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Ростовский Государственный Медицинский Университет
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Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2899_Библиотеки_им_академика_М_И_Перельмана

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Viralswabs:
Swabvesiclesifrashpresent Considerthroat/rectalswabforenterovirus.
Bloods
FBC,U&E,LFT,CRP,andcoagulationprofile Bloodcultures Serumglucoseandprotein(pairedwithCSF) HIVtestinginallpatients.
Imaging
CThead:
If↑intracranialpressureissuspectedclinically,aCTheadmustbeperformedpriortolumbar puncture(LP).
Other
LP:
Should be done as soon as possible but do not delay treatment if it cannot be done immediately Ensureadequatereversalofanticoagulationpriortoperforming IncludeviralPCRforHSV1,HSV2,VZV,andenterovirus:
Thesetestswillidentify90%ofcasesofviralencephalitis Cerebrospinalfluid(CSF)PCRforHSVhasasensitivityandspecificity>95%ifdone
betweendays2and10oftheillnessinimmunocompetentadults Considerfurtherviralandantibodytestingaspertheadviceoflocalmicrobiology/infectious disease/neurologyteams SeeTable49.2.
Table49.2LPinterpretationinviralencephalitis
Test Resultsuggestiveofviralencephalitis
CSFopeningpressure ↔or↑
CSFcolour Clear
CSFprotein Mildly↑
CSF/serumglucoseratio ↔
CSFwhitecellcount Moderately↑
CSFlactate <2mmol/Lrulesoutabacterialcause
Bacterialcultures Nogrowth
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Normal CSF does not rule outHSV encephalitis—up to 10% of initial LPs are normal. If clinicalsuspicionishigh,theLPshouldberepeatedwithin24–48hours.
MRIbrain:
Within24–48hoursifdiagnosisisuncertain—moresensitiveandspecificthanCT Cingulategyrusandmedialtemporallobeoedema±haemorrhage orrestricteddiffusionare suggestiveofHSVencephalitis IfunabletotolerateMRI,performaCTheadwithcontrast
EEG:
Ifconsideringapossiblepsychiatricdiagnosis,encephalopathicchangesonEEGmayhelpto differentiate SubclinicalseizureactivitywillalsoshowonEEG.
Management
Acutemanagement
IVaciclovir
MustgiveempiricaltreatmentofIVaciclovir10mg/kgTDSif:
InitialCSForimagingresultssuggestviralencephalitis Resultswillnotbeavailablewithin6hours Thepatientisveryunwellordeteriorating
ContinueIVaciclovirfor14–21days,thenrepeattheLPtoconfirmCSFisnegativeforHSVPCR IfHSVPCRisstillpositive,continueIVaciclovirandrepeatLPweeklyuntilnegative.
Steroids
SteroidsshouldnotbeusedroutinelyinHSVencephalitis However,thereisanoverlapbetweenthepresentationsofencephalitisandmeningitis,andmany patientsaregivensteroids(andantibiotics)asempiricaltreatmentformeningitis(seeChapter52).
Supportivemanagement
IVfluidsandcorrectionofelectrolyteimbalances Seizurecontrol(seeChapter50).
Referrals
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Urgentintensivetherapyunit(ITU)reviewifdecreasingGCSscore Neurologyreviewwithin24hours Notifyinfectiousdiseaseteamifaninfectiouscauseissuspected.
Treatmentafterstabilization
Musthaveoutpatientneurologyfollow-upwithongoingrehabilitationandtherapyinput Make patient aware of support provided by voluntary sector organizations, e.g. Encephalitis Society
Specialconsiderations
Returningtraveller
If returningfrommalariaendemicareas,dorapidmalaria antigentestingandthreethickandthin bloodfilms Getadvicefrominfectiousdiseaseteamearlyasthepatientmayrequireadditionalinvestigations.
Immunocompromised
Encephalitisshouldalwaysbeconsideredinimmunocompromisedpatientswithanalteredmental state,evenifthefeaturesseematypical Itmay be appropriateto doaCT scanbefore the LP, asseverelyimmunocompromised patients mayhavelesionsonCTwithoutfocalneurology.AnMRIshouldalsobedoneurgently Consider thatatypicalpathogensmaybe responsibleforencephalitisinanimmunocompromised patient, e.g. Cryptococcus neoformans or Toxoplasma gondii; therefore, discuss with microbiologypriortosendingCSFasadditionaltestsmaybeneeded.
Antibodymediated
No pathognomonic signs, however the following should raise suspicion and lead to a discussionwithneurology:
Subacutepresentation(weeks–months) Orofacialdyskinesia(involuntarymovementsofthemouthorface) Choreoathetosis(rapidorslowinvoluntarymovements) Faciobrachialdystonia(involuntaryjerkingofthearmandthesamesideoftheface) Hyponatraemia Intractableseizures.
