Sam speaks to Intensivists Dr Jonathan Casement and Dr Rob Everitt about reduced consciousness and acute and post-seizure management.
Approach to fluctuating GCS Eyeball the patient / ABCs Calling a code – certainly if the patient is not rousable! 777 (or your local hospital emergency number)
This is Sam, medical house officer I need the adult resus team to attend North Shore Hospital, ward 10, room E3.
Initial assessment Big picture
Vitals
Pupils Wide: drugs, alcohol, adrenaline
Constricted: opiates
How does the patient respond to questions?
Assess GCS
Differential Intracranial or extracranial?
Surgical sieve
Overdose, head injury, seizure, diabetic, epileptic, previous episodes, medications
Don’t ever forget glucose
Collateral history, including from other patients in the room
Vitals + Examination General inspection + peripheries
Neuro exam aimed at identifying localising signs
Consider investigations ABGs, glucose, FBC, electrolytes, creatinine, cardiac enzymes, ketones, TFTs, blood cultures, alcohol, coags
ECG, CXR, catheter urine
Consider CT head, LP
Rarely toxicology (urine and blood)
Consider the “3 coma antidotes” Glucose: if hypoglycaemia confirmed on BSL give 100mL of glucose 10% IV
Thiamine: 100mg IV/IM (for patients with chronic alcohol abuse or chronic malnutrition)
Naloxone: 400 micrograms (1 ampule) in a resus situation (concerned about airway)
80 microgram boluses for somnolent patients that are just difficult to rouse. Repeat every minute with a 10 mL flush until alert.
Maximum of 10 mg in total.
Note short half-life, so often need repeat doses.
Document Basics (date/time/name/reason for review).
Positives and pertinent negatives.
Impression and differential with justification.
Clear and specific plan.
Consider discussion with senior and escalation.
Acute seizure management DRSABCs
Airway 100% oxygen via non-rebreather or bag mask
Recovery position (protect the patient and staff from injury)
Breathing Sats probe
Circulation Pulse
CRT
Don’t attempt BP during seizure
Duration >5 minutes Code code if not done already
IV access (IO if failed IV)
Seizure control: Lorazepam (or midazolam) 4 mg IV (give 2 mg, flush, then another 2 mg slowly and flush).
IM midazolam 10 mg is the treatment of choice if no IV access is available. The dose may be repeated if required after 10 minutes. Maximum midazolam dose of 20 mg IM over 24 hours.
Rectal diazepam 10 mg if above not IV and IM access unavailable (empty rectum first).
Lorazepam has a longer anti-epileptic effect than diazepam as it is not redistributed to adipose tissue. If lorazepam is not immediately available do not delay but proceed with diazepam or midazolam.
An anticonvulsant must be started if there is more than one seizure.
Post-seizure management IV access
Secondary survey for injury and infective causes
History and description of the events surrounding the seizure. Who witnessed it?
What situation was the patient in before it started?
Incontinence or tongue biting.
Post-ictal features.
Does the patient remember the episode?
Alcohol and drug history
Consider EtOH/hand gel if alcoholic or possibly malnourished, consider IV thiamine.
Head injury history
Senior review for workup of aetiology and preventative strategy
Stop gabapentin and tramadol
Diagnosis is clinical and is established on the basis of the patient’s account and on any eyewitness description. A detailed neurological examination is required. Features suggestive of a seizure include: Absence of syncopal prodrome (nausea, pallor, sweating, dimmed vision)
Period of post-ictal drowsiness and/or confusion
Tongue biting or urinary/faecal incontinence
Note: Syncope can provoke a seizure if cerebral hypoperfusion is prolonged.
Investigations FBC, glucose, electrolytes, Ca2+, Mg2+, creatinine, LFT
Antiepileptic serum levels
Consider urine/serum toxicology/alcohol screen
Consider prolactin levels
CXR (hypoxic seizure)
CT head: particularly if fever, focal neurological symptoms or signs, or slow recovery
EEG/MRI: selected patients, usually performed as an outpatient
Management Treat underlying aetiology.
Generally, do not start anticonvulsant therapy following a first seizure, unless a structural brain abnormality is demonstrated.
All patients must be told they cannot drive a motor vehicle for 12 months after a seizure. This is your responsibility. Shortening of this restriction can occur in only very special circumstances (e.g. a provoked seizure). Patients should also be advised of potential risks of swimming alone, SCUBA diving, working at heights and other high-risk activities. Document in the notes that this advice has been given.
Discuss with medical registrar. Generally start an anticonvulsant if benzodiazepine was required.
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