ACUTE NEUROLOGICAL CONDITIONS90 General Medical Emergencies
3 Exclude all the following ‘acute symptomatic’ secondary causes of a seizure
in any patient presenting with a first seizure or a sporadic seizure:
(i) Hypoglycaemia.
(ii) Head injury.
(iii) Hypoxia.
(iv) Infection – especially meningitis, encephalitis, cerebral abscess,
HIV or a febrile seizure in a child.
(v) Acute poisoning, e.g. alcohol, tricyclic antidepressants,
anticholinergics, theophylline, cocaine, amphetamine and
isoniazid.
(vi) Drug withdrawal, e.g. alcohol, benzodiazepine, narcotics,
cocaine.
(vii) Intracranial pathology:
(a) space-occupying lesion
(b) cerebral ischaemia
(c) subarachnoid or intracerebral haemorrhage.
(viii) Hyponatraemia, hypocalcaemia, uraemia and eclampsia.
4 Check a blood glucose test strip.
(i) Give 50% dextrose 50 mL i.v. if it is low, after taking blood for a
laboratory glucose estimation, or give glucagon 1 mg i.m. when
venous access is impossible.
5 Insert an i.v. cannula and take blood for FBC, U&Es, LFTs, and a drug and
alcohol screen.
(i) Proceed to ABGs, blood cultures, ECG, CXR and CT head scan
as indicated clinically, and attach a cardiac monitor and pulse
oximeter to the patient.
(ii) Send urgent anticonvulsant levels if the patient is on treatment.MANAGEMENT
1 Give high-dose oxygen via a face mask. Aim for an oxygen saturation above
94%.
2 Make sure the head is protected from harm and turn the patient semi-prone.
Do not attempt to wedge the mouth open.
3 Give midazolam 0.05–0.1 mg/kg up to 10 mg i.v., diazepam 0.1–0.2 mg/kg up
to 20 mg i.v. or lorazepam 0.07 mg/kg up to 4 mg i.v. if the patient is having a
seizure, or if the seizure recurs.
4 Refer the following patients for admission to the medical team:
(i) Suspected underlying cause such as meningitis, tumour, etc.
(ii) A seizure exceeding 5 min, or recurrent seizures, especially if
there is no full recovery between them.
(iii) Residual focal central nervous system (CNS) signs.
(iv) Seizure following a head injury (refer to the surgeons).