A 19-year-old man is brought to the emergency department due to a seizure. The patient's roommate was awakened by a noise 30 minutes ago and found him "convulsing" on the bed. Emergency medical services were called, and the patient had another brief seizure episode in the ambulance. He has no history of seizure or other medical conditions. The roommate says the patient went to bed late last night after a fraternity party. Temperature is 37.2 C (99 F), blood pressure is 148/90 mm Hg, and pulse is 94/min. On physical examination, the patient is somnolent, groans to painful physical stimuli, and does not follow instructions. There is a small tongue laceration. While being examined, the patient has another generalized tonic-clonic seizure, which terminates after administration of intravenous lorazepam. Which of the following is the most appropriate next step in the management of this patient?

Question

A 19-year-old man is brought to the emergency department due to a seizure.  The patient's roommate was awakened by a noise 30 minutes ago and found him "convulsing" on the bed.  Emergency medical services were called, and the patient had another brief seizure episode in the ambulance.  He has no history of seizure or other medical conditions.  The roommate says the patient went to bed late last night after a fraternity party.  Temperature is 37.2 C (99 F), blood pressure is 148/90 mm Hg, and pulse is 94/min.  On physical examination, the patient is somnolent, groans to painful physical stimuli, and does not follow instructions.  There is a small tongue laceration.  While being examined, the patient has another generalized tonic-clonic seizure, which terminates after administration of intravenous lorazepam.  Which of the following is the most appropriate next step in the management of this patient?

Quizplus · Accepted Answer

Explanation: Generalized convulsive status epilepticus (GCSE) is defined as a seizure lasting ≥5 minutes or as ≥2 seizure events in which the patient does not completely regain consciousness (as in this patient). GCSE commonly occurs in patients with a structural brain abnormality (eg, brain tumor, stroke), metabolic abnormality (eg, hyponatremia, hypoglycemia), infection (eg, meningitis), or drug withdrawal (eg, alcohol, benzodiazepines). It is also common in epilepsy, particularly in patients who are noncompliant with antiepileptic medications, and may be the presenting feature of the disease. Regardless of underlying etiology, GCSE requires immediate treatment as prolonged seizures are associated with neuronal injury and death. An actively seizing patient should be stabilized (ie, evaluate airway, breathing, circulation) and undergo rapid neurologic evaluation. Intravenous access and fingerstick glucose should be obtained. Concurrently, intravenous benzodiazepines (eg, lorazepam, diazepam) should be administered for seizure termination; midazolam may be administered intramuscularly if intravenous access is unavailable. In addition, a nonbenzodiazepine antiepileptic medication should be administered to prevent seizure recurrence. Recommended medications include fosphenytoin, phenytoin, levetiracetam, or valproic acid. After this initial stabilization, neuroimaging (eg, brain MRI, head CT) should be performed to evaluate for any underlying structural abnormality, hemorrhage, or area of ischemia (Choice D). Any patient who does not return to a normal state of consciousness after medical therapy should undergo continuous electroencephalography to rule out nonconvulsive status epilepticus (Choice B). (Choice A) Intravenous phenobarbital is an antiepileptic used to treat focal or generalized seizures. However, it is not used as first-line therapy due to its slow onset of action and potential for significant sedation and respiratory depression. (Choice C) Lumbar puncture is indicated in cases of suspected meningitis or encephalitis, which can cause seizures but are typically associated with additional signs of infection (eg, fever). It is not routinely performed on all patients with GCSE as prolonged seizure activity can cause a cerebrospinal fluid pleocytosis, which may muddy the diagnosis. In addition, lumbar puncture should only be performed after head imaging to rule out a space-occupying lesion. Educational objective: Generalized convulsive status epilepticus is defined as a seizure lasting ≥5 minutes or ≥2 seizure events in which the patient does not completely regain consciousness. Intravenous benzodiazepines (eg, lorazepam, diazepam) should be administered for seizure termination. In addition, a nonbenzodiazepine antiepileptic medication should be administered to prevent seizure recurrence; recommended medications include fosphenytoin, phenytoin, levetiracetam, or valproic acid.

A 19-Year-Old Man Is Brought to the Emergency Department Due