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Furtherreading
1.BMJBestPractice(2020).Encephalitis.Availableat:https://bestpractice.bmj.com/topics/en-uk/436
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Chapter50
Epilepsy
Guideline: NICE CG137 (Epilepsies: diagnosis and management):
https://www.nice.org.uk/guidance/cg137
OUPdisclaimer:OxfordUniversity Press makesno representation, express or implied, that the drugdosagesarecorrectand thatthe recommendations are an exclusive or mandatory course of care. All health professionals readingthistexthavearesponsibilitytoevaluateitsappropriatenessandtake theindividualneedsofthepatientintoaccount.
Localtrustguidelines:pleaserefertoyourlocalguidelinesasnecessary.
Overview
Epilepsy is a neurological disorder characterized by recurrent unprovoked seizures. Although common, the diagnosis can be difficult to make, with up to 30% of patients incorrectlylabelledwithepilepsy.Epilepsycancausestatusepilepticuswhichisamedical emergency. This is defined as a seizure lasting >5 minutesor when a patient has more thanoneseizurewithin5minutes,withoutregainingfullorbaselineconsciousness.
Diagnosis
History
Firstseizure
Anypatientwhopresentstotheemergencydepartmentwithasuspectedseizureneedsto be assessed to rule out other causes of TLoC (see Chapter 9), such as vasovagal or cardiacsyncope,ornon-epilepticattackdisorder(alsoknownaspsychogenicseizuresor pseudosyncope).
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Establishiflossofconsciousnessoccurredandtheduration Geta clearpictureoftheeventsbefore,during,andaftertheseizure,obtaininginformationfrom anyeyewitnessesasnecessary.Forexample,intonic–clonicseizures:
Before: any warning signs, abnormal sensations, automatisms, or emotional change (aura if followedbyafocalseizure) During:↑toneandshakingoftheupperandlowerlimbs,urinaryincontinence(mayalsooccur innon-epilepticevents),andtonguebiting After:periodofconfusionor↓GCSscore
Checkforprecipitatingfactorssuchasalcoholordrugabuse,orinfections.
Knownepilepsy
Usualseizuretypeandfrequency,usualantiepilepticmedications,andanyrecentchanges Descriptionofeventspre,during,andpostseizure.Wasthisatypicalseizureforthepatient? Establishanyprecipitatingfactors.Inparticular,checkcompliancewithmedication.
Examination
Allpatientspresentingwithaseizureshouldundergoacardiovascular,neurological,and mentalstateexamination.
Investigations
Investigations aim to rule out reversible causes of seizures (such as infection, hypoglycaemia,electrolytedisturbanceordrugmisuse)andreducediagnosticuncertainty.
Bedside
ECGtoscreenforcommoncausesofcardiacsyncope Urinarydrugscreensshouldbeconsideredwhereappropriate.
Bloods
FBC U&E Creatinekinase Boneprofile Magnesium Glucose CRP Lactate(VBG)—raisedlactatecanbesupportiveinthediagnosisofseizures.
Imaging
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ConsiderchestX-raytocheckforsignsofaspiration Consider CT head, particularlyif first seizure, to rule out acute intracranial pathology such as haemorrhage.
If the diagnosis is not clear from the history or eyewitness account, the following canbeconsideredinspecialistclinicsaspartofthepatient’sfollow-up:
Other
EEG
Shouldonlybe carriedouttosupportasuspecteddiagnosisofepilepsy.Itshouldnotbeusedin isolationto confirm or refutethe diagnosis, or if the history suggeststhepatienthada syncopal event,duetothelikelihoodofafalse-positiveresult If a standard EEGhas not beenhelpful in contributing to the diagnosis, a sleep-deprived EEG shouldbecarriedoutinpreferencetorepeatEEGs Longer-term ambulatorymonitoring or video-telemetry can be considered if despite performing EEGthediagnosisremainsuncertain.
MRIbrain
Usefulinidentifyingstructuralabnormalities.
Itisparticularlyrecommendedin:
New-onsetseizuresinanadult Patientsaged<2years Focal-onsetseizures Continuationofseizuresdespitefirst-lineinvestigations.
Classification
Seizuresaretypically classifiedinaccordancewiththearea ofonset,levelofawareness (infocalseizures),andpresenceofmotorsymptoms.SeeTable50.1.
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Table50.1Seizureclassification
Typeofseizure Symptoms
Focal (Awareness unimpaired)
Motor Automatisms:lipsmacking,chewingmovements
Atonic:suddenlossoftoneinonepartofthebody Clonic:jerkingmovementsofonepartofthebody Myoclonic:briefshock-likejerksofamusclegroup Tonic:suddenincreaseintone,stiffnessofonepartofthebody
Non­motor
Abnormalfeelingsorsensationssuchasanabdominalrising,déjàvu,suddenintense emotions,unusualtastesorsmells,visualdisturbancessuchashallucinationsorflashing lightsorfeelingsofnumbnessortingling
Focal to bilateral
Previouslytermedsecondarygeneralizedseizures,typicallypresentwithanaurafollowed byatonic–clonicseizure
Generalized (Awareness impaired)
Motor Tonic–clonic:lossofconsciousnesswithstiffness,generalizedlimbjerking,followedbya
postictalphase Clonic/tonic/myoclonic/atonic:asdescribedabovebutaffectingtheentirebody
Non­motor
Absence:ceaseactivity,appearblankasiftheyaredaydreamingorstaring,lastingafew seconds
Management
Acuteepilepticseizure
Community
Generalmanagement
Donotrestrainthepatient Moveanything which may be potentially dangerous, e.g. hotdrinks, toprevent thepatientfrom harmingthemselvesastheyfit Trytoprotecttheirheadwithapillowortowelifpossible,andloosenanyclothingaroundtheir neck Oncetheseizureterminates,placethepatientintherecoverypositiontoawaittransfertohospital. Recordthelengthoftheseizure.
