A 14-year-old girl with a history of juvenile myoclonic epilepsy is brought to the emergency department after 2 generalized tonic-clonic seizures that started approximately 1 hour ago. She has not returned to baseline between seizures. The patient was prescribed daily levetiracetam, but her parents suspect that she has not taken it for the past week. On arrival, her airway is patent and she has good respiratory effort. Her blood pressure is 123/82 mm Hg, pulse is 130/min, respirations are 16/min, and pulse oximetry is 99% on 2 L oxygen via nasal cannula. The patient's eyes are open, but she is not responding to commands. Neurologic examination shows pupils that are equal but minimally responsive to light. Rhythmic non-suppressible twitching of the mouth, both arms, and both legs has persisted for 10 minutes. Fingerstick glucose is 115 mg/dL. Which of the following is the most appropriate next step in management of this patient?

Question

A 14-year-old girl with a history of juvenile myoclonic epilepsy is brought to the emergency department after 2 generalized tonic-clonic seizures that started approximately 1 hour ago.  She has not returned to baseline between seizures.  The patient was prescribed daily levetiracetam, but her parents suspect that she has not taken it for the past week.  On arrival, her airway is patent and she has good respiratory effort.  Her blood pressure is 123/82 mm Hg, pulse is 130/min, respirations are 16/min, and pulse oximetry is 99% on 2 L oxygen via nasal cannula.  The patient's eyes are open, but she is not responding to commands.  Neurologic examination shows pupils that are equal but minimally responsive to light.  Rhythmic non-suppressible twitching of the mouth, both arms, and both legs has persisted for 10 minutes.  Fingerstick glucose is 115 mg/dL.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c004_4b86_8f63_07a1f72ab848_MD0005_00 Common factors that decrease seizure threshold include medication noncompliance, intercurrent illness, electrolyte abnormalities, sleep deprivation, and head injury. This patient's medication noncompliance is the most likely trigger for her seizure. Historically, status epilepticus has been defined as a single continuous seizure for >30 minutes or multiple seizures occurring in a short period with no return to baseline mental status; however, for treatment purposes, shorter cutoffs are used, as described in the flowchart. An actively seizing patient should undergo immediate assessment of the airway, breathing, and circulation. An intravenous line should be placed in anticipation of medication administration and laboratory testing (eg, serum glucose to rule out hypoglycemia as the etiology). Abortive therapy is recommended for seizures lasting >5 minutes, as delayed treatment can result in increased risk of complications (eg, hypoxemia, acidemia). First-line treatment is a benzodiazepine (eg, lorazepam, diazepam) and should not be delayed, even if there is difficulty obtaining intravenous access. If seizure activity persists, fosphenytoin should be administered. (Choice A) This patient's tachycardia, minimally responsive pupils, and seizure suggest that she is having an epileptic seizure rather than a psychogenic nonepileptic seizure. An electroencephalogram can be used to confirm seizure activity, but benzodiazepine abortive therapy is the time-sensitive priority. (Choice B) Barbiturates (eg, phenobarbital) should be administered if status epilepticus has persisted despite administration of benzodiazepines and phenytoin derivatives. Barbiturates are long-acting and often result in respiratory depression and sedation; therefore, other agents should be tried first. (Choice D) Naloxone is a pure opioid antagonist used to treat opioid overdoses, which classically present with pinpoint pupils, sedation, and respiratory depression. This patient's presentation is not consistent with an opioid overdose. (Choice E) Brain MRI is the preferred imaging modality to assess for underlying structural abnormalities but is not typically performed in the acute setting. A head CT is preferred to rule out intracranial hemorrhage in an actively seizing trauma patient. Neither study is indicated in this patient with a known seizure disorder. Educational objective: Benzodiazepine therapy is the first-line treatment for status epilepticus and should be administered for seizures lasting >5 minutes. Medication noncompliance, electrolyte abnormalities, sleep deprivation, and intercurrent illnesses lower the seizure threshold. References: Drug management for acute tonic-clonic convulsions including convulsive status epilepticus in children. (http://www.ncbi.nlm.nih.gov/pubmed/18646081) Treatment of community-onset, childhood convulsive status epilepticus: a prospective, population-based study. (http://www.ncbi.nlm.nih.gov/pubmed/18602345)

A 14-Year-Old Girl with a History of Juvenile Myoclonic Epilepsy