Sam speaks to Intensivists Dr Jonathan Casement and Dr Rob Everitt about reduced consciousness and acute and post-seizure management.

Approach to fluctuating GCS

* Eyeball the patient / ABCs

* Calling a code – certainly if the patient is not rousable!

* 777 (or your local hospital emergency number)

* This is Sam, medical house officer I need the adult resus team to attend North Shore Hospital, ward 10, room E3.

* Initial assessment

* Big picture

* Vitals

* Pupils

* Wide: drugs, alcohol, adrenaline

* Constricted: opiates

* How does the patient respond to questions?

* Assess GCS

* Differential

* Intracranial or extracranial?

* Surgical sieve

* Overdose, head injury, seizure, diabetic, epileptic, previous episodes, medications

* Don’t ever forget glucose

* Collateral history, including from other patients in the room

* Vitals + Examination

* General inspection + peripheries

* Neuro exam aimed at identifying localising signs

* Consider investigations

* ABGs, glucose, FBC, electrolytes, creatinine, cardiac enzymes, ketones, TFTs, blood cultures, alcohol, coags

* ECG, CXR, catheter urine

* Consider CT head, LP

* Rarely toxicology (urine and blood)

* Consider the “3 coma antidotes”

* Glucose: if hypoglycaemia confirmed on BSL give 100mL of glucose 10% IV

* Thiamine: 100mg IV/IM (for patients with chronic alcohol abuse or chronic malnutrition)

* Naloxone:

* 400 micrograms (1 ampule) in a resus situation (concerned about airway)

* 80 microgram boluses for somnolent patients that are just difficult to rouse. Repeat every minute with a 10 mL flush until alert.

* Maximum of 10 mg in total.

* Note short half-life, so often need repeat doses.

* Document

* Basics (date/time/name/reason for review).

* Positives and pertinent negatives.

* Impression and differential with justification.

* Clear and specific plan.

* Consider discussion with senior and escalation.

Acute seizure management

* DRSABCs

* Airway

* 100% oxygen via non-rebreather or bag mask

* Recovery position (protect the patient and staff from injury)

* Breathing

* Sats probe

* Circulation

* Pulse

* CRT

* Don’t attempt BP during seizure

* Duration >5 minutes

* Code code if not done already

* IV access (IO if failed IV)

* Seizure control:

* Lorazepam (or midazolam) 4 mg IV (give 2 mg, flush, then another 2 mg slowly and flush).

* IM midazolam 10 mg is the treatment of choice if no IV access is available. The dose may be repeated if required after 10 minutes. Maximum midazolam dose of 20 mg IM over 24 hours.

* Rectal diazepam 10 mg if above not IV and IM access unavailable (empty rectum first).

* Lorazepam has a longer anti-epileptic effect than diazepam as it is not redistributed to adipose tissue. If lorazepam is not immediately available do not delay but proceed with diazepam or midazolam.

* An anticonvulsant must be started if there is more than one seizure.

Post-seizure management

* IV access

* Secondary survey for injury and infective causes

* History and description of the events surrounding the seizure.

* Who witnessed it?

* What situation was the patient in before it started?

* Incontinence or tongue biting.

* Post-ictal features.

* Does the patient remember the episode?