Status Epilepticus

May Loke – Advanced Trainee

Definitions : Neurocritical care guidelines 2012

5 minutes or more of clinical/EEG seizure activity OR two or more intermittent seizure activity without full recovery in between

Significant increase in morbidity and mortality with seizures lasting >30minutes – Mortality rates at 1hr 30-40% for generalised status epilepticus

Management points

A and B management is priority – will avoid complications
Early seizure termination
Avoid complications
Find underlying cause (– check glucose, toxins)

Complications with seizures

Hypermetabolic state
Hypoxia, hypercarbia, hypoglycaemia, hyperthermia, rhabdomyolysis, DIC

Evidence behind the treatment

1st line Tx – benzodiazepines

The only evidence based treatment
Based on three large trials and Cochrane review
NCC guidelines – lorazepam iv ideal benzo of choice (long acting 4-6h with less resp depression that diazepam)

  • Alldredge et al N Eng J Med 2001 A comparison of lorazepam, diazepam and placebo for treatment of out of hospital SE
  • Leppik Jama 1983 Double blind study of lorazepam and diazepam and status epilepticus
  • Treiman N Eng J Med 1998 a comparison of four treatments for generalised SE
  • Prasad 2005 Cochrane review anticonvulsant therapy for SE

2nd line treatment

Phenytoin, Valproate, Keppra
Phenytoin – our traditional second line treatment but now becoming more controversial due to side effect profile and newer drugs
Should we be using valproate/keppra instead?
Newer evidence shows equal if not improved efficacy in seizure termination and less side effects

Article from Seizure 2014 metanalysis of 27 studies
“the relative effectiveness of five anti epileptic drugs used in the treatment of benzodiazepine resistant status epilepticus” concluded phenytoin should not be used as first line treatment

Studies for valproate and Keppra mainly class 2 and 3 evidence – based on small studies and chart reviews.

Recently Journal of clinical neuroscience 2015
Levetiracetam vs phenytoin in the management of SE
Randomised trial of 44 patients – showed no difference between keppra and phenytoin

3rd line evidence : phenobarbitone, thiopentone, propofol, midazolam

Barbiturates falling out of favour due to high side effect profile
No evidence to show benefit of one third line treatment over other

4th/5th/6th line treatment Ketamine possible antiepileptic benefit… no evidence

Trauma Scoring Systems

Dr Kaushik Basu – Advanced Trainee

Trauma is a important cause of morbidity and mortality in the developed countries during the first four decades of life and the burden is even higher in the developing countries.

There is a need for the proper assessment of the trauma patient to have the best possible outcome.

The scoring system serves several purposes’ like proper triage and assessment of the patients, for prediction of the outcome ,for quality assurance and fro research purposes.

The scoring system is based on physiological parameters, anatomical description of the wounds and a combination of the two. Examples being : RTS, IIS,TRISS.

The GCS was developed 40 years back to assess the conscious level in the head injury patients.

Though it is being widely used in the evaluation of trauma patient but it has several shortcomings.

For example it was not originally intended to be converted into a single score ,its components’ are more important that the combined score. The same GCS will predict different TBI mortality depending on the components. Again there is a problem with the inter-rater reliability even between the experienced physicians. It does not take into account the brain stem reflexes.

Due to the shortcomings of the GCS several new scoring system has been developed like Simplified Motor Score which uses the motor component of the GCS ,The Full Outline of Unresponsiveness or the Four score .But all these scoring system have the same problem like GCS in terms of their complexities.

Due to widespread adoption GCS is still used for the assessment of TBI though it should be usesd cautiously because of its limitations and ongoing education in needed to make sure that it is applied correctly.



