Presentation given by Dr Catherine Poots from Craigavon Area Hospital at the 2014 Northern Ireland Intensive Care Society annual Coppel Prize on Wednesday November 26th

1. CRAIGAVON AREA HOSPITAL
INTENSIVE CARE UNIT
COPPEL PRIZE PRESENTATION 2014
NORTHERN IRELAND INTENSIVE CARE SOCIETY
CATHERINE POOTS
CT1 ACCS 26/10/2014

2.  Incidence of Status Epilepticus in adults: 4-27/100 000/year1,2
 Definition of Status Epilepticus (SE)3
 5 minutes or more of continuous clinical seizure activity OR
 Recurrent seizure activity without recovery in between
 Classification of SE4
 Convulsive
 Non-convulsive
 Refractory SE5
 SE that does not respond to standard treatment regimes

3.  Aim
 To investigate the management of patients admitted to ICU
with SE/uncontrolled seizures before, during and after their
admission
 Objectives
 Was there a preventable reason for SE?
 Was local protocol adhered to prior to ICU admission?
 Were patients admitted to ICU within the recommended
timeframe?
 What was the resource utilisation of patients admitted to
ICU (including EEG)?
 Were patients followed up by a Neurology service and what
was 30 day mortality?

4.  100% of patients to be initially managed
according to Southern Trust protocol (in
line with NICE clinical guidelines) 7,8
 100% of patients admitted to ICU within
30-90 minutes7,8

5. STAGE EMERGENCY AED THERAPY
PREMONITORY (PRE-HOSPITAL) DIAZEPAM 10-20mg PR (x2) or
MIDAZOLAM 10mg PO
EARLY STATUS LORAZEPAM 0.1mg/kg IV (x2)
ESTABLISHED STATUS PHENYTOIN INFUSION (15-18mg/kg)
or FOSPHENYTOIN or
PHENOBARBITAL
REFRACTORY STATUS
(60-90 MINUTES AFTER INITIAL
THERAPY)
GENERAL ANAESTHESIA
(PROPOFOL / MIDAZOLAM /
THIOPENTAL SODIUM)
ANAESTHESIA CONTINUED FOR
12-24 HOURS AFTER THE LAST
SEIZURE

6.  Retrospective
 ICNARC – all patients admitted to CAH ICU
between 01/08/10 and 31/07/13 with a diagnosis
of SE or uncontrolled seizures (78)
 PAS used to identify those patients seen at
Neurology OPC either before or after admission
(26)
 Single auditor
 Medical & Neurology case notes and NIECR

7. GENDER
MALE (13)
FEMALE (13)

8. 7
6
5
4
3
2
1
0
AGE RANGES
16-25 26-35 36-45 46-55 56-65 66-75 76-85
NUMBER OF CASES

9. STATEMENT PATIENT KNOWN TO HAVE EPILEPSY %(n)
YES 57.7% (15)
NO / NOT DOCUMENTED 42.3% (11)
AEDS TAKEN PRIOR TO
ADMISSION
PATIENTS WITH
EPILEPSY
% (n)
PATIENTS WITHOUT
STATEMENT OF
EPILEPSY % (n)
LEVETIRACETAM/KEPPRA 38.5% (10) 3.8% (1)
VALPROATE/EPILIM 23.0% (6) 3.8% (1)
LAMOTRIGINE/LAMICTAL 15.4% (4) 0
OTHER AED 15.4% (4) 0
PHENYTOIN/EPANUTIN 11.5% (3) 0
CARBAMAZEPINE/TEGRETOL 3.8% (1) 0
CLOBAZAM/FRISIUM 0 3.8% (1)
NO AED 0 38.5% (10)

10. PATIENTS KNOWNTO HAVE EPILEPSY % (n)
SERUM AED CHECKED 33.3% (5)
SERUM AED NOT CHECKED 66.7% (10)
SERUM C2H5OH CHECKED ON
ADMISSION
%(n)
MEASURED 92.3% (24)
LEVEL <10 80.8% (21)
LEVEL >10 11.5% (3)

