A 29-year-old woman with a history of epilepsy is brought to the emergency department 30 minutes after a seizure. The patient was at a party where she had consumed alcohol when she experienced a generalized tonic-clonic seizure. She had another brief seizure in the ambulance. On arrival, the patient is stuporous and not following instructions and withdraws all extremities from painful stimuli. While being evaluated, she has another seizure that terminates after a dose of intravenous lorazepam is administered. Serum chemistry panel is normal, CT scan of the head reveals no abnormalities, and blood alcohol level is 0.06%. Serum levetiracetam level, which she takes at home, is subtherapeutic, and an additional dose is administered. The patient has no further seizure activity but remains unresponsive an hour after treatment. In addition to continued supportive care, which of the following is the most appropriate next step in management of this patient?

Question

A 29-year-old woman with a history of epilepsy is brought to the emergency department 30 minutes after a seizure.  The patient was at a party where she had consumed alcohol when she experienced a generalized tonic-clonic seizure.  She had another brief seizure in the ambulance.  On arrival, the patient is stuporous and not following instructions and withdraws all extremities from painful stimuli.  While being evaluated, she has another seizure that terminates after a dose of intravenous lorazepam is administered.  Serum chemistry panel is normal, CT scan of the head reveals no abnormalities, and blood alcohol level is 0.06%.  Serum levetiracetam level, which she takes at home, is subtherapeutic, and an additional dose is administered.  The patient has no further seizure activity but remains unresponsive an hour after treatment.  In addition to continued supportive care, which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d5cb_c183_bc81_cdebf9e17ae7_MD0003_00 This patient with epilepsy has had multiple generalized convulsive seizures without interval recovery of consciousness, which is consistent with generalized convulsive status epilepticus (GCSE). Prolonged seizures are associated with neuronal injury and death; therefore, patients with GCSE should be treated immediately with benzodiazepines to terminate seizure activity. This patient was appropriately treated with multiple doses of benzodiazepines (eg, lorazepam) followed by adjunctive intravenous antiepileptic drug (AED) therapy (eg, levitarecetam). appropriately treated Following such a therapy, patients with GCSE typically regain responsiveness in 10-20 minutes. Persistent unresponsive state, as seen in this patient, may be due to either: Sedation due to persistent effects of benzodiazepines or ongoing seizure activity without physical manifestations (ie, nonconvulsive status epilepticus). Therefore, to differentiate between these 2 states, electroencephalography should be performed. If electrographic seizure activity continues despite benzodiazepines and AED, a continuous infusion of benzodiazepines can be initiated, and propofol or pentobarbital can be used in refractory cases. (Choice A) Alcohol withdrawal or intoxication can precipitate seizures. However, activated charcoal does not absorb alcohol, and activated charcoal should not be given to patients with a reduced level of consciousness due to the risk of vomiting. In addition, this patient's seizures are likely related to a history of epilepsy and subtherapeutic AED level. (Choice C) Flumazenil is a competitive antagonist that may be used to reverse benzodiazepine sedation. However, it is unclear whether this patient's unresponsiveness is related to benzodiazepine effects or ongoing seizure activity, which would require additional benzodiazepines. In addition, because of the risk of precipitating further seizures, sedation related to benzodiazepine use after GCSE is managed with supportive therapy (eg, securing airway and assisting breathing if necessary) rather than flumazenil. (Choice D) An MRI of the head is often obtained after a seizure to evaluate for possible structural abnormalities in the brain that may be leading to seizures. However, GCSE is an emergency that can result in neuronal injury and death. Therefore, evaluation for persistent seizure activity (and subsequent cessation of seizure activity by using benzodiazepines) is a much higher priority than obtaining further neuroimaging. (Choice E) This patient remains unresponsive. Additional work-up and treatment is urgently needed to determine whether the patient is having ongoing nonconvulsive status epilepticus. Educational objective: Patients who remain unresponsive after generalized convulsive status epilepticus require electroencephalography to differentiate between sedation due to benzodiazepines and persistent nonconvulsive status epilepticus.

A 29-Year-Old Woman with a History of Epilepsy Is Brought