Neurology · Year 3 · from Neurology

Case 3: Status Epilepticus

Patient Demographics

  • Age: 58 years
  • Sex: Male
  • Occupation: Bus driver (not currently working due to epilepsy)

Chief Complaint

EMS: "Continuous seizure activity for 15 minutes, still seizing."

History of Present Illness

The patient has a known history of epilepsy (focal to bilateral tonic-clonic seizures) for 20 years, on levetiracetam and phenytoin. His wife reports he ran out of phenytoin 3 days ago and was unable to refill due to insurance issues. This morning, she witnessed him have a seizure that has not stopped. EMS administered lorazepam 4 mg IV en route without improvement. On arrival to ED, he is still having rhythmic bilateral clonic movements, now 25 minutes since seizure onset.

Neurological Examination Findings

During Status Epilepticus:

  • Unresponsive to verbal or painful stimuli
  • Continuous bilateral rhythmic clonic jerking of extremities
  • Eyes deviated upward
  • Cyanotic, tachycardic (HR 130), BP 180/100
  • Incontinent
  • O2 sat 88% on room air

After Seizure Termination (40 minutes):

  • GCS 10 (E2 V3 M5)
  • Post-ictal state
  • Pupils 5 mm, reactive
  • No focal deficits appreciated

Status Epilepticus Definition

Convulsive Status Epilepticus (CSE):

  • Continuous seizure activity ≥5 minutes, OR
  • ≥2 discrete seizures without return to baseline between
  • This patient: 25+ minutes of continuous convulsive activity = Established Status Epilepticus

Neuro Workup

  • Labs:
  • Glucose: 165 mg/dL
  • Sodium: 136, Potassium: 3.2
  • Calcium: 8.8, Magnesium: 1.7
  • Phenytoin level: <2 mcg/mL (subtherapeutic; goal 10-20)
  • Levetiracetam level: 18 mcg/mL (therapeutic)
  • Lactate: 6.2 (elevated from seizure)
  • ABG: pH 7.22, pCO2 50, pO2 65 (respiratory and metabolic acidosis)
  • CBC, ammonia: Normal
  • Urine drug screen: Negative
  • CT Head: No acute findings, known left frontal encephalomalacia
  • Continuous EEG: Electrographic seizure activity confirmed; later shows postictal suppression

Diagnosis

Established convulsive status epilepticus secondary to AED non-compliance (phenytoin withdrawal)

Management

Initial Stabilization (0-5 minutes):

  1. Secure airway - bag-mask ventilation, prepare for intubation
  2. IV access x2, cardiac monitoring
  3. Finger-stick glucose - treat if hypoglycemic (not applicable here)
  4. Thiamine 100 mg IV (empiric)

First-Line Treatment (5-10 minutes):

  1. Lorazepam 4 mg IV (given by EMS) - can repeat once
  2. Or: Midazolam 10 mg IM if no IV access
  3. Or: Diazepam 10 mg IV

Second-Line Treatment (10-30 minutes):

  1. Fosphenytoin 20 mg PE/kg IV (loading dose) given - seizure terminated
  2. Alternatives: Levetiracetam 60 mg/kg IV, valproate 40 mg/kg IV, or phenobarbital 15 mg/kg IV
  3. If seizure recurs, give additional 5-10 mg PE/kg fosphenytoin

Refractory Status (>30 minutes - would have occurred if second-line failed):

  1. Intubation and mechanical ventilation
  2. Continuous infusion of: Midazolam 0.2 mg/kg bolus, then 0.1-2 mg/kg/hr; or Propofol 2 mg/kg bolus, then 30-200 mcg/kg/min; or Pentobarbital 5-15 mg/kg bolus, then 0.5-5 mg/kg/hr
  3. Goal: EEG burst-suppression for 24-48 hours

Post-SE Management:

  1. Phenytoin maintenance dose resumed
  2. ICU admission for monitoring
  3. Continuous EEG for 24 hours to monitor for non-convulsive status
  4. Address barriers to medication access
  5. Social work consult for medication assistance program

Complications to Monitor:

  1. Aspiration pneumonia
  2. Rhabdomyolysis (check CK)
  3. Neurogenic pulmonary edema
  4. Cardiac arrhythmias
  5. Neuronal injury from prolonged seizure

Clinical Image

Image Description: Continuous EEG recording showing generalized rhythmic ictal activity consistent with electrographic status epilepticus.

Attribution: Image from Wikipedia Commons, public domain. Source: https://commons.wikimedia.org/wiki/File:Status_epilepticus_EEG.png

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