Seizures

Question:

You are asked to review a 32-year-old patient who is admitted to the hospital after a first seizure. There is no significant past medical history. You are asked to review the patient as a patient had a witnessed tonic-clonic seizure two hours back. How would you approach the following case?

Answer:

I would start by getting a focused history if the patient is able to give a brief history or review the notes and speak to the nurse looking after the patient to get a handover on the events. I would review his past medical history and medication list to see if there are any medications that could have led to the seizures. I would also review the bloods that were done so far to look specifically for any provoking factor that led to the seizures. After this, I would go on to do a focused assessment using the A to E approach.

Airway: I would ensure the airway is patent and if necessary insert an airway adjunct such as OP or NP airway. If the patient is tolerating an airway adjunct, I would be really worried and seek the help of the critical care team after my assessment.

Breathing: I would look at the observations, specifically the oxygen saturation and the respiratory rate. If the patient is hypoxic or if the patient has an increased work of breathing, I’ll start the patient on supplemental oxygen therapy. I would also get a PEFR and an ABG done for this patient to see what the pH, pO2, pCO2, HCO3, and lactate are. I would be very concerned if the pCO2 is rising. I would also arrange a portable CXR for the patient.

Circulation: I would look at the observations, specifically the BP, heart rate, and CRT. If there is evidence of hypotension or tachycardia, I would give a fluid challenge to the patient to see if there is an adequate response. And if the patient remains hypotensive despite the first fluid challenge, I will give another fluid challenge and ensure the critical care team is aware of the patient. I would also ensure the patient has a working cannula and send basic bloods including septic screening. I would also request an ECG for the patient.

Disability: I would check the patient’s blood glucose, temperature, and do a focused neurological assessment that includes GCS. Specifically, if the GCS is less than 8 or if there are focal neurological deficits, I would be concerned and investigate this further.

Question:

On revisiting the history, the patient mentions that he had two seizures prior to admission and has been experiencing daily morning headaches for the last 4 weeks. He had no childhood seizures and has no past medical history of significant illnesses. On examination, you notice that he has subtle right-sided pyramidal tract weakness. What would you do next?

Answer:

Based on the symptoms and the signs mentioned to me, I think that his seizures may be triggered by a secondary cause and would need to be investigated. I would start by repeating the bloods to look for any electrolyte imbalances and do an urgent CT scan of his head. I will discuss with my senior regarding this and consider starting him on antiepileptics. Based on his risk profile, I would aim for an anti-epileptic that has a rapid onset of action and can be uptitrated quickly, such as levetiracetam. If the CT head is normal, I would consider escalating this to the Neurology team and discuss with them about getting an MRI scan of the head.

Question:

Whilst still waiting for the CT head four hours later, the patient has a medical emergency call and has continuously seized for the last 10 minutes or so. There has not been any recovery in between. How would you manage this?

Answer:

The patient is in status epilepticus and I would ensure that the medical emergency team is called and we start off by doing an A to E assessment, specifically looking at maintaining his airway. If needed, we will insert an airway adjunct until the ICU team arrives. We would also ensure that the patient has two cannulas and start the patient on status epilepticus treatment. We would first give IV lorazepam 4 mg and observe for a response. If there’s no response, we would need to escalate to either levetiracetam, valproate, or phenytoin and load the patient on these medications. I will ensure that the ICU team is fast bleeped if there is a worry about airway compromise or if the patient is not responding to the loading dose of one or two anti-epileptic medications. I will update the family or the next of kin of the clinical situation and ensure that they are aware of what’s going on with the patient and convey to them the plan of action.