Case-based discussion: 1 History You are the clinician working on a - - PowerPoint PPT Presentation

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Case-based discussion: 1 History You are the clinician working on a - - PowerPoint PPT Presentation

Feb 26, 2023 171 likes •494 views

Case-based discussion: 1 History You are the clinician working on a busy ward and havent had a break for 8 hours. On your way to the toilet, the emergency buzzer goes off. A 62-year-old 00:57 man is having a tonic-clonic seizure. You are the

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History

You are the clinician working on a busy ward and haven’t had a break for 8 hours. On your way to the toilet, the emergency buzzer goes off. A 62-year-old man is having a tonic-clonic seizure. You are the first clinician on the scene.

Observations

HR 95, BP 130/45 mmHg, RR 15, SpO2 95%, Temp 37.2

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Case-based discussion: 1

00:57

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Question: 1

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Question: 2

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History

You are the clinician working on a busy ward and haven’t had a break for 8 hours. On your way to the toilet, the emergency buzzer goes off. A 62-year-old man is having a tonic-clonic seizure. You are the first clinician on the scene.

Observations

HR 95, BP 130/45 mmHg, RR 15, SpO2 95%, Temp 37.2

4

Case-based discussion: 1

00:57

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Definition

  • Seizure > five minutes or
  • Recurrent seizures without regaining consciousness in

between

  • Convulsive vs non-convulsive

Epidemiology

  • Mortality
  • Adults: 15-20%
  • Children: 3-15%
  • Longer duration associated with poorer prognosis
  • Most common neurological emergency in children

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Introduction

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Aetiology

Causes

  • Epilepsy: poor medication compliance
  • Febrile convulsion
  • Infection
  • Stroke
  • Cerebral haemorrhage
  • Alcohol abuse
  • Recreational drug use
  • Electrolyte imbalance: hyponatraemia and hypocalcaemia
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Aetiology

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Aetiology

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Aetiology

Generalised Focal (Impaired or retained consciousness)

Motor Tonic-clonic Tonic Clonic Myoclonic Atonic Automatisms Tonic Clonic Myoclonic Atonic Non-motor Absence Autonomic Emotional Sensory Cognitive

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Aetiology

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  • Mechanisms required for seizure termination fail
  • Imbalance between excitation and inhibition
  • Cerebral damage occurs after ~ 30 mins of convulsive status

epilepticus

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Pathophysiology

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Clinical features

Symptoms Signs

Limb jerking Loss of consciousness Limb stiffness Post ictal: confusion and reduced GCS Tongue biting Urinary incontinence

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Investigations

Bedside

  • ECG: arrhythmia
  • Blood glucose: hypoglycaemia

Bloods

  • Venous blood gas: lactic acidosis
  • FBC and CRP: possible infection
  • Electrolytes: in particular, hyponatraemia and hypocalcaemia
  • Anti-epileptic drug levels

Imaging

  • CT head: structural brain lesion

Specialist tests

  • Lumbar puncture (LP): CNS infection
  • EEG
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History

You are the clinician working on a busy ward and haven’t had a break for 8 hours. On your way to the toilet, the emergency buzzer goes off. A 62-year-old man is having a tonic-clonic seizure. You are the first clinician on the scene.

Observations

HR 95, BP 130/45 mmHg, RR 15, SpO2 95%, Temp 37.2

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Question: 3

00:57

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Management

Airway

  • Start timing
  • Position: semi-prone with head facing down
  • Suction
  • Airway adjuncts

Breathing

1. Observations: RR 15, SpO2 95% 2. Peripheral exam: not cyanosed 3. Central exam: trachea central, equal air entry 4. Urgent investigations: CXR 5. Management: High flow oxygen

1 2

*Addendum: oropharyngeal airway should be avoided or only inserted when the patient is not seizing

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Management

Circulation

1. Observations: HR 95, BP 130/45 2. Peripheral exam: CRT 2s, regular pulse, well perfused 3. Central exam: normal heart sounds 4. Urgent investigations: IV access and bloods 5. Management: commence AEDs

Disability

  • DEFG: don’t ever forget glucose!
  • GCS: E V M

Exposure

  • Evidence of underlying cause
  • Trauma
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History

You have now inserted an oropharyngeal airway which your patient tolerates. You have commenced high flow oxygen and inserted a cannula. The patient is in status epilepticus. No help has arrived.