Imaging in Trauma

Alexander Kochi – Advanced Trainee

Ultrasonography in the Trauma Room

Benefits of USS:

  • quick, accessible, portable, binary, non-invasive, repeatable, cheap
  • used for FAST, basic echo, detection of PTx, nerve blocks, fractures, foreign bodies, placement of devices such as lines / catheters

Evidence for USS:

  • ability of USS to identify need for laparotomy in unstable patients:

(133 patients / 3 studies1,2,3)

  • sensitivity 100%
  • specificity 96%
  • negative predictive value 100%
  • ability of USS to identify free fluid in abdominal cavity of all-comers (unstable plus stable) with blunt abdominal trauma:

(6,000+ patients / 18 studies4)

  • sensitivity 75%
  • specificity 98%
  • negative predictive value 94%
  • ability of USS to identify free fluid in abdominal cavity of stable patients with blunt abdominal trauma5:
    • sensitivity 40%
    • specificity 98%
    • negative predictive value 94%
  • ability of USS to detect pneumothorax in supine trauma patients compared to CXR6:
    • sensitivity 28-75% CXR vs 86-98% USS
    • specificity 100% CXR vs 97-100% USS

The Panscan:

Who gets a ‘panscan’?

  • decision based on:
    • clinical judgement, patient condition / compliance, mechanism of injury, physical examination findings (incl. cluster of injuries)
    • decision rules may help (NEXUS, Canadian head and C-spine, SCRAP – note there is no decision rule for the abdomen)
  • useful for identifying occult injuries (intracranial, retroperitoneal)
  • thought to change management and alter disposition
  • possibly used for clinician ‘peace of mind’

Risks of scanning:

  • radiation exposure:
    • a trauma series + panscan = ~ 30mSv of radiation7, ~1:300 chance (0.35% increased risk) of malignant cancer (tiny individual risk compared to 1:4 chance of dying of malignant cancer in all people regardless of exposure)
  • increased unnecessary interhospital transfers from places that don’t have access to CT / after hours CT
  • patient deterioration in the radiology department
  • risk of picking up and then treating ‘incidentaloma’ causing patient to become a victim of medical imaging and treatment (VOMIT)
  • contrast reactions and adverse effects
  • cost



  1. J Trauma. 1996 Nov;41(5):815-20: Hypotension after blunt abdominal trauma: the role of emergent abdominal sonography in surgical triage, Wherrett LJ, Boulanger BR, McLellan BA, Brenneman FD, Rizoli SB, Culhane J, Hamilton P
  2. Ann Surg. 1998 Oct; 228(4): 557–567: Surgeon-performed ultrasound for the assessment of truncal injuries: lessons learned from 1540 patients, G S Rozycki, R B Ballard, D V Feliciano, J A Schmidt, and S D Pennington
  3. J Trauma. 1994 Sep;37(3):439-41: Can ultrasound replace diagnostic peritoneal lavage in the assessment of blunt trauma?, McKenney M1, Lentz K, Nunez D, Sosa JL, Sleeman D, Axelrad A, Martin L, Kirton O, Oldham C
  4. Ng, Alexander., Trauma Ultrasonography: the FAST and Beyond, Dec 2001, available:
  5. 2010 Oct;148(4):695-700; discussion 700-1. doi: 10.1016/j.surg.2010.07.032. Epub 2010 Aug 30, FAST scan: is it worth doing in hemodynamically stable blunt trauma patients?, Natarajan B Gupta PK, Cemaj S, Sorensen M, Hatzoudis GI, Forse RA.
  6. Acad Emerg Med. 2010 Jan;17(1):11-7. doi: 10.1111/j.1553-2712.2009.00628.x,
Sensitivity of bedside ultrasound and supine anteroposterior chest radiographs for the identification of pneumothorax after blunt trauma, Wilkerson RG, Stone MB.
  7. X-Ray Risk Calculator, Available:


