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Common seizure and status epilepticus exam questions for medical finals, OSCEs and MRCP PACES

 

Question 1. Definition of status

Define status epilepticus

  • Status epilepticus is when a seizure continues for longer than five minutes or when multiple shorter seizures occur with incomplete recovery between them

 

Question 2. Causes of seizures

Give four causes of seizures or status epilepticus in an individual with epilepsy

  • Drug withdrawal, non-compliance or therapy alteration
  • Inter-current illness
  • Metabolic derangements
  • Seizure threshold-lowering drugs

Give four causes of seizures in an individual with no history of epilepsy

  • Drug overdose e.g. amphetamines, tricyclic antidepressants (TCAs)
  • Drug withdrawal e.g. alcohol
  • Central nervous system (CNS) injury
  • CNS infection

What features in the history would suggest a seizure as opposed to an alternative cause of transient loss of consciousness?

  • Previous history
  • Convincing prodrome
  • Tonic-clonic convulsions
  • Tongue biting
  • Urinary incontinence
  • Post-ictal period

 

Question 3. Management of seizures

On recognition of a seizure, outline your initial management steps

  • Instruct nursing staff to prepare lorazepam 4 mg IV in 4 ml of 0.9% saline (1mg/ml) with a 10 ml 0.9% saline flush and start the clock
  • Remove any objects in the immediate environment on which the patient might injure themselves
  • Roll the patient on to their side whilst supporting the airway with a jaw thrust
  • Insert a nasopharyngel airway and provide high-flow oxygen
  • Attach monitoring (pulse oximetry, non-invasive blood pressure, three-lead cardiac monitoring)
  • Obtain IV access and take bloods

What metabolic condition must be promptly excluded and what are the options for its rapid correction

  • Hypoglycaemia
    • Dextrose 50% 50 ml IV
    • Dextrose 20% 100 ml IV
    • Dextrose 10% 250 ml IV
    • Glucogel/Hypostop if IV access still not available

If after a maximum of five minutes the seizure has not terminated, what treatment is indicated and what are the options for giving this?

  • Give the first dose of benzodiazepine
    • If IV access available, give up to 4 mg of lorazepam IV in 1 mg boluses titrated to effect; the goal is to give the patient just enough lorazepam but no more, thereby terminating the seizure but not leaving them excessively obtunded
    • If IV access is unavailable, give diazepam 10 mg per rectum (PR) or midazolam 10 mg buccal and keep trying to obtain IV access

If this had already been given, how would this change you management?

  • Do not give more than two doses of benzodiazepine so if already given, proceed to the next step

 

Question 4. Further management of seizures or status

If ten minutes later (i.e. after 15 minutes) the seizure has not terminated, what treatment is indicated and what are the options for giving this?

  • Give the second dose of benzodiazepine
  • If IV access available, give up to 4 mg of lorazepam IV in 1 mg boluses titrated to effect; the goal is to give the patient just enough lorazepam but no more, thereby terminating the seizure but not leaving them excessively obtunded
  • If IV access is unavailable, give diazepam 10 mg per rectum (PR) or midazolam 10 mg buccal and keep trying to obtain IV access

If ten minutes later (i.e. after 25 minutes) the seizure has not terminated, what treatment is indicated?

  • Phenytoin 18 mg/kg IV or phenobarbital 20 mg/kg IV if patient normally takes oral phenytoin

 

Question 5. Investigation of seizures

What are the indications for CT head in status epilepticus?

  • First presentation
  • Not done previously (i.e. a previous admission)
  • Clinical features suggests new neurology
  • Precipitated by TBI