seizures Flashcards
A-E for seizures?
I WOULD FIRST SEE ITS SAFE TO APPROACH WHILST APPROACHING - LOOKING AT THE TYPE OF SEIZURE
make sure there is a person timing the seizure whilst startin with my A-E
put the patinet on recovery position
and see if the airway is patent , check for any signs of obstruction
we can help the airways by doing a simple chin lift head tilt
if at any poitn i do feel the airways are compromised then i would put out an arrest call
A NASOPHARYNGEAL AIRWAY WOULD BE A REASONABLE OPTION IF THERE WERE CONCERNS ABOUT BREATHING.
ADMINISTER 100% OXYGEN VIA A NON-REBREATHER MASK AND START CONTINUOUS SATURATION MONITORING (what causes morbidity in seizures is hypoxia and hypoglycaemia)
auscultate the chest
and have percussion
if i have help take an ABG and for somone go order a CXR as i continue with my AE
check the capillary refill time
check the pulse - is it regular or fast with good volume , if the pulse is fast or slow or if i cannot feel it i would ask for an ECG
place 2 large bore IV cannula - and at this time also take some routine bloods and VBG if an ABG is not already taken
in the bloods i would ask for FBC , coag , LFT , UE , CRP , LACTATE,MAGNESIUM , TSH , GROUP AND SAVE , check glucose , bone profile
BLOOD CULTURES
CHECK BP
at this point i would also ask the nurse to prepare lorazepam
after that i would ascultate the heart , check for jvp , get an ecg if we can after sezing
i would go to e
check AVPU
check for any lump , bumps , palpate the abdomen
chck for any signs of dvt or infe ction sites
ASK TO REVIEW THE NOTES AND MEDICATION CHART TO SEE IF THERE IS ANY HISTORY OF SEIZURE OR IF THE PATIENT IS ON ANY ANTI-EPILEPTIC MEDICATION
The patient continues having generalised tonic clonic seizures approaching five minutes. What would be your initial management of this patient?
Check for obvious reversible causes and correct hypoglycaemia or metabolic derangements. For example, if hypoglycaemia were the cause of the seizure, IM glucagon can be given. If this is not suitable or not effective, glucose 10% intravenous infusion, or alternatively glucose 20% intravenous infusion should be given.
If the seizure continues beyond 5 minutes, consider first line medical therapy with benzodiazepines.
in the first instance, treatment with buccal midazolam or rectal diazepam may be more straight forward if IV access is proving difficult.
Lorazepam would be the medication of choice if IV access had been obtained - usually 4mg as a slow bolus into a large vein.
If no response within 10min give a second dose. Beware respiratory arrest during the last
part of the injection. HAVE FULL RESUSCITATION FACILITIES TO HAND FOR ALL IV BENZODIAZEPINES
AS YOU ARE CONSIDERING GIVING MEDICATIONS WHICH COULD SEDATE THE PATIENT AND POTENTIALLY CAUSE PROBLEMS OF THEIR OWN, MAKE SURE THAT A CARDIAC ARREST OR MET CALL IS PUT OUT SO THAT YOU CAN GET FURTHER ASSISTANCE WITH THIS PATIENT
Thiamine 250mg IV over 30min if alcoholism or malnourishment suspected
What investigations would you order for this patient?
bedside investigation
bloods - fbc , ue , lft , coag , group and save , crp , electrolytes - magnesium , calcium , thyroid function , bone profile
glucose
ecg
Urine dipstick’s - MSU if we can get some
CXR !!!!
BLOOD CULTURES
VBG
once the patient is more stable we can order an EEG
and CT head or an MRI head
What could be the cause of the seizure in this scenario?
DEVELOPMENT OF SEIZURES POST INSULT. THE SEIZURE THRESHOLD IS LIKELY TO BE LOWER AND THEREFORE COMMON STRESSORS OCCURRING IN HOSPITAL PATIENTS MAY EASILY TIP THIS PATIENT INTO SEIZURE.
PATIENT HAS HAD MULTIPLE CHEST INFECTIONS AND NOT HAD ISSUES WITH SEIZURES IN THE PAST, THAT WE ARE AWARE OF. IT WOULD BE IMPORTANT TO RULE OUT INFECTION AS A CAUSE
Hypoglycaemia is another common cause of seizure
Electrolyte disturbances are also common in hospital patients.
could be the initiation of new medications
TCA , SSRI , HALOPERIDOL , TRAMADOL , LITHIUM , fluroquinilones
important to consider further acute intracranial pathology including the possibility of a further bleed or ischaemic insult (for example due to vasospasm) in this patient group.
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
put out a resuscitation call or MET call
drop in saturations on 100% oxygen would suggest that the patient may be tiring, and they have not responded to medication thus far.
They may require IV medication and second line therapies may be required including loading of levetiracetam and phenytoin.
Beware BP lower and do not use if bradycardic or heart block. Requires BP and ECG monitoring.
levetiracetam may be quicker to administer and have fewer adverse effects
going to need airway support and you would need the ITU SpRs assistance for managing this
General anaesthesia phase: Continuing seizures require expert help with induction with general anaesthesia with continuous monitoring in ICU
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 EAC
suggest starting antiepileptics?
neurologists now start antiepileptics following a second epileptic seizure
after the first seizure if any of the following are present:
the patient has a neurological deficit
brain imaging shows a structural abnormality
the EEG shows unequivocal epileptic activity
the patient or their family or carers consider the risk of having a further seizure unacceptable
Generalised tonic-clonic seizures drug treatment ?
males: sodium valproate
females: lamotrigine or levetiracetam
Focal seizures tx ?
first line: lamotrigine or levetiracetam
second line: carbamazepine, oxcarbazepine
Absence seizures (Petit mal) tx ?
first line: ethosuximide
second line:
male: sodium valproate
female: lamotrigine or levetiracetam
carbamazepine may exacerbate absence seizures
Myoclonic seizures tx ?
males: sodium valproate
females: levetiracetam
Tonic or atonic seizures?
males: sodium valproate
females: lamotrigine
Seizures driving tx?
first unprovoked/isolated seizure: 6 months off
if there are no relevant structural abnormalities on brain imaging and no definite epileptiform activity on EEG.
If these conditions are not met then this is increased to 12 months.
for patients with established epilepsy or those with multiple unprovoked seizures:
may qualify for a driving licence if they have been free from any seizure for 12 months
