Status epilepticus in viral encephalitis

Question 1

A 24 year old woman is admitted to hospital with suspected viral encephalitis and is commenced on high-dose aciclovir. On the first night of her hospitalisation she has a generalised seizure which is persisting for more than 10 minutes. How would you manage her?

Answer 1

Impression
Given the non-remitting seizure lasting for more than 10 minutes, this meets criteria for status epileptics and as such this patient should be emergently managed utilising the status pathway. This presentation is likely secondary to her viral encephalitis. Key complications I am concerned about are hypoxia, cerebral oedema and rhabdomyolysis.

DDx causes to consider

• other infective (meningitis)
• electrolyte derangement
• SOL
• Meds: other drugs, acyclovir A/E
• withdrawal: Delirium tremens

Goals

• Call MERT and assemble team, begin emergent management with 2x benozdiazepine (middaz) and then anti-epileptic drugs
• concurrent A to E assessment, Consider Ddx and treat any underlying causes

Question 2

Status - Resuscitation

Answer 2

Resuscitation
- Press for MERT call, call for senior help, assemble resus team, move to resus bay/ED if appropriate.

• start the stopwatch! Give first Midaz IM or buccal or intranasal if no IV access is gained already.

A- ensure no aspiration by clearing secretions, consider adjuncts and progression to intubation if refractory to treatment, airway manoeuvres if ?compromised - ?NP airway, suction for vomitus
B- RR, SP02, supplemental 02 as required
C - Gain IV access, initial bloods (VBG, UEC, CMP, LFT, CRP/ESR, FBC, cultures if septic, CK [rhabdo]). Administer fluids and correct electrolyte derangements. Cease Acyclovir in the short term as may be causative agent in this case (this is a rare A/E, increased risk with higher doses).
D - GCS, may be indication for intubation, protect
E - temp, exposure, limit injury by placing in left-lateral position, urine toe screen
F and G as per normal

Pathway;

• 1st short acting benzodiazepines, wait 5 mins
• 2nd short acting benzodiazepines, wait 5 mins
• AED: leviteracetam, phenytoin, valproate, carbemazepine, etc)
• Then RSI for intubation if still non-remitting

Question 3

Status - Hx

Answer 3

History

• take collateral; onset of seizure, type (generalised vs focal), did it change? any pre-ceding symptoms. any ongoing neuro deficits, evidence of raised ICP, evidence of systemic infection.
• HPI: known epilepsy? other drugs onboard?
• complications: LOC, fevers, confusion, agitation
• Medications, allergies
• Any relevant PMHx: renal disease, epilepsy, neurological disease/deficits

Question 4

Status - Ex

Answer 4

Examination

• as per A to E assessment
• Vitals
• Neuro examination
• assess semiology of the seizure

Question 5

Status - Ix

Answer 5

Investigations

• as per resus
• once stable, CT/MRI brain +/- LP to investigate potential causes

Question 6

Status - Mx

Answer 6

Management
Acute
- as per resus, aim remittance of status and then prevent relapse

Ongoing

• consider underlying diagnosis
• treat reversible causes
• consider adding an AED relevant to the classification of the seizure (focal = carbamazepine, general = valproate)
• referral to neurologist, particularly if ongoing focal deficits, development of status plan for future
• avoid triggers