"improving intensive care in Scotland"

Neurological emergencies

Drugs for treating status epilepticus

1. Benzodiazepine: see local protocols. Diazepam, lorazepam. E.g. given in medical emergencies handbook.

  • Diazepam Emulsion: 2mg incrementally to 10mg over 5 mins, or
  • Lorazepam 4mg IV (repeat once 15 mins later)

Both can cause respiratory, cardiovascular compromise and reduced consciousness

2. Phenytoin

  • 10-15mg/min, slow IV infusion (in frail, hypotensive give in two divided doss)
  • ECG and BP monitoring mandatory
  • Follow with maintenance, 100mg three times a day iv

3. Continuing SE after 30 minutes

  • Administer general anaesthesia (thiopentone or propofol) to abolish seizures, intubate and ventilate and admit to intensive care
  • Consider monitoring using EEG to assess status (may be non-convulsive)
  • Refer for specialist advice
  • Establish:
    • Adequate monitoring: neuro obs (GCS, pupils), pulse, RR, invasive BP, Temp, ECG, SpO2
    • Urgent investigations: U & E; LFTs; Ca and Mg; Glucose; ABG; coagulation; FBC
    • Specialist investigations: consider CT scan head; CSF examination
    • Other treatment considerations:
    • Glucose 50ml 50% and thiamine 250 mg (Pabrinex) if appropriate
    • IV fluids: 0.9% sodium chloride (not Dextrose 5%)
    • Acidosis: avoid bicarbonate

ICU management

  • Secure airway/breathing, correct hypoxia
  • Support circulation and manage complications
  • Control seizures: anaesthetic agents
  • Monitoring: haemodynamics, SpO2, ABG, EEG, ICP/CPP
  • CFAM/EEG guided therapy
  • Multi-modal neuro monitoring
  • Don’t use muscle relaxants if possible: assess seizure activity
  • Keep PaCO2 normal
  • Good circulating volume, CO and MAP
  • Saline and colloid:avoid hypotonic solutions which can cause hyponatraemia
  • Remember that autoregulation may be lost
  • Normalise blood glucose
  • Treat pyrexia
  • ICP may be raised; ensure: tapes for ETT and 20 degree head-up to optimise cerebralvenous drainage

You are now ready to take the MCQ test

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