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;
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Start timing 5 minutes
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Protect airway, ensure nothing put in the mouth
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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;
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Airway
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Breathing - check oxygen saturations, respiratory rate, listen to chest, assess work of breathing, breathing depth - if concerns give high flow oxygen
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Circulation
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Pulse, Blood pressure, capillary refill time, mucus membranes, skin turgor, fluid input/output, catheter is septic
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IV access - large bore and bloods including CRP
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Give fluid challenge of 250ml crystalloid solution if evidence of shock
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If suspecting bleeding, you may need to activate the Major Haemorrhage Protocol
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Disability - GCS, pupillary response, blood sugar, temperature
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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;
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Protect airway, ensure nothing put in the mouth
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Recovery position, protect head and remove objects in the vicinity likely to cause injury
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Give IV lorazepam 1mg stat
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Ensure crash team and neurosurgery registrar on the way
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If settles continue with A-E assessment
For people having other types of seizures (for example focal, tonic, atonic, and myoclonic seizures):
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Protect airway, ensure nothing put in the mouth
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Recovery position, protect head and remove objects in the vicinity likely to cause injury
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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.
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Allergies
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Medications – anti-epileptics
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Past medical history – hx of epilepsy, diabetes
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Last meal
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Events leading up to this point – neurosurgical procedure performed, difficulties encountered, recent bloods
Neurological examination and initial investigations
Neurological examination
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Cranial nerve examination
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Peripheral nerve examination
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Cerebellar examination
Initial investigations
Bloods - as above + magnesium, calcium and phosphate
CT brain- discuss with Registrar first
