CBL: Status Epilepticus

Learning Objectives

• Define status epilepticus (SE) as incessant electrical seizure activity.
• Recognize the role of EEG as key to diagnosis and monitoring.
• Outline treatment steps including ICU-level care and escalating anticonvulsants.

Vignette

A 55-year-old woman is found unconscious at home after a week of fever and fatigue presumed to be influenza. On ED arrival she is unresponsive (GCS 3). Airway protection is required, and she is intubated/ventilated. Last known normal was ~8 hours prior. No prior seizures or head trauma; no sedatives administered in the ED.

PMH: Psoriasis, osteoarthritis. Medications: Ibuprofen 400 mg PRN (~daily). Allergies: None. Social: Non-smoker, non-drinker; car rental clerk. ROS via spouse: Fever/fatigue; otherwise negative for rash, bleeding, bowel/bladder issues, respiratory/cardiac complaints, dysphagia, or visual symptoms.

Examination

T 102.1°F, HR 98, BP 110/61. Unresponsive to voice/touch/pain; no spontaneous movement or vocalization. Sinus tachycardia. Pupils moderately dilated and nonreactive; absent blink to threat. Tone mildly reduced; no fasciculations. DTRs symmetric; plantar responses downgoing. No sensory responses; cerebellar/gait not testable.

Localization & Neuroanatomy

An unconscious, febrile patient raises concern for CNS infection such as meningitis, which can irritate the cortex and trigger coma or seizures. Alternative etiologies include subarachnoid hemorrhage, stroke, sepsis, toxic/metabolic causes, or continuous seizure activity (status epilepticus). The presentation here is consistent with SE in the context of presumed viral meningitis, but etiology requires urgent workup.

Diagnosis

Immediate priorities: airway/breathing/circulation; point-of-care glucose; broad-spectrum IV antibiotics; labs (CBC, electrolytes, glucose, infectious studies); and lumbar puncture for bacterial/viral testing when safe. HSV encephalitis is a key consideration—CSF may show pleocytosis/RBCs or HSV DNA; MRI can show temporal lobe changes; HSV frequently provokes seizures and SE.

SE is incessant seizure activity that may lack overt motor signs—patients can appear simply comatose. EEG is essential for diagnosis/monitoring; typical findings include generalized epileptiform discharges or periodic spikes. A normal EEG argues strongly against SE. Brain MRI is useful to evaluate causes; LP is indicated when infection is suspected.

Treatment

Ensure pulmonary support (intubation as needed). Treat identified causes (e.g., hypoglycemia, hyponatremia, infection). When etiology is unclear, initiate anticonvulsants following an escalation protocol:

1. IV lorazepam 1 mg; repeat in 5 minutes if no improvement.
2. If persistent, give IV phenytoin or fosphenytoin 20 mg/kg.
3. If still refractory, options (no single consensus) include IV levetiracetam, midazolam, phenobarbital, or propofol to suppress cortical activity.
4. Maintain seizure freedom for ~24 hours with continuous EEG monitoring.
5. As the patient improves, transition from IV to oral agents (e.g., levetiracetam, phenytoin, topiramate).

Management should involve neurology consultation and often ICU-level care.

Teaching Points

• SE can be nonconvulsive—use EEG early when mental status is unexplained.
• Time is brain: rapid benzodiazepine loading followed by a longer-acting agent.
• Always search for and correct reversible precipitants (glucose, sodium, infection).

References

1. Module adapted from provided teaching text on status epilepticus, emphasizing EEG diagnosis and stepped treatment.