seizure secondary to ICH, Hypertensive bleed.pptx

Case of Hypertensive ICH

1. BLEED,BLAST,AND BEYOND :TACKLING POST-HEMORRHAGIC SEIZURE Presenter: Dr. Sanju Saji Department: Emergency Medicine Hospital: Indira Gandhi Co-operative Hospital, Kochi

2. Identification Name: C.K. Sulochana Age/ Sex : 68 years / Female Weight: 51 kg Height: 143 cm Date of Admission: 28/09/2025 Unit: Emergency Department

3. Mode of Arrival & Triage Brought by relatives Mode: Wheelchair Triage Category: RED (Critical) Reason: Altered sensorium and left sided weakness

4. Chief Complaints • Sudden-onset left-sided weakness – 30 min before arriving to hospital • Vomiting – 1 episode • Cough with expectoration – 2 days • Generalized tonic- clonic seizure – developed after arrival in ED

5. Primary Survey (ABCDE) Airway : Threatened Airway No facial trauma, no oral bleeding, no foreign body visualised Breathing : RR -12bpm SpO ₂ - 99 %RA , Shallow breathing ,no cyanosis ,no tracheal deviation Circulation : BP 280/140mmHg, HR 98 /min, Peripheral pulses palpable Capillary refill <2sec , no raised JVP/pedal oedema No external bleeding /signs of shock.

6. Disability : GCS –E2V2M6 ,Pupils – Pseudophakia left, 2mm reactive right Left side weakness noted UL >LL , no neck stiffness/cranial nerve palsy Blood sugar :111mg /dl Exposure : Afebrile, No external injuries No cyanosis ,no bruise , no bite marks/ tongue injury

7. Adjuncts to primary survey ABG - PH 7.50 / PaCO ₂ 34.7 / HCO₃⁻ 19 Lactate: 3.0 mmol/L Mixed Acid-Base Disorder: Respiratory Alkalosis with Underlying Metabolic Acidosis (Lactic) ECG: Bradycardia with ectopics CXR: Early aspiration changes

8. Initial Intervention Protected airway ,breathing ,circulation Administered 100%O2 by mask. Oral suctioning done Insert Nasopharyngeal airway Established 2 large bore IV cannula Took samples Inj midazolam 2mg iv stat Started on IV labetalol 10 mg stat Shifted to do CT Brain

9. Secondary Survey >Signs and symptoms •Patient Apparently normal 30 min prior to arrival •Developed Sudden left-sided weakness of upper and lower limbs followed by one episode of vomiting, projectile. • While in ED: generalized tonic- clonic seizure (~2 min) followed by Post-ictal unresponsiveness • Mild cough with expectoration 2 days, afebrile • No prior seizures or trauma /No alcohol withdrawal >No known allergy /drug allergy >On Antidiabetic and anti hypertensive medication

10. >Past history : Hypertension (poorly controlled), Old CVA (1 year) No h/o head injury /neurosurgical procedure No h/o anticoagulant use >Last meal : 1 hour before coming to hospital >Social history Non –smoker /Non alcohol consumption No h/o withdrawal symptoms

11. General Examination General Appearance : Patient conscious , not oriented to time ,place and person, ill –looking Pallor /icterus/cyanosis/clubbing/lymph adenopathy / pedal edema -ABSENT Extremities : No edema or deformity

12. Neurological Examination • Post-ictal phase, GCS 6/15 (E1V1M4) • Left-sided hemiparesis: UL > LL involvement • Muscle tone: Increased on left side • Power: 1/5 in left UL and LL • Reflexes: Exaggerated on left side • Plantar response: Extensor on left side, flexor on right • Sensory: Grossly intact • No neck stiffness • No cranial nerve palsy • Pupils:Pseudophakia left, 2mm reactive right

13. Head-to-Toe Assessment Head & Scalp: • No external injuries, no hematoma or laceration Eyes: •Pupil- Pseudophakia left, 2mm reactive right ; no papilledema • Fundus exam deferred (due to poor sensorium) Ears/Nose/Throat: • No CSF leak, bleeding, or tongue bite noted Chest: • Symmetrical expansion; bilateral air entry • Coarse crepts at bases

14. Cardiovascular: • S1S2 normal, no murmurs • Peripheral pulses palpable Abdomen: • Soft, non-tender, bowel sounds present • No hepatosplenomegaly Extremities: • Left-sided weakness (power 1/5), right side 5/5 • No cyanosis, edema , or deformity Skin: • No petechiae, bruising, or pressure sores

15. Investigations CT Brain: Massive ICH with ventricular extension & mass effect

16. Differential Diagnosis 1. Seizure secondary to hypertensive intracerebral hemorrhage (most likely) 2. Seizure secondary to metabolic causes 3. Post-stroke seizure 4. Hypoglycemia 5. Electrolyte imbalance 6. Meningitis 7. Drug Induced 8. Poisoning 9.Brain Abscess

17. Final Diagnosis • Acute Intracerebral Hemorrhage (ICH) due to hypertensive crisis • New-onset seizure secondary to ICH • Accelerated hypertension with Cushing’s reflex • Aspiration pneumonia (LRTI)

18. Emergency Management • ​ Airway/Breathing: • ​ INTUBATION: Performed post-seizure due to drop in GCS and I/V/O Increase ICP . A 7.5 ET tube was inserted after pre- oxygenation and pre- medication (Propofol , Scoline ). • ​Ventilation started on ACV mode. • ​ Circulation (Aggressive Neurological and BP Management): • ​ Anti-seizure: Inj midazolam 2mg iv followed by inj levipil 1gm iv stat.