Observations

HR 95, BP 130/45 mmHg, RR 15, SpO2 100%, Temp 37.2

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Question: 4

5:07

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History

The patient is continuing to fit. The anaesthetist has appeared and asks you what you would like to do next.

Observations

HR 105, BP 110/45 mmHg, RR 19, SpO2 96%, Temp 38.4

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Question: 5

15:30

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Management: convulsive status epilepticus

Time Treatment

Early: <10 minutes

  • Rectal diazepam 10-20mg or buccal midazolam 10mg
  • First line: IV lorazepam 4mg
  • Repeat once after 10 - 20 minutes
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History

The patient is continuing to fit.

Observations

HR 115, BP 100/45 mmHg, RR 19, SpO2 94%, Temp 39.0

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Question: 6

24:07

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Management: convulsive status epilepticus

Time Treatment

Early: <10 minutes

  • Rectal diazepam 10-20mg or buccal midazolam 10mg
  • First line: IV lorazepam 4mg
  • Repeat once after 10 - 20 minutes

Established: 10-60 minutes

  • Alert on call anaesthetist
  • Phenytoin 15-18mg/kg infusion and/or
  • Phenobarbital 15mg/kg bolus

Refractory: 60-90 minutes General anaesthesia (rapid sequence induction) with one

  • f:
  • Propofol
  • Midazolam
  • Thiopental

Transfer to ICU

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History

The patient has stopped fitting and you have saved the day! His eyes do not open when you shout his name. When you pinch his eyebrow he opens his eyes and moves away. His speech is confused.

Observations

HR 100, BP 110/45 mmHg, RR 19, SpO2 95%, Temp 38.1

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Question: 8

29:33

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Time Treatment

>5 minutes

  • IV lorazepam
  • Buccal midazolam or rectal diazepam

>15 minutes

  • Repeat IV lorazepam

>25 minutes

  • Phenytoin or
  • Phenobarbital if on regular phenytoin

>45 minutes General anaesthesia (rapid sequence induction) with one

  • f:
  • Thiopental

Transfer to paediatric ICU

Management: convulsive status epilepticus in children

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Management: non-convulsive status epilepticus

Treatment is not as urgent compared to convulsive status epilepticus

  • Awareness: commence or reinstate maintenance oral anti-epileptic therapy
  • Lack of awareness: manage as convulsive status epilepticus
  • Anaesthesia rarely required
  • Much better outcomes compared to convulsive status epilepticus
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Complications

System Complication

Acute

  • Hyperthermia
  • Pulmonary oedema
  • Cardiac arrhythmia
  • Cardiovascular collapse

Chronic

  • Epilepsy
  • Neurological deficit
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Top-decile questions

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Top-decile question

  • Fetchner syndrome: variant of Alport’s syndrome
  • Riddoch syndrome: visual impairment often caused by lesions in the occipital lobe which limit the

sufferer's ability to distinguish objects

  • Rasmusen syndrome: rare encephalitis affecting one side of the brain in children
  • Exploding head syndrome: experiences unreal noises that are loud and of short duration when

falling asleep or waking up

  • Alex in wonderland syndrome: experience distortions in visual perception of objects such as

appearing smaller or larger

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Top-decile question

  • New-onset refractory status epilepticus (NORSE) is a rare but challenging condition, characterized by

the occurrence of a prolonged period of refractory seizures with no readily identifiable cause in

  • therwise healthy individuals
  • Autoimmune encephalitis is the most common cause
  • EBV and leptomeningeal carcinomatosis are involved in a small number of cases
  • The others are irrelevant
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Recap

  • Status epilepticus: seizure > 5 mins or the patient does not regain consciousness between 2

seizures

  • Convulsive status: most often refers to a tonic-clonic seizure and requires urgent management
  • ABCDE management
  • Anti-epileptics commenced if the seizure > 5 mins
  • Benzodiazepines are first-line
  • Associated with high mortality
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References

1) ICUnurses / CC BY-SA (https://creativecommons.org/licenses/by-sa/4.0) 2) ICUnurses / CC BY-SA (https://creativecommons.org/licenses/by-sa/4.0) Video 1: https://www.youtube.com/watch?v=qgo6LIosP6Y&feature=emb_title Video 2: https://www.youtube.com/watch?v=OroIkCTHSek&feature=emb_title Video 3: https://www.youtube.com/watch?time_continue=1&v=Nds2U4CzvC4&feature=emb_title

All other diagrams and flowcharts were made by BiteMedicine and are not suitable for redistribution

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