Neurological Emergencies Dr. Amal Alkhotani MBBCH, FRCPC, Epilepsy and EEG

24 year old male patient with history of generalized seizure disorder since age of 10. He was brought to emergency department with 3 GTC seizures without recovery of consciousness. In emergency room patient started to have GTC that persist after 5 minutes.

What is status epilepticus? What are major causes of SE? What is the potential complication of SE? What is your management plan for this patient?

Status epilepticus Traditionally SE is defined as continuous or repetitive seizure activity persisting for at least 30 minutes without recovery of consciousness between attacks. Recently definition changed to consider seizure lasting 5 to 10minutes is considered as SE. ( Jenssen et al,2006 )

Causes Prior history of epilepsy % Stroke 19-20% Medication change 18% ETOH/ drugs 12% Others :- - Anoxia - Metabolic - Infection - Trauma - Tumor

Complications Overall mortality is approximately % % of patients who survive SE left with new or disabling neurologic deficit.

Complications Neuronal injury. Systemic disturbance:- - Pulmonary edema - High output failure. - Cardiac arrhythmia - Aspiration pneumonia. - Fever. - metabolic disturbance. - Hypoxia - Acute tubular necrosis. - Rhabdomyolysis.

Classification Convulsive. Nonconvulsive status epilepticus (NCSE).

Management Initial step involve basic life support; administer O2, check vital signs, assessing and maintaining airway, establishing IV access. Check blood glucose, send blood for CBC, chemistry, Ca, Mg, PO4, LFTs, AED drug levels & toxicology screen.

1 st line agents Benzodiazepines e.g. lorazepam, diazepam. Use 2-4 mg of lorazepam IV: may repeat if seizure persist, repeateX1in 5 minutes. Or use diazepam 2.5mg to 5 mg IV. In absence of of IV access use diazepam 20mg rectally or midazolam 10 mg buccally or IM.

2 nd line agents IV phenytoin or fosphenytoin( not available). Phenytoin 20mg/kg at rate of 50mg/min. Patient should be on cardiac monitor. Why? DO NOT MIX WITH GLUCOSE/ DEXTROSE.

Valproic acid IV can be used instead of phenytoin. Loading dose of 30mg/kg to 60mg/kg can be used. RCT compared IV VPA to IV phenytoin in patient with SE showed better response to VPA group (66% VS 44% in phenytoin treated patient) IV valproic acid is NOT AVAILABLE at KSA.

Refractory SE Defined as generalized convulsive or NCSE that persist clinically or electrographically despite 1 st & 2 nd line treatment. Mortality in RSE is about 50%.

Medications that can be used in patient with RSE One of the following drugs can be used ( patient need an intubation and admission to ICU) 1- Midazolam infusion. 2- Propofol infusion. 3- IV phenobarbital loading. If Sz persist can switch to1or 2 or use continous IV phenobarbital infusion.

Remember Look for and treat underlying cause. Have a high suspension for encephalitis in a new onset SE. The longer duration of seizure is the worse prognosis.

Headache 67 year old female present with sudden severe headache and rapidly deteriorating LOC. 23 year old with chronic headache present to ER with unilateral headache & vomiting that did not respond to simple analgesic. 25 year old female on oral contraceptives present with 1 week history of progressive headache and new onset right leg weakness.

Red Flags For Worrisome Headaches New onset headache or onset of new type of headache or change of preexisting headache. Progressive worsening headache. Worst ever pain. Age > 50. Abrupt onset headache. Headache initiated by exertion or valsalva. Head trauma. Neurological symptoms & signs. Systemic symptoms & signs. Secondary risk factors.

What will be your next step in evaluating patient number 1? Important physical signs: 1- vital signs. 2- LOC. 3-Meningeal signs. 4- Fundus examination. 5- localizing neurological signs. CT head looking for SAH. If CT is normal lumber puncture should be performed.

Management plan for SAH ABC Admit to high dependency area. Bed rest & analgesia. BP control AVOID NITROPRUSSIDE or NITROGLYCERINE. Labetalol is preferred. Arrange for cerebral angiogram. Neurosurgery.

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