231005 Status epilepticus initial treatment-Nghi Y3.pptx

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1. Case Presentation Lê Vĩnh Nghi, MD Internal Medicine Resident VinUniversity GME Program Supervisor: Dr. Phạm Đăng Hải

2. Chief complaint 05/10/2023 66-year-old male presented to ED with altered mental status 2

3. History of Present Illness (family member) 05/10/2023 3 Morning: Family member called him but no answer → Another family member came to check and found out he was having seizure on bed (with unknown-time) No information about what happened before the event (+) symptoms: confused, not responding to noise, eyes rolling upwards, clonic, loss of bladder control, sweating (-) symptoms: fever, weakness Cannot know: headache, blurred vision, dizziness, chest + abdominal pain, palpitation, feces + urination characteristic 4 – 5 days 1 day Admission Lately, he had blurred vision He had been staying alone at home for 4 – 5 days with no family members, drank more alcohol and less appetite The night before the event, he was still in normal status (through video call with family member) → Cottage hospital: still seizure, treated with antiepileptic, ET, antibiotics, vasopressor → Not better in conciousness → Family self-transferred to 108 (no transferred report)

4. Video clip at cottage hospital 05/10/2023 4

5. Past Medical History 05/10/2023 5 PMH: HTN, DM2; prior stroke (2017, no document), recovered; many unwitnessed episodes of seizure with loss of bladder and bowel control after stroke (he told his family that he fell sometimes, after reawaken, he found out that he had urine and feces uncontrolled, but afterwhich, there were no visit for evaluation) PSH: None Meds: HTN and stroke (no prescription from family member yet), DM2 Insulin (self-injected, no compliance, according to his preferences) Allergy, Family: None Social: Smoking: None. Drug: None Alcohol: 200 – 300 ml/day, more on those days at home

6. Physical Examination (ED) 05/10/2023 6 Level of conciousness: Intubated + sedated, RASS -3 No edema, no rash, no signs of trauma VS: HR 140, BP 130/90 (Adre + Dobu), T 37 O C, RR 18, SpO2 98% HEENT: Atraumatic. No bleeding from nose, ear Eyes: PERRLA, 2mm Thyroid: non-enlarged. Normal lymph nodes

7. Physical Examination 05/10/2023 7 Cardiovascular: No cardiomegaly or thrills; RRR, no [murmur, gallop, rub, distant heart sounds, JVD] Respiratory: No rales or diminished breath sounds, normal [tactile fremitus + percussion + chest expansion + respiratory pattern] Abdomen: Symmetry, no (lesion + mass + distention), normal bowel sounds, no shifting dullness, no pain on palpation Musculoskeletal: No defects, tenderness, masses Neurologic: sedated, nuchal rigidity (-), no seizure during examination

8. One liner 05/10/2023 8 66 year-old alcoholic male, history of stroke, non-compliant HTN and DM2, presents to ED with altered mental status associated with status epilepticus. PE shows sedated and no signs of trauma, other findings are unremarkable Differential diagnosis Labs tests, imaging

9. CBC + CMP (ED) CBC CMP WBC 16,26 Na 137 Neu% 90,5 K 4 RBC 4,59 Cl 100 HGB 15,2 Calci ionized 1,04 (0,9 – 1,3) HCT 45 Glucose 34 MCV 98 (80 – 100) Urea 18,3 MCH 33 (24 – 33) Creatinine 225 PLT 223 Bilirubin TT / DR 16 / 3 AST / ALT 26 / 13 HbA1c 9,3 05/10/2023

10. Other biochemistry 05/10/2023 CRP 153 Mg 0,38 (0,73 – 1,06)

11. Coagulation 05/10/2023 PT (%) 100 (normal) aPTT 33 (normal) Fibrinogene 5 D-dimer > 7000

12. Arterial blood gas (ED) 05/10/2023 Arterial blood gas pH 7,37 pCO2 28 pO2 83 FiO2 60% HCO3- 16,2 Lac 10,8 AnGap 18 Serum osm 342

13. CSF analysis (LP 3 days later) 05/10/2023 Cell Color Biochemistry Clear WBC: 1 RBC: 0 Glucose: 8 (serum G: 10) Protein: 0.47 Opening pressure: not performed Rivalta test: (-)

14. CSF virus 05/10/2023 HHV, VZV, CMV, EBV, HSV (-)

15. Autoimmune encephalitis 05/10/2023 NMDA, AMPA, GABAB, LG11, DPPX, CASPR2 (-)

16. Blood cultures 05/10/2023 Blood cultures (-) both samples

17. Head CT-scan 05/10/2023 Prior lacunar ischemic stroke (R caudate + lentiform nucleus) No hemorrhage No brain herniation

