Learning Objectives
- Status epilepticus is a dangerous condition of incessant electrical seizure activity
- SE is diagnosed by EEG
- Treatment of SE may require intensive care, strong anticonvulsants and sometimes other interventions
History
A 55 year old woman is found in her bed, unconscious. She is brought to the emergency room. She had been complaining of fevers and fatigue for the past week, and she had taken off time from work, thinking that she had influenza.
When she is brought to the hospital, she appears unconscious. Glasgow coma scale score is 3. Evaluation of her ABC’s suggests she is at risk of aspiration, and she is treated with endotracheal intubation and mechanical ventilation. Questioning of her spouse reveals she has no history of head trauma, seizure, or severe illness. She was last awake earlier in the morning, which was about 8 hours ago.
She was not treated with sedating medication in the ER.
Her past medical history is relevant for psoriasis and osteoarthritis. At this time, she is taking ibuprofen as needed, on average 400 mg daily. She has no history of allergies to medications.
Her family history shows that her mother died of a heart attack at age 80 and her father has been diagnosed with prostate cancer. He is 83.
She does not smoke or drink. She works as a clerk at a car rental agency.
Her husband is asked about the review of systems. He indicates fever and fatigue as above. She has not had a rash, bleeding, bruising, difficulty with bowel or bladder function, coughing, shortness of breath, chest pain, changes in her arthritis symptoms, trouble with swallowing or her vision in the past month.
Examination
Temperature 102.1 F, pulse 98, blood pressure 110/61. She is not alert. She is found lying on a bed with her eyes closed. She does not respond to voice, touch, pinprick or nail bed pressure. She does not make a sound. There are no spontaneous movements. The cardiovascular exam reveals sinus tachycardia. When her eyes are opened, the pupils are dilated moderately, and they are not reactive to light. There is no blink to confrontation. Muscle tone is mildly reduced, and there are no fasciculations. Reflexes of the major tendons (biceps, triceps, quadriceps, Achilles) are normal on both sides, toes go downwards to plantar stimulation. There is no response to the sensory exam. She is not able to do the cerebellar exam or walk.
Localization and Neuroanatomy
This is a case of an unconscious patient with a fever. Considering the history, meningitis should be suspected as the cause. Meningitis is an inflammation of the meninges, often due to bacterial and viral infections. As the meninges are adjacent to the cortex, inflammation in that area affects cortical function, and can lead to clinical loss of consciousness- either via coma or seizure. This clinical condition could also occur in the setting of subarachnoid hemorrhage, stroke, sepsis, medication overdose, or a continuous, incessant seizure in the setting of epilepsy. The cause in this case cannot easily be determined by the information presented so far, but it is consistent with a case of status epilepticus in the setting of viral meningitis.
Diagnosis
This particular case would best be handled by providing supportive cardiac and pulmonary care, performing a rapid glucose measurement, rapidly initiating broad spectrum antibiotics by intravenous route, drawing blood tests for blood count, glucose, electrolytes, and infection, and performing a spinal tap for bacterial and viral infections. In particular, Herpes Simplex Virus may cause a condition such as this one. It may cause an elevated white cell and red cell count in the CSF, or it may show up as viral DNA in the CSF, and sometimes it may show temporal lobe necrosis on MRI. HSV commonly causes seizures; sometimes these present as status epilepticus.
Status epilepticus is a case of incessant seizure. At times there is motor activity, on and off, but it is common that patients with this condition appear unconscious. People who suffer from this condition are often people with epilepsy, meningitis, cerebral anoxia, or people with a severe brain injury. In the case of status epilepticus, it is very important to rapidly treat the condition as well as attempt to find the cause. The longer the time the patient spends in status epilepticus the more likely there may be sustained deleterious cognitive or behavioral consequences. As with other first time seizures, it is important to take rapid measurements of blood glucose and electrolytes. An EEG is a very helpful test to do as a second step of diagnosis. Status epilepticus may show generalized seizure activity, recurrent sharp or spike waves, even if there is no motor activity on the bedside examination. A normal EEG excludes the diagnosis of SE. A brain MRI is also very useful in this condition. Spinal tap is often performed when the cause of status is suspected to be an infection.
Treatment
When status epilepticus is suspected, it is important to provide pulmonary support, as aspiration and breathing cessation frequently accompany this condition. If the cause is known – it should be treated. This is why it is essential to evaluate for causes such as hypoglycemia, hyponatremia, infection and others. When the cause is not apparent, anticonvulsant treatment will be needed.
An example of a protocol for the anticonvulsant treatment of status epilepticus is:
- IV 1 mg lorazepam once, repeated in 5 minutes if there is no improvement
- IV phenytoin or fosphenytoin 20 mg / kg once if there is no improvement
- If neither of these are successful, there are several options but no consensus. Neurology providers often recommend either IV levetiracetam, midazolam, phenobarbital, or sometimes propofol to help quiet the cerebral electrical activity.
- Keep the patient free of seizures for 24 hours, continuous EEG monitoring is recommended
- As the patient improves, IV medications can be substituted for oral medications, such as levetiracetam, phenytoin, topiramate, etc.
The treatment of a patient with status epilepticus should be conducted with the care or consultation of a neurologist.
Review Questions
- Status epilepticus is
a. a condition of continuous electrical seizures
b. the same as a diagnosis of epilepsy
c. a dangerous condition which may result in aspiration or breathing cessation
d. usually caused by alcohol withdrawal
e. both A and C - Status epilepticus should be diagnosed by:
a. blood tests for glucose, sodium and calcium
b. EEG
c. MRI of the brain
d. both B and C
e. All of the above - The recommended order of anticonvulsant treatment for status epilepticus is
a. phenobarbital, phenytoin, levetiracetam, propofol
b. phenytoin, lorazepam, phenobarbital, propofol
c. propofol, diazepam, levetiracetam, phenytoin
d. lorazepam, phenytoin, levetiracetam / phenobarbital / propofol
e. lorazepam, levetiracetam, propofol, phenytoin