Fluids in Trauma

Alistair Hamilton – Advanced Trainee

  1. Coagulopathy of Trauma
  • Between 30-50% of multitrauma patients arrive to DEM coagulopathic
  • This is complex, but mainly due to hyperfibronlysis / usage of factors & platelets
    • Also contributing: hypothermia causing CF & plt dysfunction / fluid replacement (even blood) / inflammation of trauma
  1. Role of Tranexamic Acid
  • TXA inhibits conversion of plasminogen to plasmin, thus preventing firbinolysis
  • CRASH-2 currently guides our practice
    • Placebo-c RCT of 20,000 patients, showing 1.5% mortality reduction
      • Sickest patients benefited most
      • Earlier treatment beneficial, but late treatment increased mortality
      • TXA is safe. Nil increase in thrombotic events
    • Criticised because mainly done in developing world, where there is no L1 trauma care, so the effect in our scenario remains unknown. Also, many patients had no significant bleeding.
  • MATTERs trial (observational) – military study, retrospective
    • Found mortality reduction with TXA far in excess to CRASH-2
    • Further support for TXA
  • PATCH trial started recently in Australia
    • Will assess TXA in our context (i.e. L1 trauma scenarios) – result will guide future practice
  • Current advice: 1g loading dose + 1g over 8 hours, in all bleeding trauma patients. Start within 3 hours, but ideally earlier (e.g. pre-hospital).
  1. Massive Transfusion – when to initiate
  • Clinical judgement performs well against other methods, and is practical.
    • Trigger should probably be bleeding trauma patient, after 2-4 units of blood given
  • Many scoring systems also exist – 70% predictive accuracy
    • ABC, McLaughlin, and TASH are best known
    • Rely on clinical factors / labs / radiology, and don’t perform better than clinical gestalt
  • ROTEM also predicts MTP need with around 70% predictive reliability (FIBTEM A10 <7)
  1. How to guide Product replacement
  • Massive transfusion actually worsens coagulopathy of trauma
    • Fibrinogen replacement, however, seems to correct the coagulopathy
  • If using ratios in MT, higher ratios are preferable. PROPPR evaluated this (1:1:1 vs 1:1:2)
    • PROPPR trial was equivocal, but had design flaws, so no statistically sig mortality benefit
      • However, high ratio group exsanguinated less & achieved better haemostasis
  • Rather than using ratios, it makes better scientific sense to use viscoelastic tests (TEG / ROTEM)
    • These give dynamic info on clot formation / firmness / breakdown
    • ROTEM: EXTEM and FIBTEM are the important graphs in trauma patients
    • Can be viewed in live time, with result in 10 mins. Gives direct guidance on specific product usage
    • No proven mortality benefit (YET!) over ratios, as use in trauma is quite recent
      • But: makes scientific sense / works in other bleeding patients with coagulopathy (e.g. obstetrics, cardiothoracics) / helps guide fibrinogen replacement, as well as other products\

*The future: it is likely that transfusion treatment in future will be guided by ROTEM / TEG, rather than ratio guided MT. The data supporting this will probably emerge over the next 5 to 10 years. Meanwhile, PATCH study will give us better information on TXA, in patients going to L1 trauma centres.

Useful References

  1. Traumatic Hemorrhagic Shock: advances in fluid management. Cherkas, D. Emergency Medicine Practice. Vol 13, No 11, November 2011
  2. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage – CRASH 2.   by Shakur, Haleema;   Roberts, Ian;   Bautista, Raúl; more…   The Lancet, 2010, Volume 376, Issue 9734
  3. Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial. By Holcomb JB et al JAMA. 2015 Feb 3;313(5):471-82
  4. Effect of thromboelastography (TEG®) and rotational thromboelastometry (ROTEM®) on diagnosis of coagulopathy, transfusion guidance… by Da Luz, Luis Teodoro;   Nascimento, Bartolomeu;   Shankarakutty, Ajith Kumar; more…   Critical care (London, England), 2014, Volume 18, Issue 5
  5. Early and individualized goal-directed therapy for trauma-induced coagulopathy by Schöchl, Herbert;   Maegele, Marc;   Solomon, Cristina; more… Scandinavian journal of trauma, resuscitation and emergency medicine, 2012, Volume 20, Issue 1


Police Custody and Medical Clearance

Dr Kaushik Basu – Emergency Medicine Advanced Trainee

In our day to day practice we often come across a situation where we have to medically clear a person who is being brought to the DEM by the QPS with a medical condition and needs to be taken back to the watch-house.

Patient’s medical condition can vary from minor to more serious illness and like any other patient ,he /she needs a full assessment and appropriate investigation before a disposition plan can be made.

If the patient is well enough to look after themselves, then they can be safely be discharged under police custody otherwise they need to be admitted to the hospital under police guard for further treatment or may be transferred to a secure unit.

As per the documentation is concerned we should start our notes stating that “the patient presented to the DEM under lawful custody with ………..” and also the circumstances under which the patient was brought to the DEM should also be mentioned in our notes.

When the patient is discharged from the DEM we should write in the discharge letter that “There is no ongoing risk to the patient and is deemed to be discharged from the hospital BUT we should avoid writing that the patient is fit for the watch-house custody.”