HistoryYou are the clinician working on a busy ward andhaven’t had a break for 8 hours. On your way to thetoilet, the emergency buzzer goes off. A 62-year-oldman is having a tonic-clonic seizure. You are the firstclinician on the scene.

ObservationsHR 95, BP 130/45 mmHg, RR 15, SpO2 95%, Temp37.2

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Case-based discussion: 1

00:57

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Question: 1

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Question: 2

HistoryYou are the clinician working on a busy ward andhaven’t had a break for 8 hours. On your way to thetoilet, the emergency buzzer goes off. A 62-year-oldman is having a tonic-clonic seizure. You are the firstclinician on the scene.

ObservationsHR 95, BP 130/45 mmHg, RR 15, SpO2 95%, Temp37.2

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Case-based discussion: 1

00:57

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

TonicClonic

MyoclonicAtonic

AutomatismsTonicClonic

MyoclonicAtonic

Non-motor Absence AutonomicEmotionalSensory

Cognitive

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Aetiology

• 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 SignsLimb jerking Loss of consciousness

Limb stiffness Post ictal: confusion and reduced GCS

Tongue biting

Urinary incontinence

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InvestigationsBedside• 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

HistoryYou are the clinician working on a busy ward andhaven’t had a break for 8 hours. On your way to thetoilet, the emergency buzzer goes off. A 62-year-oldman is having a tonic-clonic seizure. You are the firstclinician on the scene.

ObservationsHR 95, BP 130/45 mmHg, RR 15, SpO2 95%, Temp37.2

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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

Breathing1. Observations: RR 15, SpO2 95%2. Peripheral exam: not cyanosed3. Central exam: trachea central, equal air entry 4. Urgent investigations: CXR5. Management: High flow oxygen

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2

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Management

Circulation1. Observations: HR 95, BP 130/452. Peripheral exam: CRT 2s, regular pulse, well perfused3. Central exam: normal heart sounds4. Urgent investigations: IV access and bloods5. Management: commence AEDs

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

Exposure• Evidence of underlying cause• Trauma

HistoryYou have now inserted an oropharyngeal airwaywhich your patient tolerates. You have commencedhigh flow oxygen and inserted a cannula. The patientis in status epilepticus. No help has arrived.

ObservationsHR 95, BP 130/45 mmHg, RR 15, SpO2 100%, Temp37.2

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Question: 4

5:07

HistoryThe patient is continuing to fit. The anaesthetist hasappeared and asks you what you would like to donext.

ObservationsHR 105, BP 110/45 mmHg, RR 19, SpO2 96%, Temp38.4

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Question: 5

15:30

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Management: convulsive status epilepticusTime Treatment

Early: <10 minutes • Rectal diazepam 10-20mg or buccal midazolam 10mg

• First line: IV lorazepam 4mg

• Repeat once after 10 - 20 minutes

HistoryThe patient is continuing to fit.

ObservationsHR 115, BP 100/45 mmHg, RR 19, SpO2 94%, Temp39.0

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Question: 6

24:07

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Management: convulsive status epilepticusTime Treatment

Early: <10 minutes • Rectal diazepam 10-20mg or buccal midazolam 10mg

• First line: IV lorazepam 4mg

• Repeat once after 10 - 20 minutesEstablished: 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 of:• Propofol• Midazolam• Thiopental

Transfer to ICU

HistoryThe patient has stopped fitting and you have savedthe day!

His eyes do not open when you shout his name.When you pinch his eyebrow he opens his eyes andmoves away. His speech is confused.

ObservationsHR 100, BP 110/45 mmHg, RR 19, SpO2 95%, Temp38.1

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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 of:• 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

• Fechtner syndrome: a variant of Alport syndrome

• Riddoch syndrome: visual impairment often caused by lesions in the occipital lobe which limit the sufferer's ability to distinguish objects

• Rasmussen syndrome: a rare encephalitis affecting one hemisphere in children, resulting in seizures. The cause is not entirely understood. Seizures gradually increase in frequency, are difficult to control and, after a period of time, the child will usually develop a weakness of the side of the body that is affected by the seizures

• Exploding head syndrome: a condition where the person experiences unreal noises that are loud and of short duration when falling asleep or waking up. It has an unknown cause and is benign

• Alex in Wonderland syndrome: also known as Todd's syndrome. People experience distortions in visual perception of objects, such as appearing smaller or larger. Associated with epilepsy, intoxicants, infections, fevers, and brain lesions

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Top-decile question

• New-onset refractory status epilepticus (NORSE) is a rare but challenging condition, characterized bythe occurrence of a prolonged period of refractory seizures with no readily identifiable cause inotherwise 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_titleVideo 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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