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

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

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

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

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

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

What are the indications for CT head in status epilepticus?