Neuroscience · Year 2 · from Neuroscience
Case 3: Status Epilepticus
Patient Presentation
Demographics: 45-year-old male
Chief Complaint: Continuous seizure activity for 15 minutes
History of Present Illness: EMS was called when the patient was found by coworkers having a generalized convulsion at work. Shaking has continued during transport and upon arrival to the ED - total duration now 15 minutes. He has a known history of epilepsy diagnosed 10 years ago, treated with phenytoin. His wife reports he ran out of phenytoin 4 days ago and has not refilled it.
On Arrival:
- Generalized tonic-clonic movements ongoing
- Cyanotic
- Incontinent
- Not following commands
Initial Assessment:
- Vital signs: BP 168/102, HR 128, T 38.1C, SpO2 84% on room air
- Glucose: 142 mg/dL (normal - not hypoglycemic)
Diagnosis: Convulsive status epilepticus secondary to anti-seizure medication non-compliance
Treatment Protocol:
0-5 Minutes (Initial Stabilization):
- ABCs: Oxygen via non-rebreather mask, suction, positioning
- IV access x 2
- Glucose check: 142 mg/dL (no dextrose needed)
- Labs drawn: CBC, CMP, phenytoin level, toxicology
5-20 Minutes (First-Line Benzodiazepine):
- Lorazepam 4 mg IV push
- Seizure continues after 3 minutes
- Lorazepam 4 mg IV push (second dose)
- Seizure stops at 22 minutes total duration
20-40 Minutes (Second-Line Agent):
- Despite seizure stopping, patient given loading dose to prevent recurrence:
- Fosphenytoin 20 mg PE/kg IV infusion (patient weight 80 kg = 1600 mg PE)
- Cardiac monitor during infusion
Post-Seizure:
- Phenytoin level returns: <1 mcg/mL (undetectable - confirms non-compliance)
- Patient remains postictal for 45 minutes, then gradually awakens
- By 2 hours, following commands; confused but improving
- CT head: No acute abnormality
ICU Monitoring:
- Continuous EEG monitoring for 24 hours: No electrographic seizures
- Maintenance phenytoin resumed
- Social work consultation for medication access/compliance
Clinical Course: Patient was extubated (was briefly intubated for airway protection during ongoing seizures). No further seizures occurred. He was discharged on day 2 with phenytoin at previous dose and arrangements for medication assistance program. EEG showed rare interictal epileptiform discharges but no seizures.
Clinical Pearl: Status epilepticus is a medical emergency defined as seizure activity lasting >5 minutes (the point at which spontaneous termination is unlikely). The treatment protocol follows a time-based escalation:
- First-line: Benzodiazepine (lorazepam IV, or midazolam IM if no IV)
- Second-line: Fosphenytoin, levetiracetam, or valproate IV
- If refractory: Anesthesia (propofol, midazolam infusion, or pentobarbital) with continuous EEG monitoring
Medication non-compliance is the most common cause of status epilepticus in patients with known epilepsy. Mortality of convulsive status epilepticus is approximately 20%, with risk of permanent neurological injury from excitotoxicity.
Clinical Image
Image Description: Electroencephalogram (EEG) demonstrating generalized 3 Hz spike-and-wave discharges, the classic pattern seen in absence epilepsy. This characteristic pattern shows synchronous, bilaterally symmetric spike-and-wave complexes that appear simultaneously across all scalp electrodes, reflecting the generalized nature of the seizure.
Attribution: Image from Wikipedia (https://en.wikipedia.org/wiki/Spike-and-wave), Creative Commons license.