assess if any danger to yourself and the patient
* Assess the type of seizure (generalised vs focal)
A
- Difficult in seizing pt (esp if pt biting down)
- Try and maintain an open airway through positioning manoeuvres
- Nasopharyngeal airway would be a reasonable option if concerns about breathing
B
- Administer 100% oxygen via a non-rebreathe mask
- Continuous saturation monitoring
- If SpO2 dropping or signs of cyanosis, immediate resuscitation call
C
- Establish 2x large bore IV access (esp for haemodynamic support or to give meds)
- Monitor HR and BP
- Take routine bloods including electrolytes and a lactate
D
- BM, temperature
- Assess pupils, GCS
- Adequately expose and assess
- Review notes and medication chart (on any antiepileptic medication?)
- You want to know how the pt has been over the last 24 hours - if any precipitating factors - might need collateral Hx
E
- Expose for any obvious signs of injury, infection
2 x large bore IV access useful as lines easily disturbed in fitting pt
The patient continues having generalised tonic clonic seizures approaching five minutes. What would be your initial management of this patient?
if GTCS > 5 min = status epilepticus > medical emergency
Remember in this instance not to overreach yourself. Do simple things first, oxygen initiation correction of obvious precipitants (eg glucose). Understanding about medications used in the treatment of seizures in hospital will be important and you should have some idea based on your experience, but you will not have to give specifics. Talking about benzodiazepines as first line is enough in this instance. The last point of the answer below is also important to emphasise to your interviewers. Make sure you show them that you are thinking about patient safety.
**Initial Management of Generalised Tonic-Clonic Seizures
Immediate Safety and Monitoring:
* Maintain patent airways > nasopharyngeal airway
* Start high-flow oxygen and continuous SpO2
* Obtain IV access and monitor for hypotension, which may require IV fluid boluses.
Identify and Correct Reversible Causes:
* Check for hypoglycaemia and correct with IM glucagon or IV glucose (10% or 20%).
* Assess for other metabolic disturbances and correct as needed.
First-Line Medical Therapy:
If the seizure continues beyond 5 minutes, administer benzodiazepines (one of).
* IV lorazepam 4mg, rpt 5-10min
* Buccal midazolam 10 mg, rpt 5-10 min
* Rectal diazepam 10-20mg, rpt 5-10 min
Escalation and Airway Support:
* Due to the risk of sedation from the medications, I’d make sure that the car
Prepare for airway support and seek senior assistance promptly.
- Avoid glucose 50% due to risk of extravasation injury and difficulty in administration.
What investigations would you order for this patient?
Remember as before, start simple and build up
Bedside
* Monitor HR, BP, SpO2, T - real time feedback on interventions
* ABG (metabolic disturbances, lactate, PaO2 etc)
* Bloods: FBC, U&E, LFTs, Phosph, Mg, Calcium
* Blood cultures, urine MC&S, CXR (if signs of sepsis)
Further investigations:
* CT head/MRI, EEG may be useful but not acutely
LFTs - hepatic encephalopathy could precipitate
What could be the cause of the seizure in this scenario?
The pt admitted with brain injury (SAH due to ruptured ACOM aneurysm)
* The risk for seizures already increased c.f. other patients
* Amount of SAH bleeding is a big RF for seizure development, as threshold for seizure lower
Most common causes
* Infection - chest in this case
* Electrolyte disturbances - common in hospital pts - pt had a stroke, could have issues with feeding
* **New medicatons **(some meds lower seizure threshold)
* Acute intracranial pathology - further bleed or ischaemic insult (vasospasm)
You give 10mg of buccal midazolam and then a further 10mg as per your hospital policy but the patient continues to have seizures which have continued for 10 minutes. Sats are at 94% on 15L, heart rate is 130 bpm with a blood pressure of 164/97.
How would you further manage this patient?
- Put a resuscitation call / MET call if senior help has not yet arrived
- The drop in SpO2 on 100% NRB > pt is tiring
They may require 2nd-line anticonvulsants
* Levetiracetam, phenotyoin, soidum valproate
Pt will require airway support - ITU SpR
Once seizure stopped:
* Transfer to ITU - high risk of further seizures
* Repeat neuro exam
* CT head / MRI / EEG (as discussed)
The Resuscitation Team arrive to assist you in managing this patient. Please take one minute to hand over this patient to the Acute Medical Registrar.
Situation: This is a 45 year old gentleman in persistent convulsive status despite two treatments with buccal midazolam of 10mg each.
Background: He has been admitted following a sub arachnoid haemorrage due to a rupture of an ACOM aneurysm which has been coiled. He is not known to have had seizures previously but has had several chest infections.
Assessment: Seizures have continued for 10 minutes despite two doses of 10mg buccal midazolam. The patient is tachycardic, hypertensive and saturating at 94% on 15L of oxygen. I have requested blood tests including a VBG to assess for any electrolyte disturbance of evidence of hypoglycaemia.
Recommendations: Now that the medical team have arrived to support you can consider escalation of treatment, airway management, and prioritisation of further tests to identify the cause of the seizure.