19. • ​ ICP Management: Inj. Mannitol 20%   100 ml IV stat. • ​ BP Control: Inj. Labetalol 20 mg IV stat ; NTG infusion started at 4.8ml/hr with 25mg /50 ml NS • ​ Other: Inj. Tranexa 1 gm IV stat, Inj. Magnex Forte 1.5gm stat i /v/o infection • ​ Disposition: • ​Admission under Neurosurgery in MICU

20. Summary 68-year-old hypertensive female with prior CVA Presented with left hemiparesis → developed seizure in ED CT: Massive ICH with ventricular extension Managed with airway protection, seizure & BP control, ICP measures Case was discussed with Dr.Baiju by ER Physician (Dr Nadeem). Before shifting to ICU post intubation patient shows decerebrate posturing. Relatives were informed about the poor prognosis and severe brainstem damage after seeing the same

21. SEIZURE & STATUS EPILEPTICUS – EMERGENCY MEDICINE PRESENTATION References: Oxford Emergency Medicine | Tintinalli’s Emergency Medicine 9e |Rosen’s emergency medicine| NICE | ILAE |

22. OBJECTIVES • Define seizure and epilepsy
• Classify seizures & status epilepticus
• Recognize emergency presentations
• Outline structured management for adults, pediatrics • Identify complications and disposition decisions

23. DEFINITION DEFINITION REFERANCE : ROSEN’S EMERGENCY MEDICINE Seizure : A paroxysmal event characterised by temporary involuntary changes in the patient caused by abnormal and excessive activity of a group of cortical neurons. Epilepsy : Defined as the occurrence of 2 or more unprovoked seizure. Status Epilepticus ( SE ): Defined as 5 minutes or more of continuous seizure activity without return to baseline between s eizures.

24. Refractory SE : Defined as persistent Seizure activity despite the IV administration of adequate amount of 2 antiepileptic agents usually exceeds 60 minutes. Febrile seizures : Defined as a seizure occurring in the presence of fever without CNS infection or other cause (occurs in children b/w 6 months and 6 years

25. CLASSIFICATION OF SEIZURES

26. ETIOLOGY

27. Paroxysmal Disorders: Differential Diagnosis SYNCOPE PSEUDOSEIZURE /PSYCHOGENIC SEIZURE HYPERVENTILATION SYNDROME MIGRAINE HEADACHE WITH AURA MOVEMENT DISORDER BREATH-HOLDING SPELLS RIGORS OR CHILLS

28. Initial Approach – ABCDE (Resuscitation Phase) A – Airway - Ensure patency (position lateral to prevent aspiration). - Remove any foreign body / dentures. - Insert oropharyngeal airway if needed (after seizure stops). B – Breathing - Administer 100% O₂ by mask. - Monitor SpO ₂ . - If apneic → Bag-valve-mask ventilation , consider intubation if prolonged seizure or GCS <8.

29. C – Circulation - Check BP, HR, ECG . - Establish IV access × 2. - Draw blood for glucose, electrolytes, Ca²⁺, Mg²⁺, renal, LFT, toxicology, AED levels . - Treat hypoglycemia immediately if suspected . D – Disability (Neuro) - Assess GCS, pupils, tone, focal signs . - Check capillary blood glucose immediately. E – Exposure - Look for trauma, tongue bite, signs of infection, rash (meningococcal).

30. Immediate Empirical Measures Hypoglycemia - 50 mL of 50% Dextrose IV (or 5 mL/kg in children) after 100 mg Thiamine IV (if alcoholism/malnutrition). Hypocalcemia - 10 mL of 10% Calcium Gluconate IV over 10 mins . Hypomagnesemia - 2 g MgSO ₄ IV over 5–10 mins .

31. MANAGEMENT IN ADULTS Reference: Tintinallis EM

32. MANAGEMENT IN CHILDREN REFERANCE : ROSEN’S EM

33. INVESTIGATIONS • CBC, RFT, LFT, Electrolytes, Glucose
• ABG, Calcium, Magnesium
• Toxicology screen (alcohol, drugs)
• CT/MRI brain after stabilization
• EEG if persistent altered sensorium Pregnancy test if needed

34. COMPLICATIONS • Hypoxia, aspiration, lactic acidosis • Rhabdomyolysis → acute kidney injury • Cardiac arrhythmias (from drugs) • Neurologic deficit / cognitive decline • Maternal/ fetal hypoxia (pregnancy)

35. TAKE-HOME MESSAGE • Treat rapidly: time = brain
• Secure airway early
• Administer benzodiazepine within 5 min
• Escalate stepwise → ICU if refractory
• Always search & treat the underlying cause