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Seizures are a serious and sometimes life threatening condition that you need to be able to recognise and manage in an acute setting. This guide gives an overview of the recognition and immediate management of seizures (using an ABCDE approach). 

Airway

Is the patient able to talk? (if so the airway is patent)

Place the patient in the recovery position if possible (to reduce risk of airway compromise).

 

Noisy breathing suggests airway compromise

  • Perform the head tilt, chin lift maneuver.
  • If noisy breathing persists try a jaw thrust.
  • If airway still appears compromised use an airway adjunct (e.g. oropharyngeal airway).
  • Use suction to clear airway secretions – also ensure any loose fitting dentures are removed.
  • An anaesthetist should be contacted as soon as possible to enable advanced airway management.

Breathing

Administer oxygen

Give high flow oxygen via a non-rebreather mask.

 

Assess the patient

Oxygen saturation – aim to keep 94-98%

Air entry – auscultate to assess air entry

Respiratory rate – may be reduced by anticonvulsive agents – e.g. Lorazepam

Chest X-ray – to evaluate possibility of aspiration

Circulation

Assess the patient

BP / Pulse if hypotensive resuscitate with IV fluids (always consider pre-eclampsia in women with hypertension.)

Capillary refill time central – should be <2 seconds

 

Gain IV access and take bloods

Gain IV access

Take blood samples  FBC / U&Es / Calcium / Magnesium / LFT / Glucose / Coagulation / Toxicology (including antiepileptic drug level is already on treatment)

 

Anticonvulsant treatment

First line treatment²

Benzodiazepine – multiple options and routes (consult local guidance)

  • Lorazepam (IV) is often used as a first line therapy (0.1 mg/kg (usually a 4 mg bolus, repeated once after 10−20 minutes; rate not critical).²
  • Failure to respond to first line treatment requires input from critical care.
  • Give usual AED medication if already on treatment.

 

Second line (should be instituted by anaesthetist / critical care)²

Phenytoin infusion – requires BP and ECG monitoring

Dexamethasone – if vasculitis or cerebral oedema (tumour) possible

 

Other treatments to consider²

Administer glucose (50 ml of 50% solution) and/or intravenous thiamine (250 mg) as high potency intravenous Pabrinex if any suggestion of alcohol abuse or impaired nutrition².

 

Other investigations

Arterial blood gas (ABG):

  • Assessment of oxygenation
  • pH – acidosis would suggest the need for urgent critical care input
  • Lactate – again raised levels would support the need for critical care input

Disability

Assess GCScontinue to reassess GCS – if <8 anaesthetic support for the airway is required

Check blood glucose – hypoglycaemia may be the underlying cause or contributing to a reduced GCS

Assess pupilsmay give clues as to a cause for seizure – drug overdose / intracerebral pathology

Exposure

Expose patient’s entire body looking for:

  • Rashmeningococcal septicaemia
  • Hidden sources of sepsis – i.e. infected leg ulcer
  • Other secondary injuries – may have trauma secondary to seizure 

Reassess ABCDE

It is essential to continually reassess ABCDE and treat issues as you encounter them.  This allows continual reassessment of the response to treatment and early recognition of deterioration.

If the patient does not respond to treatment, or deteriorates,  critical care input should be involved as soon as possible.

References

1. Oxford handbook of Clinical Medicine – management of status epilepticus – p809

2. Epilepsies: diagnosis and management. Nice guidance (CG137) – Published date:

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