Emergency Medicine · Year 3 · from Emergency Medicine

Case 3: Status Epilepticus - Seizure That Won't Stop

Patient Demographics

  • Age: 34 years
  • Sex: Male
  • Occupation: Construction worker

Chief Complaint

"He's been seizing for 10 minutes and won't stop."

History of Present Illness

EMS called to construction site for a 34-year-old male found having generalized tonic-clonic seizure. Coworkers report seizure began approximately 15 minutes ago with brief pauses but continuous activity. Patient has no known seizure history. EMS administered midazolam 10mg IM en route with no response.

Initial Assessment

ESI Level: 1 - Active seizure, life-threatening

First Impression:

  • Appearance: Ongoing tonic-clonic activity
  • Work of breathing: Compromised during seizure
  • Circulation: Cyanotic during tonic phase

Vital Signs (between seizure activity):

  • Heart rate: 132 bpm
  • Blood pressure: 168/102 mmHg
  • Respiratory rate: Unable to assess (seizing)
  • SpO2: 84% (during seizure) improving to 94% (post-ictal)
  • Temperature: 38.2C
  • GCS: 3 (during seizure)

Primary Survey During Active Seizure

Airway:

  • Compromised during tonic phase
  • Secretions present
  • Positioned on side, suction available
  • No airway adjunct placed during active seizure

Breathing:

  • Apneic during tonic phase
  • Irregular during clonic phase
  • Oxygen via non-rebreather when possible

Circulation:

  • Tachycardic
  • IV access attempted (difficult during seizure)
  • IO access placed in right tibia

Disability:

  • GCS 3 during seizure
  • Bilateral tonic-clonic activity
  • No lateralizing features

Exposure:

  • No obvious trauma
  • Incontinent of urine

Status Epilepticus Management Protocol

Definition: Seizure >5 minutes OR recurrent seizures without return to baseline

Timeline:

  • T=0 (ED arrival, ~15 min into seizure): Lorazepam 4mg IV
  • T=5 min: Continued seizure - Lorazepam 4mg IV repeat
  • T=10 min: Continued seizure - Fosphenytoin 20 mg PE/kg IV loading
  • T=25 min: Breakthrough seizure - Levetiracetam 60 mg/kg IV
  • T=35 min: Refractory status - Propofol infusion, intubation

Secondary Survey (Post-Intubation)

SAMPLE History (from coworkers):

  • Symptoms: Sudden collapse, generalized seizure
  • Allergies: Unknown
  • Medications: Unknown, coworkers unaware of any
  • PMH: Unknown
  • Last Meal: Lunch 2 hours ago
  • Events: Working normally, then collapsed

Physical Examination:

  • Head: No obvious trauma, no Battle sign or raccoon eyes
  • Pupils: 4mm, reactive
  • Tongue: Lateral tongue laceration (bite)
  • Neck: No rigidity (after paralysis for intubation)
  • Cardiac: Tachycardic, regular
  • Lungs: Coarse breath sounds bilaterally (aspiration risk)
  • Extremities: No track marks, no medic alert bracelet

Diagnostic Testing

Point-of-Care:

  • Glucose: 68 mg/dL (give D50)
  • VBG: pH 7.18, pCO2 52, lactate 8.2

Labs:

  • Sodium: 118 mEq/L (CRITICAL - severe hyponatremia)
  • Potassium: 3.2 mEq/L
  • BUN/Cr: 8/0.9
  • Calcium: 9.2 mg/dL
  • Magnesium: 1.6 mg/dL
  • Ammonia: Normal
  • Urine drug screen: Negative

CT Head: No acute intracranial abnormality

Additional History (obtained from wife by phone):

  • Patient is a heavy beer drinker
  • Has been trying to "cut back" this week
  • No prior seizure history
  • No psychiatric history

Diagnosis

Status Epilepticus secondary to:

  1. Severe hyponatremia (beer potomania with recent decreased intake)
  2. Possible alcohol withdrawal contributing

Management

Seizure Control:

  • Propofol infusion for burst suppression
  • Continuous EEG monitoring

Hyponatremia Correction:

  • 3% hypertonic saline 100 mL bolus
  • Goal: Raise sodium 4-6 mEq/L in first few hours
  • Maximum correction: 8-10 mEq/L in 24 hours (avoid osmotic demyelination)
  • Serial sodium levels every 2-4 hours

Supportive Care:

  • Mechanical ventilation
  • Thiamine 500mg IV (before glucose, given alcohol history)
  • Magnesium repletion
  • Aspiration pneumonia prophylaxis monitoring

Disposition

  • ICU admission
  • Continuous EEG
  • Slow sodium correction
  • Wean sedation after 24 hours seizure-free
  • Neurology consultation
  • Social work/addiction services

Teaching Points

  1. Status epilepticus is time-critical: Mortality increases with duration; aggressive early treatment essential
  2. Benzodiazepines first: Lorazepam or midazolam are first-line; can repeat once
  3. Second-line agents: Fosphenytoin, levetiracetam, or valproate if benzos fail
  4. Refractory status: Requires anesthetic agents (propofol, midazolam infusion, or pentobarbital) and intubation
  5. Always check sodium: Hyponatremia is common, treatable cause of seizures
  6. Hyponatremia correction: Too rapid correction risks osmotic demyelination syndrome; document sodium carefully
  7. Beer potomania: Chronic low-solute intake leads to impaired free water excretion

Clinical Image

Image Description: Continuous EEG tracing demonstrating generalized rhythmic epileptiform discharges consistent with electrographic status epilepticus, with high-amplitude spike-and-wave complexes occurring at approximately 2-3 Hz.

Attribution: Image from Wikimedia Commons, EEG in status epilepticus. Licensed under CC BY-SA 3.0. Source: https://commons.wikimedia.org/wiki/File:Spike-waves.png

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