Critical Care Medicine-Neurologic Disorders>>>>>Seizure Disorder
Question 1#

A 19-year-old male with known generalized epilepsy was brought to the emergency department for convulsive status epileptics. He has had nausea, emesis, and a low grade fever for the last 5 days and has been unable to take his home antiepileptic drug. He is having ongoing low amplitude, rhythmic clonic movements of his bilateral arms and legs. His vitals are as follows: heart rate 86, blood pressure 106/68, SpO2 100% on 2 L nasal canula, temperature 100.2°C. EMS administered 2 mg of lorazepam and had cessation of clonic movements but still altered and not back to baseline mental state.

What is the next best medication treatment for this patient?

a. Intubate the patient and start propofol
b. Monitor the patients for few hours and order EEG
c. Additional lorazepam to dose of 0.1 mg/kg followed by fosphenytoin with loading dose of 15 mg/kg IV
d. Obtain CT head to further evaluate the etiology and rule out structural abnormalities

Correct Answer is C

Comment:

Correct Answer: C

The patient has history of generalized epilepsy and presented with likely breakthrough seizures which in this case meets the diagnosis of convulsive status epilepticus. Benzodiazepine is the first-line therapy. Lorazepam, diazepam, or midazolam are appropriate choices of benzodiazepine. In this case, patient already received an initial dose of an appropriate firstline agent (lorazepam) but not at an appropriate total dose. Lorazepam dose is 0.1 mg/kg with max dose of 4 mg/dose and may be repeated once if seizures persisted. At this point, readministration of a benzodiazepine is appropriate. There is no evidence-based preferred second-line agent for management of status epilepticus. The recommended agents for control of status epileptics are IV fosphenytoin/phenytoin and sodium valproate. The use of levetiracetam in treating status epilepticus is controversial, although it has been used in many institutions as a second-line agent. If none of these agents are available, IV phenobarbital can be considered. If patient continues to seize despite first- and second-line therapies, redosing second-line agent, securing airway, and anesthetic doses of either midazolam, propofol, or less likely phenobarbital should be considered. Further seizure evaluation is needed including comprehensive metabolic and infectious panel, given history of fevers, as well as imaging of the head, especially if he has any neurological exam abnormalities, once his underlying status epilepticus is under control.

References:

  1. Brophy GM, Bell R, Claassen J, et al. Guidelines for the evaluation and management of status epilepticus. Neurocrit Care. 2012;17:3-23.
  2. Eue S, Grumbt M, Muller M, et al. Two years of experience in the treatment of status epilepticus with intervenous levetiracetam. Epilepsy Behav. 2009;15:467-469.