MEDizzy - A 38-year-old man with a history of seizure disorder

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A 38-year-old man with a history of seizure disorder presents with generalized convulsive status epilepticus. He had been having persistent seizure activity for 20 minutes when emergency medical services were activated. He was given paralytic agents in the feld to allow for intubation as well as lorazepam 8 mg intravenously (IV). Upon arrival in the emergency department 20 minutes later, the neuromuscular blockade has worn of and generalized seizure activity is again apparent. His initial temperature is 39.2°C with blood pressure of 182/92 mmHg, heart rate of 158 bpm, respiratory rate of 38 breaths/min, and SaO2 of 95% on mechanical ventilation with an assist control mode with a set rate of 15, tidal volume of 420 mL, positive end-expiratory pressure of 5 cmH2O, and FiO2 of 0.6. What is the next step in the management of this patient?

ExplanationStatus epilepticus is a medical emergency that can result in severe metabolic derangements, hyperthermia, cardiorespiratory collapse, and irreversible neuronal injury. Prompt recognition and appropriate treatment are necessary to prevent long- term sequelae of this neuronal injury. Status epilepticus is defned as continuous seizures or repetitive discrete seizures with impaired consciousness in the interictal period. Status epilepticus has many subtypes, with the most common subtype leading to presentation and critical care admission being generalized convulsive status epilepticus (GCSE). The duration of seizure activity that leads to a diagnosis of GCSE is typically defned as 15–30 minutes, but practically, if intervention with anticonvulsant medication is required to stop the seizure activity, then one must be concerned about GCSE. Likewise, if a seizure is of sufcient duration to cause signifcant metabolic or cardiorespiratory consequence, GCSE must be considered. Once GCSE is diagnosed, initial treatment should include basic cardiopulmonary support, including maintaining an appropriate airway, establishing venous access, and obtaining samples of laboratory analysis to identify contributing laboratory abnormalities. It is important to understand that suppression of convulsive activity through the use of paralytic agents does not suppress the epileptic activity in the central nervous system and does not prevent ongoing neuronal injury and death. Thus, when these agents are used for rapid-sequence intubation, the treating team should also continue treatment for GCSE through appropriate use of IV benzodiazepines initially followed by loading doses of either IV phenytoin or fosphenytoin, valproic acid, or levetiracetam. In many cases, continuous EEG monitoring may be required to determine when the seizure activity has ceased. If the seizure activity fails to break with these agents, further therapy with propofol or pentobarbital may be required. In more severe cases, inhaled anesthetics may be required. In addition, it is important to treat any underlying infection or metabolic derangements.