Tag: resus

Fluctuating GCS and seizures

Fluctuating GCS and seizures

Sam speaks to Intensivists Dr Jonathan Casement and Dr Rob Everitt about reduced consciousness and acute and post-seizure management.

Approach to fluctuating GCS

  • Eyeball the patient / ABCs
    • Calling a code – certainly if the patient is not rousable!
      • 777 (or your local hospital emergency number)
      • This is Sam, medical house officer I need the adult resus team to attend North Shore Hospital, ward 10, room E3.
  • Initial assessment
    • Big picture
    • Vitals
    • Pupils
      • Wide: drugs, alcohol, adrenaline
      • Constricted: opiates
    • How does the patient respond to questions?
  • Assess GCS
  • Differential
    • Intracranial or extracranial?
    • Surgical sieve
    • Overdose, head injury, seizure, diabetic, epileptic, previous episodes, medications
    • Don’t ever forget glucose
  • Collateral history, including from other patients in the room
  • Vitals + Examination
    • General inspection + peripheries
    • Neuro exam aimed at identifying localising signs
  • Consider investigations
    • ABGs, glucose, FBC, electrolytes, creatinine, cardiac enzymes, ketones, TFTs, blood cultures, alcohol, coags
    • ECG, CXR, catheter urine
    • Consider CT head, LP
    • Rarely toxicology (urine and blood)
  • Consider the “3 coma antidotes”
    • Glucose: if hypoglycaemia confirmed on BSL give 100mL of glucose 10% IV
    • Thiamine: 100mg IV/IM (for patients with chronic alcohol abuse or chronic malnutrition)
    • Naloxone:
      • 400 micrograms (1 ampule) in a resus situation (concerned about airway)
      • 80 microgram boluses for somnolent patients that are just difficult to rouse. Repeat every minute with a 10 mL flush until alert.
      • Maximum of 10 mg in total.
      • Note short half-life, so often need repeat doses.
  • Document
    • Basics (date/time/name/reason for review).
    • Positives and pertinent negatives.
    • Impression and differential with justification.
    • Clear and specific plan.
    • Consider discussion with senior and escalation.

Acute seizure management

  • DRSABCs
  • Airway
    • 100% oxygen via non-rebreather or bag mask
    • Recovery position (protect the patient and staff from injury)
  • Breathing
    • Sats probe
  • Circulation
    • Pulse
    • CRT
  • Don’t attempt BP during seizure
  • Duration >5 minutes
    • Code code if not done already
    • IV access (IO if failed IV)
    • Seizure control:
      • Lorazepam (or midazolam) 4 mg IV (give 2 mg, flush, then another 2 mg slowly and flush).
      • IM midazolam 10 mg is the treatment of choice if no IV access is available. The dose may be repeated if required after 10 minutes. Maximum midazolam dose of 20 mg IM over 24 hours.
      • Rectal diazepam 10 mg if above not IV and IM access unavailable (empty rectum first).
      • Lorazepam has a longer anti-epileptic effect than diazepam as it is not redistributed to adipose tissue. If lorazepam is not immediately available do not delay but proceed with diazepam or midazolam.
      • An anticonvulsant must be started if there is more than one seizure.

Post-seizure management

  • IV access
  • Secondary survey for injury and infective causes
  • History and description of the events surrounding the seizure.
    • Who witnessed it?
    • What situation was the patient in before it started?
    • Incontinence or tongue biting.
    • Post-ictal features.
    • Does the patient remember the episode?
    • Alcohol and drug history
    • Consider EtOH/hand gel if alcoholic or possibly malnourished, consider IV thiamine.
  • Head injury history
  • Senior review for workup of aetiology and preventative strategy
  • Stop gabapentin and tramadol
  • Diagnosis is clinical and is established on the basis of the patient’s account and on any eyewitness description. A detailed neurological examination is required. Features suggestive of a seizure include:
    • Absence of syncopal prodrome (nausea, pallor, sweating, dimmed vision)
    • Period of post-ictal drowsiness and/or confusion
    • Tongue biting or urinary/faecal incontinence
    • Note: Syncope can provoke a seizure if cerebral hypoperfusion is prolonged.
  • Investigations
    • FBC, glucose, electrolytes, Ca2+, Mg2+, creatinine, LFT
    • Antiepileptic serum levels
    • Consider urine/serum toxicology/alcohol screen
    • Consider prolactin levels
    • CXR (hypoxic seizure)
    • CT head: particularly if fever, focal neurological symptoms or signs, or slow recovery
    • EEG/MRI: selected patients, usually performed as an outpatient
  • Management
    • Treat underlying aetiology.
    • Generally, do not start anticonvulsant therapy following a first seizure, unless a structural brain abnormality is demonstrated.
    • All patients must be told they cannot drive a motor vehicle for 12 months after a seizure. This is your responsibility. Shortening of this restriction can occur in only very special circumstances (e.g. a provoked seizure). Patients should also be advised of potential risks of swimming alone, SCUBA diving, working at heights and other high-risk activities. Document in the notes that this advice has been given.
    • Discuss with medical registrar. Generally start an anticonvulsant if benzodiazepine was required.
Hypotension

Hypotension

Sam speaks to Intensivists Dr Jonathan Casement and Dr Rob Everitt about differentiating and managing hypotension.

Differential

  • Life threatening
    • Acute haemorrhage
      • On the floor and four more
    • Sepsis
    • Arrhythmia/cardiac
    • Drugs (including transfusion reaction)
    • Anaphylaxis
  • Dehydration (beware the accuracy of this diagnosis)
  • Epidural anaesthesia
  • Heart failure
  • Pregnancy
  • Syncope/postural
  • Neurological
    • Positional
    • PD
    • Diabetes

Approach

  • Eyeball the patient / ABCDEF
  • Calling a code
    • 777 (or your local hospital emergency number)
    • This is Sam, medical house officer I need the adult resus team to attend North Shore Hospital, ward 10, room E3.
  • History
    • Why are they in hospital?
    • Post-op?
    • Onset, timing & trend of hypotension
    • Postural
    • Medications
    • Associated symptoms
      • Pain is very concerning
    • ROS
  • Vitals + Examination
    • End-of-bed-o-gram is probably the most important
    • Peripheries for perfusion and pulse
    • Manual BP
      • Both arms
      • Cuff size
    • Urine output
    • Drain output
  • Consider investigations
    • Keep in mind these may be of limited value
    • ABG (lactate, glucose, Hb)
    • ECG
  • Management
    • Fluid challenge only if hypovolaemic
      • 250 – 500 mL stat
    • Rehydrate gradually
    • Transfusion
      • Target Hb >70
      • Use one unit then reassess
    • Avoid transfusion outside daylight hours
    • Catheterise and measure fluid balance
    • Fix the underlying cause
    • Have a low threshold to escalate to a senior
    • Clear observation and escalation plan if cause is unclear
  • Document
    • Review past notes
    • Basics (date/time/name/reason for review)
    • Positives and pertinent negatives
    • Impression and differential with justification.
    • Have you eliminated life threatening conditions?
    • Beware an impression of dehydration.
    • Are they actually hypovolaemic?
    • Why would they be dehydrated on the ward?
    • Clear and specific plan
    • Monitoring
    • Consider discussion with senior and escalation, especially if called back to patient again