Post Operative Seizure
You are the neurosurgery CT1 fast bleeped to see a 34-year-old man on the ward who had a craniotomy earlier that day. He is having a seizure but is not a known epileptic. How would you proceed?

Example answer introduction
This is a medical emergency and I would attend immediately. I would ask the caller to also put out a peri-arrest call and also inform the neurosurgical registrar immediately. On my arrival I would assess the patient according to the CCrISP/ALS algorithms.
Initial Assessment and Simultaneous Resuscitation
On arrival:
If having active tonic-clonic seizure;
-
Start timing 5 minutes
-
Protect airway, ensure nothing put in the mouth
-
Recovery position, protect head and remove objects in the vicinity likely to cause injury
If less than 5 minutes then I would place in recovery position, and continue with A-E stabilisation;
-
Airway
-
Breathing - check oxygen saturations, respiratory rate, listen to chest, assess work of breathing, breathing depth - if concerns give high flow oxygen
-
Circulation
-
Pulse, Blood pressure, capillary refill time, mucus membranes, skin turgor, fluid input/output, catheter is septic
-
IV access - large bore and bloods including CRP
-
Give fluid challenge of 250ml crystalloid solution if evidence of shock
-
If suspecting bleeding, you may need to activate the Major Haemorrhage Protocol
-
-
Disability - GCS, pupillary response, blood sugar, temperature
-
Exposure - rashes, systemic signs of shock - expose the whole abdomen - there may be clues!!
During this acute phase state remember to provide constant reassessment
During initial assessment I would send bloods for FBC, U&E, LFTs, CRP, Lactate, blood glucose, Trop I, clotting studies, Group and Save and blood and urine cultures if spiking a temperature.
If having active tonic-clonic seizure lasting more than 5 minutes or 3rd seizure within the last hour;
-
Protect airway, ensure nothing put in the mouth
-
Recovery position, protect head and remove objects in the vicinity likely to cause injury
-
Give IV lorazepam 1mg stat
-
Ensure crash team and neurosurgery registrar on the way
-
If settles continue with A-E assessment
For people having other types of seizures (for example focal, tonic, atonic, and myoclonic seizures):
-
Protect airway, ensure nothing put in the mouth
-
Recovery position, protect head and remove objects in the vicinity likely to cause injury
-
If settles continue with A-E assessment
These patient may require antiepileptic medication however this should be discussed with neurosurgery registrar first.
Focused history
He is likely to be post-ictal, so I would read the medical notes and speak to nursing staff for further information.
-
Allergies
-
Medications – anti-epileptics
-
Past medical history – hx of epilepsy, diabetes
-
Last meal
-
Events leading up to this point – neurosurgical procedure performed, difficulties encountered, recent bloods
Neurological examination and initial investigations
Neurological examination
-
Cranial nerve examination
-
Peripheral nerve examination
-
Cerebellar examination
Initial investigations
Bloods - as above + magnesium, calcium and phosphate
CT brain- discuss with Registrar first