Neurology · Year 3 · from Neurology
Case 3: Status Epilepticus
Patient Demographics
- Age: 34 years old
- Sex: Male
- History: Known epilepsy
Prehospital
EMS called for witnessed seizure at home. Per wife, patient has known epilepsy (on levetiracetam) but ran out of medication 3 days ago. Seizure activity began approximately 10 minutes before EMS arrival. Generalized tonic-clonic seizure ongoing when paramedics arrived.
EMS Treatment:
- Midazolam 10mg IM given
- Seizure continued
- Transported to ED (estimated seizure duration now 15 minutes)
Emergency Department
Arrival Assessment:
- Ongoing generalized tonic-clonic seizure
- Total seizure duration: ~18 minutes
- Vital Signs: HR 130, BP 180/100, SpO2 91% on non-rebreather, Temp 38.2C
- Cyanosis present
- Incontinent of urine
Clinical Image
Image: EEG recording showing continuous generalized seizure activity with rhythmic spike-wave discharges, characteristic of generalized convulsive status epilepticus.
Image Source: Wikimedia Commons Attribution: EEG case, Educational use URL: https://commons.wikimedia.org/wiki/File:Status_epilepticus_EEG.png
Definition of Status Epilepticus
| Type | Definition |
|---|---|
| Convulsive SE | ≥5 minutes of continuous seizure OR ≥2 seizures without return to baseline |
| Non-convulsive SE | EEG seizure activity without overt convulsions |
| Refractory SE | Continues despite 2 appropriate medications |
| Super-refractory SE | Continues ≥24 hours despite anesthesia |
This patient has convulsive status epilepticus (>5 minutes)
Treatment Protocol
Time 0-5 min (Stabilization):
- ABCs: Supplemental O2, position patient
- Midazolam 10mg IM (already given by EMS) ✓
- IV access obtained
Time 5-20 min (First-line benzodiazepine given, need second-line):
- Seizure continues despite midazolam
- Fosphenytoin 20 mg PE/kg IV at 150 mg PE/min
- (Alternatives: Valproic acid 40 mg/kg IV or Levetiracetam 60 mg/kg IV)
Time 20 min:
- Seizure continues after fosphenytoin loading complete
- Now meets criteria for REFRACTORY STATUS EPILEPTICUS
Time 20-40 min (Refractory SE):
- Intubation for airway protection
- Propofol bolus 2 mg/kg then infusion 50-100 mcg/kg/min
- (Alternative: Midazolam infusion or pentobarbital)
- Continuous EEG monitoring initiated
Time 30 min:
- Clinical seizure activity stopped
- EEG shows burst suppression (goal achieved)
Workup for Status Epilepticus
Immediate Labs:
- Glucose: 95 mg/dL (normal)
- BMP: Na 136, others normal
- Antiepileptic drug level: Levetiracetam <5 mcg/mL (subtherapeutic - confirms non-compliance)
- Urine toxicology: Negative
- CBC: WBC 12,000 (stress response)
Imaging:
- CT head: No acute intracranial abnormality
Etiology
Most likely: Antiepileptic medication non-compliance
- Confirmed by subtherapeutic levetiracetam level
- Patient ran out of medication 3 days ago
ICU Course
Day 1:
- Maintained on propofol infusion
- Continuous EEG: Burst suppression achieved
- Loaded with levetiracetam 2000 mg IV
- Target: Maintain burst suppression for 24 hours
Day 2:
- Propofol weaned slowly
- Continuous EEG shows no seizure activity
- Extubated successfully
- Neurologically at baseline - alert, following commands, no deficits
Assessment:
- Status epilepticus secondary to antiepileptic medication non-compliance
- No structural brain abnormality
- Resolved with treatment
Discharge Plan
- Continue levetiracetam 1500 mg twice daily
- Neurology follow-up in 2 weeks
- Counseled extensively on importance of medication adherence
- Discussed driving restrictions (state-specific, typically 3-6 months seizure-free)
- Social work consultation for medication access/financial issues
- Provided 90-day prescription to ensure medication supply
Non-Convulsive Status Epilepticus (NCSE)
Important concept: If a patient with convulsive SE has convulsions controlled but does not wake up:
- MUST obtain continuous EEG
- Up to 20-40% of patients have ongoing non-convulsive seizures
- NCSE presents as persistent altered mental status without overt convulsions
- Requires aggressive treatment
Risk factors for NCSE:
- Prior convulsive SE
- Critical illness
- CNS infection or injury
- Hypoxic brain injury
Teaching Points
- Status epilepticus is a medical emergency - mortality increases with duration
- Treatment timeline:
- 0-5 min: Benzodiazepine (lorazepam IV or midazolam IM)
- 5-20 min: Second-line AED (fosphenytoin, valproate, or levetiracetam)
- 20+ min (refractory): Anesthetic infusion (propofol, midazolam, or pentobarbital)
- Continuous EEG monitoring is essential in refractory SE and when consciousness does not recover
- Non-convulsive SE is common and easily missed - always consider in unexplained altered mental status
- Most common cause of SE in known epileptics: medication non-compliance
- Goal of anesthetic treatment: burst suppression for 24-48 hours before weaning
Key Teaching Points Summary
Severe TBI
- GCS ≤8 = severe TBI, requires intubation
- Avoid secondary injury: hypotension (SBP <90) and hypoxia (SpO2 <90)
- ICP target <22 mmHg, CPP 60-70 mmHg
- Subdural evacuation if >10mm thick or >5mm midline shift
Subarachnoid Hemorrhage
- "Worst headache of my life" = SAH until proven otherwise
- Secure aneurysm within 24 hours (coiling or clipping)
- Vasospasm occurs days 3-14; monitor with TCD and serial exams
- Nimodipine 60mg q4h x 21 days is standard of care
Status Epilepticus
- ≥5 minutes of continuous seizure = status epilepticus
- Treatment escalation: benzodiazepine → second-line AED → anesthetic infusion
- Continuous EEG for refractory SE and to detect NCSE
- NCSE is common and easily missed in ICU patients