Status Epilepticus

Today we discussed an approach to status epilepticus and seizures in general.

Defined as continuous or repeated seizures without return to baseline for 20-30min (brain activity; may not have convulsions).
NB- there is a movement to make the time part of this definition much shorter (to 5 minutes)

Most seizures last 1-2 min. You need to intervene if beyond this point. At 20 min, the seizure per se damages the brain (scarring, self-perpetuating as sz focus). Also treat if series of short sz with incomplete recovery in between.

Approach is to treat the seizure AND look for the underlying cause

Acute causes: bleed, stroke, trauma, metabolic (e.g. hypoglycemia, hyponatremia, hypocalcemia, others), infections (esp. CNS), hypoxia, intoxication/drugs (or withdrawal), major organ faiure (uremia, hepatic failure)
Chronic: mass, non-compliance with meds

Complications of sz: aspiration, orthopedic complications, lactic acidosis, rhabdomyolysis

Practical approach:

ABC- clear the airway (do NOT put anything in the pt's mouth to prevent 'tongue biting, etc), roll on side, ensure breathing (apply O2)
Get monitors- Vitals, O2 sat,
IV access
CHECK THE GLUCOSE!, If low, amp of D50, glucagon 1mg IM if no IV
Thiamine 100mg IV (esp. if EtOH, pregnant, cancer pts)
Blood: CBC, lytes, renal, Ca profile, glucose, transaminases, drug levels, tox screen

If no immediately reversible cause (e.g. hypoglycemia), drugs to use acutely:

Benzos- lorazepam IV 12-24h anti-sz effect. Loraz 0.1mg/kg at 1-2mg/min (usually 1-2mg aIV at a time, repeated to max) This will stop 80% of sz.
May give diazepam PR if no IV access. 0.2mg/kg PR x 1 or midazolam 5mg IM x1

Phenytoin (Dilantin) 20mg/kg IV load at 50mg/min (e.g. 1400mg over 30 min in 70kg)
If needed, give further 5-10mg/kg.
A couple of points about phenytoin for status:
Do not mix phenytoin and D5; it crystallizes, which is not very helpful in status epilepticus.
Never give dilantin and dopamine together; can cause profound hypotension for unclear reason

Phenobarbital: Strongly consider intubation here
20mg/kg IV @50-75mg/min. This pt should be in ICU

Others: Propofol infusion, midazolam infusion

Look for underlying- bloodwork, CT, LP if fever.
Mimics of status: myoclonus, rigors, movement disorders, herniation (early)

Link:

Click here for an excellent review of status epilepticus from Chest (yes, a weird place for it to be)

HoPingKong-isms

(hyperthermia can cause rhabdomyolysis)

1. "....What are you lying on? This is a giant question...a maximus question....are you crushed by this?"..... this was in the context of patients found either unconscious or unable to get up for prolonged periods of time. He is referring to rhabdomyolysis. The 'maximus' comment must refer to the gluteus maximus, and the 'are you crushed?'....for sure that is for crush injuries. We discussed rhabdomyolysis here.

2. "...Let's think about cardiac causes of syncope...hey....Adam is here today...". Yep, this is a Stokes-Adams Attack, named after William Stokes and Robert Adams - two Irish physicians.

3. "...Sometimes you have overt alcoholics, then there are social drinkers...I'm thinking of the smallest room in the house..." So what's the smallest room in the house? The closet. He was referring to "closet alcoholics". We discussed alcohol related issues here, seizure disorders here, and toxic alcohol ingestions here.

4. "....Think about Captain Morgan!...". This was said in the context of him shaking his arms and head - convulsing. "Yes...this is a 'Rum Fit'". Also known as an alcohol withdrawal seizure. Remember your CAGE questionnaire to screen for alcohol-related problems:

• do you feel the need to Cut back your drinking?
• do you ever feel Annoyed at people critiquing your drinking?
• do you ever feel Guilty about your alcohol consumption?
• do you ever have an Eye opener? (Alcohol first thing in the morning)

• 1 point is given every time your patient answers "yes" to a question. ....then you just add up the points.
  

• Most patients with alcohol dependence will have a score of 2 or greater. About 80% of patients without alcoholism will score 0 points.
  

Here is a paper from JAMA written by local talent on the utility of alcohol screening tools.

