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 

 Escalation
A post-op seizure in a neurosurgical patient can be indicative of a serious intracranial event. Discussion with your Registrar is vital. 
Be aware that in status epileptics discussion with anaesthetics and ICU may be required. 
If the seizure is as a result of a postoperative bleed then the patient may require listing on the emergency list and pre-operative investigations to be requested. 
Useful Resources

Managing and epileptic seizure 

Note: You may need an institutional or personal access to view some of these resources. Your medical education department or local NHS library may be able to help with access.
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