A 31 year old female with a PMH significant for epilepsy and intellectual disability presents to the ED via EMS due to continuous seizure activity. EMS reports that the patient was having tonic-clonic seizures for 30 minutes prior to their arrival—family did not feel comfortable administering her abortive antiepileptic medications as they only had Ativan in pill form. The patient continues to seize for an additional 15 minutes with EMS despite administration of a total of 10mg of intravenous versed. 

When the patient arrived to our facility, the seizure activity continued, which had now progressed to generalized tonic with some mild tremor noted in her arm and legs… 

• What you need to know:
  • Review on types of seizures
    • Tonic-clonic
      • Alternating stiffening (tonic) and rhythmic jerking (clonic)
    • Absence
      • Classically in school-aged children
      • Can have up to 100 per day
      • Brief (seconds sometimes), LOC but no loss of postural tone
      • Patients appear confused, detached, withdrawn, and may resume prior conversations/activity as if nothing happened
      • No post-ictal phase
    • Partial
      • Simple partial/focal seizures do not involve LOC
      • They can appear to cause personality changes, hallucinations—presents more like altered mental status
    • Status epilepticus
      • Most seizures stop on their own in 1-2 minutes
      • Continuous or intermittent seizures for more than 30 minutes without recovery of consciousness is known as status epilepticus
        • Most physicians will intervene at 5 minutes as the longer the seizures lasts, the less likely it is to stop as the seizure becomes self-sustaining
      • Beware of subtle subclinical status epilepticus (SSSE)
        • Sometimes it seems as though a tonic-clonic seizure has stopped but it really hasn’t—unless the patient returns to their normal state of consciousness we need to be careful not to miss subtle signs ongoing seizure
          • Rhythmic movements of the distal extremities
          • Fixed gaze deviation (looking only to one side)
          • Ongoing vital sign abnormalities (e.g. tachycardia)
  • History and physical exam
    • Seizure mimics:
      • Syncope – or syncope with hypoxic seizure – most common
        • Seizure vs syncope:
          • Seizure 5x more likely if confused thereafter (postictal confusion is the most sensitive finding for true seizure (94% sens, 70% spec)
          • Tongue biting (highly specific), aura, rhythmic shaking and dystonic posturing suggest seizure
          • Incontinence actually not that helpful to distinguish
      • Pseudoseizures
      • Movement disorders (dystonia, myoclonic jerks, tremors)
      • Narcolepsy
    • Consider key BAD causes:
      • Cardiac arrhythmia (VTach)
        • Is there a history of CHF, heart disease or the possibility of digoxin toxicity?
      • Tumor (brain mets)
        • Is there a history of cancer?
      • Infection (meningitis, brain abscess)
        • Is there a fever, new onset headache, infectious symptoms?
      • Electrolyte abnormalities (Na, Ca, Mg and Glucose)
      • Cerebrovascular (stroke, TIA)
        • Is there a history or findings of focal neuro deficits?
          • Typically the neurological examination is normal without focal abnormalities in someone with a seizure
        • Todd’s paralysis is a focal neuro deficit in the post-ictal phase–usually resolves in 30 minutes → you have to recheck the deficit
      • Trauma (subdural hematoma, brain contusion)
      • Are there signs of alcohol or drug use?
      • Environmental (heat stroke, envenomation, hypoxia) 
  • Workup
    • Labs
      • In patients with known seizure disorder on medications, the only labs usually necessary are levels of the drug that they are taking as up to 80% of seizures in those with a history of epilepsy are due to subtherapeutic medication levels
      • First time seizure
        • Thyroid studies
        • Electrolytes 
        • Consider ABG (hypoxia)
        • Consider infectious causes (could be sepsis)
    • Imaging
      • CT head if:
        • First time seizure
        • Suspicion for structural lesion or bleed
        • Significant head trauma (e.g. large hematoma/skull fracture, failure to return to baseline mental status), either preceding or secondary to the seizure
      • Other tests:
        • ECG is indicated in first time seizures or when there is a question of an arrhythmia-induced event
        • Lumbar puncture (LP) is indicated following CT if the patient is febrile or immunocompromised
  • Management 
    • Protect the patient from injury
    • Protect the patient’s airway
    • POC glucose
    • Stopping the seizure
      • Start with benzodiazepines (lorazepam and diazepam are equally effective – diazepam works faster (by about 3-5 mins) but lorazepam lasts longer)
        • Lorazepam 4 mg IV q 5 min OR
        • Diazepam 10 mg q 5min IV
        • If no IV, midazolam 10 mg IM (can also give lorazepam IM but midazolam IM works faster
        • NOTE: Do not underdose benzodiazepines in status epilepticus– may need to start a drip at 1-2mg IV/hour and titrate up to 10mg/hour 
      • If seizures persist despite a couple of doses of benzodiazepines, the next options include:
        • Phenytoin
          • Can load with 15-20 mg/kg IV given at a rate no faster than 50 mg/min 
        • Fosphenytoin
          • Can load with 15-20 mg/kg IV (dosed as phenytoin equivalents) given at a rate no faster than 150 mg/min
          • Can also give fosphenytoin IM
        • Levetiracetam
          • 1g IV over 15 minutes
        • Valproate
          • 20-40 mg/kg IV over 10 minutes
        • Phenobarbital
          • 10–20 mg/kg IV bolus at a rate of 50–100 mg/minute
        • Propofol IV drip
        • Midazolam IV drip

Case Resolution

Patient’s POC glucose was WNL, and though she continued to seize, she was protecting her airway and saturating 98% on room air. On review of the patient’s chart, it was noted that she had an allergy to phenytoin. We followed a step-wise fashion and administered a total of 8mg of Ativan, followed by 1g of keppra followed by 1040mg of phenobarbital. 30 minutes after arrival, the patient stopped seizing. 
She was then transferred to a facility with a higher level of care that could perform continuous EEG. 

Author:
Noelani Candelaria, DO
Peer Reviewed and Edited by:
Vincent Call, DO