HoPingKong-isms and "seppie"

(if you type 'seppie' into google, this comes up. I think it is Italian for cuttlefish)

1. ....."Hi...how are you? Grow up!" ..... This was in the context of a patient presenting with a decreased level of consciousness. kind of a tough one. He is referring to a Hygroma - namely, a pocket of cerebrospinal fluid (CSF) in the subdural space. Large hygromas can cause focal neurologic deficits and mental status changes. They can result from head trauma. CT showing a subdural hygroma below.

2. ....."The result of any mass on the cortex...What do soldiers and scouts do? They march."....He is referring to a Jacksonian March - where seizure activity spreads through the primary motor cortex, resulting in the clonic activity of the corresponding area of the homunculus. This often starts on the hands and moves more proximally.

3. ...."Flappy hands...you're going to flap again"....This was mentioned in the context of Hepatitis C infection. He is referring to Asterixis, commonly seen in hepatic encephalopathy, uremic encephalopathy, and hypercarbia.

4. ...."Does our patient have respiratory distress?....did you bring your purse?".....Referring to pursed lip breathing - one of the physical signs of respiratory distress. Other signs to look for include positioning (sitting up, leaning forward, 'tripoding'), nasal flaring, use of accessory muscles (intercostal retraction, use of trapezius and sternocleidomastoids), and paradoxical breathing - the inward movement of the diaphragm on inspiration.

5. ...."He has hypotension and tachycardia, and he sounds sick. What is going on? Think of something...ummmmm....seppie."..... Okay, this is not the hardest one, but I thought it was funny. He is referring to sepsis. I just liked the use of the word "seppie".

Some helpful links to the case we discussed:

1. An approach to decreased level of consciousness can be found here.
2. An approach to Acid-Base issues can be found here.
3. Stigmata of chronic liver disease can be found here.

(subdural hygroma - and how to get one)

Preeclampsia

Preeclamsia

What is it? Hypertension that develops after 20 weeks gestational age which is associated with proteinuria.

Breifly, what is the pathophysiology? The release of placental/fetal factors that alter maternal endothelial function. Ultimately there may be less vascular endothelial growth factor (VEGF) - possible from VEGF antagonists released by the placenta.

What are the diagnostic criteria?

• systolic BP >140 mmHg, or
• diastolic BP >90 mmHg, and
• proteinuria >0.3 grams in 24-hours, and
• gestational age >20 weeks

What are some of the other clinical manifestations of preeclampsia? this will relate to complications of endothelial damage and severe hypertension. Think about headaches, blurred vision, peripheral edema which may include the hands and face, pulmonary edema, and fetal compromise. Also think about end-organ damage from hypertension - you can read more at this link.

Are there risk factors? Yes, some of these include nulliparity, previous or family history of preeclampsia, preexisting hypertension, APLA syndrome or other connective tissue disease, multiple gestation, or 'extremes' of age (>40, <20). style="font-weight: bold;">Dreaded complications? Yep. Eclampsia (aka seizure), and the HELLP syndrome. HELLP stands for Hemolysis, Elevated Liver enzymes, and Low Platelets.

Okay, so what do I do? well, it's kind of complicated. First, remember that the only 'cure' is delivery. Also remember that cases can still present in the early post partum period. Get the obstetrical service involved early and ensure that the unborn child is well with a biophysical profile. Sometimes this is severe and an urgent delivery is necessary - so predelivery sterioids may be necessary to decrease fetal pulmonary complications. Otherwise, hypertension can be managed with a few drugs that are safe in pregnancy. Women with this condition should be watched very closely and there should be a very low threshold for admission to hospital.

Drugs commonly used in preeclampsia include labetolol, hydralazine, methyldopa, and nifedipine. The target blood pressure is debated, but many would agree on 130 to 150 mmHg systolic and 80 to 100 mmHg diastolic.

In severe preeclampsia, where eclampsia is a very real risk, Magnesium Sulfate is administered to reduce the seizure threshold. It is generally administered during labour and delivery, and is continued for 24-48 hours afterwards.

Here is a link on the utility of Magnesium in preventing eclampsia.
Here is a cool case of preeclampsia with a twist.

Seizure-Related Topics

• Check out the treatment of Status Epilepticus here.

• We also talked about TB meningitis, and you can read a bit more about the diagnosis and treatment of that over here.

• Check out Alcohol Withdrawal syndromes over here.