Sun21November0437PM 18

You are the ward cover foundation year doctor and are fast bleeped to a patient having a tonic clonic seizure at 2 am.

The nurse on the ward explains that the patient has been admitted for 'neuro observations' from the Emergency Department, having sustained a head injury six hours previously. The patient has an intravenous cannula in situ, however has been given PR diazepam by the nurse as this has been prescribed on the drug chart. The seizures are still ongoing about 8 minutes since starting.

The patient's last neuro observations 15 minutes ago were: HR 70, BP 135/65 mmHg, RR 18, O2 97% room air and BM 7.0

Which drug therapy would you next initiate?

(Please select 1 option)

Lorazepam 4 mg IV Correct

Midazolam 5 mg buccal

Diazepam 10 mg PR

Diazepam 10 mg IV

Phenytoin 18 mg/kg IV

Explanation

It is essential to be familiar with the management algorithm for seizures, as extended periods of seizures can lead to profound hypoxia and cerebral damage.

First line management is a benzodiazepine that can be repeated if there is no improvement after five minutes of ongoing fitting. Ideally the benzodiazepine would be given intravenously, however if an IV line is not already placed the rectal route is recommended for speed and ease of delivering treatments. It is common to have rectal diazepam prescribed on the PRN section of the drug chart as not all nursing staff will be able to administer IV drugs.

In this scenario however the presence of an IV line and ongoing seizures would warrant an IV benzodiazepine. The preferred benzodiazepine now is lorazepam as it is thought to have a quicker time of onset and shorter duration of action.

Buccal midazolam is now being used in children as it is a quick, easy route of administration avoiding distressing PR administration.

If seizures were to continue despite two doses of benzodiazepines, the phenytoin should be initiated. At this stage senior and expert help is required, as if the seizures persist then intubation and ventilation may be required.

Never forget to obtain an early blood sugar as hypoglycaemic patients will often remain refractive to antiepileptic therapies until the sugars are normalised. ABC then DEFG - do not ever forget glucose.

Answer Statistics

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91%

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1%

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6%

4

4%

Times answered: 275