11. 35
30
25
20
15
10
5
0

12. Rx PRIOR TO ICU % (n) DOSE RANGE
(AVERAGE)
DIAZEPAM/DIAZEMULS 30.7% (8) 10-20mg (12.5)
LORAZEPAM 73.1% (19) 2-12mg (4.6)
PHENYTOIN 69.2% (18) 0.3-2g (0.95)
THIOPENTONE 3.8% (1) 1mg
VALPROATE 3.8% (1) 800mg
MIDAZOLAM 3.8% (1) 5mg
NO/MISSING
11.5% (3) N/A
DOCUMENTATION

13. 20
15
10
5
0
LENGTH OF TIME TO ICU ADMISSION
0-90 91-180 181-270 271-360 361-450 451-540
MINUTES
% OF CASES

14. ORGAN SUPPORT % (n) RANGE (AVERAGE) DAYS
RESP (INVASIVE) 92.3% (24) 1-9 (2.7)
CVS 11.5% (3) 2-6 (3.6)
CRRT 0 0
EEG
Performed in 7 patients
• 2 non-convulsive status
• 2 no evidence of epileptiform discharges
• 1 alpha coma
• 1 hypoxic encephalopathy
• 1 sharp activity likely related to previous head injury and
neurosurgery

15.  Addition of Phenytoin – 42.3%
 30.7% continued on hospital discharge
 Addition of Levetiracetam – 11.5%
 Addition of Clobazam – 7.7%
 Addition of Sodium Valproate – 3.8%
 Increased dose of usual AED – 19.2%

16.  15 patients subsequently reviewed at a
SHSCT Neurology OPC
 2 patients reviewed within other NI trusts
 2 patients had ongoing disability at time of
ICU discharge
 25/26 patients alive at 30 days

17.  Patients with known epilepsy under the review of a
Neurologist
 Serum alcohol/drugs of abuse levels checked in 92.3% of
patients
 Potential provoking factor identified in 69.2% of patients
 Protocol generally well followed
 EEG performed
 Majority of patients followed up by Neurology post discharge
with low rates of ongoing morbidity and mortality

18.  Serum AED levels checked in 33.3%
 Weight rarely recorded - ?sub-therapeutic
doses of Lorazepam / Phenytoin prior to
ICU admission
 Only 15.4% of patients admitted to ICU
within recommenced timeframe of 90
minutes

19.  Small sample
 Retrospective
 Biased selection of patients
 Non-documentation / missing information
from case notes
 Use of AEDs very individualised

20.  Results shared with colleagues locally at
M&M meeting
 Review local protocol – highlight
recommendation to check serum AED levels
 Record estimated / actual weight of all
patients admitted with seizures
 Re-audit

21.  1. Sander JW The epidemiology of epilepsy revisited. Current Opinion in
Neurology, 16, 165–70 (2003)
 2. National Audit of Seizure Management in Hospitals (April 2014)
 3. Brophy G et al. Guideleines for the Evaluation and Management of
Status Epilepticus. Neurocritical Care Society Status Epilepticus Guideline
Writing Committee. April 2012.
 4 .Lowenstein DH, Alldredge BK. Status epilepticus. N Engl J Med
1998;338:970-6
 5. Shorvon S. Status epilepticus: Its clinical features and treatment in
children and adults. Cambridge, England: Cambridge University Press;
1994
 6. Chin RFM, Neville BGR & Scott RC (2004) A systematic review of the
epidemiology of status epilepticus. European Journal of Neurology, 11,
800–10.
 7. SHSCT Status Epilepticus In Adults. January 2006
 8. The epilepsies: the diagnosis and management of the epilepsies in
adults and children in primary and secondary care. NICE Clinical Guideline
137, 2012.

22.  Dr G Browne
 Dr C McAllister
 Dr K McKnight
 Dr R Forbes
 Mrs H Renshaw
 Mrs G Cullen
 Ms E Johnston