18. Chest CT-scan 05/10/2023 No pulmonary artery occlusion

19. Brain MRI (5 days after admission) 05/10/2023

20. Brain MRI 05/10/2023 Bilateral cortical and subcortical lesions at temporal, parietal, insular lobes, decreased diffusion on DWI, increased signal on FLAIR

21. ECG 05/10/2023 Sinus rhythm, rate 135

22. Chest X-ray 05/10/2023 Normal chest X-ray

23. Abdominal US 05/10/2023 Normal abdominal US

24. Cardiac US 05/10/2023 Normal cardiac US EF 65% Normal Dd, Ds R ventricle 20

25. EEG 05/10/2023 25 Dominant slow waves (R) > (L) Photic stimulation: suspected epileptic waves

26. Clinical progression 05/10/2023 26 During his stay, he’s been sufferred brief focal seizure episodes Neuro consultation: Look for meningoencephalitis (virus, autoimmune). Virus (-), treated with Dexa, no response, autoimmune antibodies (-) → Taper Dexa → Until today he is still in coma and has brief focal seizure episodes

27. Labs progression 05/10/2023 Parameter 19/09 20/09 21/09 22/09 23/09 24/09 25/09 WBC 16,26 16,67 14,42 12 10 Neu% 90,5 83,4 82,3 81 75 CRP 153 150 50 19 24 Na 137 145 154 148 142 K 4 4,5 4 4 4 Glucose 34 19 10 Creatinine 225 139 93 90 80 70 pH 7,37 7,4 7,43 7,4 pCO2 28 36 38 39 pO2 83 85 70 91 HCO3 16,2 23 25 24 Lactate 10,8 4,5 1,7 1,5 1,6

28. Evidence 05/10/2023 28 Clinical Labs Imaging Status epilepticus: unknown cause Increased WBC, Neu, CRP MRI: Bilateral cortical and subcortical lesions at temporal, parietal, insular lobes, decreased diffusion on DWI, increased signal on FLAIR → suspected of cerebral hypoxia Non-compliant insulin injection Increased markly Glucose, not excluded hypoglycemia before CT: Prior lacunar ischemic stroke (R caudate + lentiform nucleus)

29. Current diagnosis 05/10/2023 Coma complicated from cerebral hypoxia post status epilepticus / HTN, DM2, prior stroke 29

30. Unanswered Questions 05/10/2023 30 What actually cause the status epilepticus and the seizure episodes ? Hyperglycemia, Hypoglycemia Alcohol intoxication, Alcohol withdrawal syndrome Encephalopathy (Wernicke, …) Post ischemic stroke seizure Meningoencephalitis Encephalopathy …

31. Brief overview: - Status epilepticus initial treatment - Altered mental status causes - MRI: widespread restricted diffusion

32. Life threatening conditions ? 05/10/2023 32 Uptodate: Evaluation of abnormal behavior in the emergency department

33. Early treatment of status epilepticus 05/10/2023 33

34. Importance of early treatment 05/10/2023 34

35. DDx Seizure: Brain vs No-brain 05/10/2023 35

36. DDx AMS: Brain vs No-brain 05/10/2023 36

37. Emergent evaluation 05/10/2023 37 Uptodate: Emergent evaluation and management of stupor and coma in adults ABCDEF approach

38. Common patterns of widespread restricted diffusion 05/10/2023 38 Mason Sharma, A et al. Neuroimaging mimics of anoxic brain injury: A review.  J Neuroimaging . 2023 Santana LM. Differential diagnosis of temporal lobe lesions with hyperintense signal on T2-weighted and FLAIR sequences: pictorial essay. Radiol Bras. 2020

39. Clinical pearls 05/10/2023 39 Status epilepticus initial treatment Once again: altered mental status causes MRI: Common patterns of widespread restricted diffusion

40. Clinical progression 05/10/2023 41 First clinical history from family member (not living in the same house): 4 days of alcohol, less appetite, loose stool, fever 38-39, confused → Diagnosed with septic shock suspected from GI on the first day (antibiotics, vasopressor at cottage hospital, not known about glucose) → 108 Hospital: treated with Meropenem + Amikacin 1 day later, stop vasopressor

41. Clinical progression 05/10/2023 42 During his stay, he still have brief focal seizure Consultation: Look for autoimmune meningoencephalitis, treated with Dexa, but no response, and autoimmune antibodies (-) → Until today he still in coma and has brief focal seizure