Ifthepatientisnotknowntohaveepilepsy
Callanambulance
Patientwithepilepsyinstatusepilepticus
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Ifseizuresareprolonged(continuingfor>5minutes)orrepeated(≥3seizureswithin1hour),give 10mgbuccalmidazolamor10mgrectaldiazepam.Thesedosesmayberepeatedafter10minutesif needed Callanambulanceif:
Seizurecontinues5minutesaftermedicationhasbeengivenOR ThepatientoftenhasrepeatedseizuresOR ThepatienthaspreviouslyhadstatusepilepticusOR ThisisthefirsttimethatantiseizurerescuemedicationhasbeengivenOR Thereisanyconcernaboutthepatient’sclinicalstate.
Hospital
Patients in hospital with self-terminating seizures may not require any specific management. For the management of status epilepticus, see Table 50.2. Contact an
anaesthetistearlyforsupport.
Table50.2ABCDEapproachtotheinpatientmanagementofstatusepilepticus
A Airwaymanagementwithanaestheticsupport
B Measurerespiratoryrateandoxygensaturations
Give100%oxygen
C Measurepulseandbloodpressure
Gainwide-boreIVaccessandsendbloodsforFBC,U&E,LFT,glucose,CRP,andVBG
D CheckCBG
Measuretemperature
E GiveIVlorazepam4mg(dosecanberepeatedafter10–20min)
IVdiazepamcanbeusediflorazepamisunavailable,orbuccalmidazolamifIVaccesshasnotbeenpossible Ifnoimprovement,commenceaphenytoininfusion(20mg/kg,maximum2g)atarateof50mg/min Ifineffective,considergeneralanaesthesia Ifthereisevidenceofalcoholexcessormalnutrition,prescribe50mL50%dextroseand/orIVthiamine (Pabrinex®)
Treatmentafterstabilization
Performinvestigationsasdescribedpreviouslyifnotalreadycompleted All patientswhohave had a suspectedfirstseizure should be seenurgentlyby a neurologist— usuallyasareferraltothe‘firstfit’clinic Information onminimizing theriskoffutureseizures andsafetyadvice shouldbegivenprior to referral.
An eyewitness account is essential. If referring to a ‘first fit’ clinic, the patient should be advisedthatitispreferablefortheeyewitnesstoaccompanythem.
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Patienteducation
Safetyadvice
Shouldbediscussedwithallpatients:
Driving(seeChapter115):
Firstseizure:donotdrivefor6months Establishedepilepsy:shouldbeseizurefreefor1yearbeforedrivingmaybeconsidered
Injuryprevention:adviceonwatersafety(patientsshouldshowerratherthantakebathsandshould swimonlyifepilepsyiswellcontrolledandalifeguardispresent),takingcarewithheights(e.g. usingladders),andnotlockingdoors.
Otherimportantinformation
Usuallydiscussedinspecialistclinics:
Diagnosis,medication,andsideeffects,includingtheimportanceoffamilyplanning Triggeravoidancesuchassleepdeprivation,stress,alcohol,anddrugs Suddenunexplaineddeathinepilepsy,howtominimizetheriskthroughoptimumseizurecontrol Voluntaryorganizationsandfurthersourcesofsupport.
Psychologicalinterventions
CBTandrelaxationtherapiescanbeusedasadjunctstoantiepilepticdrug(AED)treatment.
Pharmacologicalinterventions
AED treatment should be initiated by specialists, and should be individualized according to seizure type, thepatient, andtheircomorbidities. First-linetreatmentoptions are listedinTable
50.3
AEDtherapyshouldbecommencedonlyafterthesecondseizure,unless:
EEGshowsepilepticactivity Thepatienthasaneurologicaldeficit Thepatient(ortheircarer)findstheriskofasecondseizureunacceptable Neuroimagingshowsastructuralabnormality ThefirstseizurewasstatusepilepticuswhichrequiredAEDtherapytocontrol
AED monotherapy is ideal, following the guidance in Table 50.3. When switching AED, the secondAEDshouldbeescalatedtoatoleratedadequatedose,beforethefirstiswithdrawn Withdrawal ofAEDsshould be undertaken onlyundertheguidance ofspecialists,withpatients fullyinformedoftherisksandbenefits,andonlyinthosewhohavebeenunprovokedseizurefree for>2years.
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