ACUTE NEUROLOGICAL CONDITIONS92 General Medical Emergencies
MANAGEMENT
1 Give the patient oxygen via a face mask, and aim for an oxygen saturation
above 94%.
2 Check the blood sugar:
(i) Give 50% dextrose 50 mL i.v. if it is low.
(ii) Give thiamine 100 mg i.v. in addition if chronic alcoholism
or malnutrition is likely, to avoid precipitating Wernicke’s
encephalopathy.
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.
(i) Beware of causing respiratory depression, bradycardia and
hypotension, especially in the elderly.
4 Get senior ED doctor help if the patient is still having a seizure:
(i) Repeat the midazolam, diazepam or lorazepam i.v. until seizures
cease.
(ii) Then give phenytoin 15–18 mg/kg i.v. no faster than 50 mg/min
by slow bolus, or preferably as an infusion in 250 mL normal
saline (never in dextrose) over 30 min under ECG monitoring, or
(iii) Give the pro-drug fosphenytoin at an equivalent dose but faster
rate.
5 Other drugs that may be used include phenobarbitone (phenobarbital)
10–20 mg/kg i.v. no faster than 100 mg/min, or clonazepam 0.5–2 mg i.v.
(i) By now, make sure the ICU team is involved if seizures continue.
(ii) All patients will require admission, possibly to a high-
dependency area.
6 Occasiona lly, if i.v. access is impossible, give:
(i) Rectal diazepam, especially in children, using parenteral
diazepam solution 0.5 mg/kg given through a small syringe (see
p. 365) or midazolam 0.5 mg/kg p.r. or via the buccal route.
7 Consider the following underlying reasons when a patient fails to regain
consciousness, despite the seizures stopping:
(i) Medical consequences of the seizures:
(a) hypoxia
(b) hypo- or hyperglycaemia
(c) hypotension
(d) hyperpyrexia
(e) cerebral oedema
(f) lactic acidosis
(g) iatrogenic over-sedation.
(ii) Progression of the underlying disease process:
(a) head injury, e.g. extradural or subdural
(b) meningitis or encephalitis