STATUS EPILEPTCUS VIGNETTE 1 C.H., a 46-year-old woman, was admitted to University Hospital because of worsening dyspnea and easy fatigability. She had exertional dyspnea for months but, over the past few days, she has been dyspneic at rest. She also had three episodes of vomiting the day prior to admission. Her medical history is significant for congestive heart failure, type-2 diabetes mellitus resulting in right leg amputation below the knee, hypertension, hepatitis B, pulmonary embolism, celiac disease, and thyroid nodule. She has been taking Aleve every day in the past six months because of left leg pain. Other home meds include Lasix, Humulin, lisinopril, metformin, metoprolol, nitroglycerin, and Norvasc. At the time of admission, BP was 124/94, HR was 62/min, RR was 18/min, and temp was 96°F. SaO2 was 97% on 2L oxygen via nasal cannula. The patient was alert and coherent but appeared very tired. She had anasarca up to the level of her clavicles. Her left leg had bullae, ecchymosis, and areas of hypopigmentation and early necrotic changes were noted on her toes. Her pupils were equally reactive to light and the rest of the neurological exam was normal. Lab test results: WBC 20,800, hemoglobin 11.8, hematocrit 37.6, platelets 193, sodium 135, potassium 5.1, chloride 108, bicarbonate 21, BUN 45, creatinine 3.3, glucose 239, CRP is 15.1 and ESR is 85. LFTs were normal but serum albumin was only 1.4. Chest x-ray showed cardiomegaly with mild pulmonary edema and right pleural fluid. Left foot x-ray revealed vascular calcifications and generalized soft tissue swelling. The patient was admitted to medicine. The day after admission, the patient developed delirium. Neurology was consulted and a stat EEG was requested. A representative segment of the tracing is shown below. The same pattern is present throughout the record.

Describe the EEG findings. Is the patient in status epilepticus? If so, what type of status epilepticus? What will you recommend to the physician(s) who consulted you?

STATUS EPILEPTICUS VIGNETTE 2 K.J., a 75-year-old female with multiple brain mass lesions, was transferred from BMC to University Hospital (UH) for “possible status epilepticus”. The patient was admitted to UH three months ago; that time brain CT was “consistent with a CVA”. However, an outpatient MRI revealed multiple tumor-like brain lesions prompting readmission three weeks ago. The diagnosis of brain tumor was corroborated with MR spectroscopy. Keppra was started and Neurosurgery was consulted. During this admission, a mass was also detected in the left breast prompting an Oncology consult. Prior to discharge, appointments were arranged for her to undergo breast biopsy and brain biopsy (these were not done for reasons that are not clear). Today, the patient was brought in to BMC for altered mental status. According to report, she had a seizure in BMC which “could not be controlled” despite 4 mg of Ativan, 5 mg of Versed, and 10 mg of Valium. The patient arrived on a non-rebreather with a BP of 139/108, HR of 108, RR of 18, temp of 96.5, and SaO2 of 100%. GCS was 6 (1 for eyes, 1 for verbal, 4 for motor). There were no overt signs of ongoing seizure activity. She had spontaneous movements of all extremities and she withdraws to pain. Her pupils were equal and reactive to light. No focal neurological deficits reported. Her breath sounds were coarse but cardiac sounds were normal. She was tachycardic with regular rhythm. Bowel sounds were also normal and she had good peripheral pulses. Lab tests at BMC showed elevated WBC (12.8), low potassium (3.0) and evidence of acute urinary tract infection. The patient was intubated and admitted to the ICU. Neurology was consulted and a stat EEG was requested. A representative segment of the tracing is shown below. The same pattern is present throughout the record.

Describe the EEG findings. Is the patient in status epilepticus? If so, what type of status epilepticus? What will you recommend to the physician(s) who consulted you?

STATUS EPILEPTICUS VIGNETTE 3 J.K. is a 61-year-old right-handed man with diabetes and a history of liver transplant (8 years ago). Six days ago, he was brought to the University Hospital ER in coma (GCS of 3) post cardiac arrest. This occurred at work; he collapsed and was found in asystole. EMS gave him two shocks, two rounds of epinephrine, and intubated him. He was placed under a post cardiac arrest cooling protocol in the ICU. On the fourth day post cardiac arrest, the patient was taken off sedation and the primary team noticed some abnormal body movements. Keppra 500 mg po bid was started. Other meds include aspirin, Plavix, Prograf, Bactrim, Lantus, Vancomycin, Zosyn, and Crestor. On the fifth day, brain CT showed subtle loss of gray-white matter differentiation and transcortical edema in the right frontal lobe five days post cardiac arrest. EEG was recorded on the sixth day, at a time when the patient has been off sedation for at least 48 hours. Around that time, the patient’s maximum temperature was 37.5, pulse rate ranged from 74 to 85, respiratory rate from 11 to 15, systolic BP from 132 to 147, and diastolic BP from 66 to 74. The patient was unresponsive to verbal stimuli but opened his eyes spontaneously. Pain stimulation resulted in grimacing, arm flexion and triple flexion of the lower extremities. Pupillary, corneal, oculocephalic, and gag reflexes were intact. The biceps, triceps, brachioradialis, patellar, and Achilles reflexes were +1 bilaterally. Babinski sign was present on the left and equivocal on the right. Labs showed WBC 14.5, hemoglobin 12.5, hematocrit 37.2, and platelets 175, sodium 139, potassium 3.4, BUN 25, creat 0.95, chloride 106, CO2 26, glucose 148, phosphate 1.7, AST 504, ALT 159, and albumin 2.0. A representative segment of the tracing is shown below. The same pattern is present throughout the record.

Describe the EEG findings. Is the patient in status epilepticus? If so, what type of status epilepticus? What will you recommend to the physician(s) who consulted you?

STATUS EPILEPTICUS VIGNETTE 4 H.K., a 31-year-old woman with a history of depression, was found down by her father. This morning, her husband saw her still sleeping before he left for work. Her father tried to contact her and could not get any response. This prompted him to go to the patient’s house where the patient was found on the floor "shaking". The initial responders also learned that the patient had an infant who died of SIDS a few months ago and that the patient was on Suboxone, the reason for which was not clear. They also found bottles of Soma in her house. The patient arrived at University Hospital with a GCS of 5. The ER physicians noticed the presence of nystagmus and tremulousness. They suspected drug overdose. The patient was intubated. Head CT was normal. The patient was still tremulous even after receiving 6 mg of Ativan IV. Fosphenytoin 1 gram load was administered and propofol drip was started at 10 mcg/kg/min. Stat EEG was requested. Propofol drip was temporarily put on hold 10 minutes before the EEG was recorded. A representative segment of the EEG tracing is shown below. The same pattern is present throughout the record.

Describe the EEG findings. Is the patient in status epilepticus? If so, what type of status epilepticus? What will you recommend to the physician(s) who consulted you?

STATUS EPILEPTICUS VIGNETTE 5 P.M. is a 70-year-old female who fell off the stairs while attending a conference in Alabama two weeks ago. She was admitted to an ICU at the University of Alabama where she was treated for subarachnoid hemorrhage and multiple fractures. Her hospital course was complicated by ARDS and her hemoglobin fell from 10.1 to 6 over a period of several days. Procrit was given as an alternative for blood (the patient is a Jehovah's Witness). She also developed atrial fibrillation and amiodarone was started. Even if she was weaned off the ventilator, she had to stay in the ICU due to persistent delirium. Her family in New Orleans decided to transfer her to University Hospital. After two weeks in Alabama, the patient was transferred to University Hospital on the following medicines: amiodarone, Lopressor, Fragmin, Procrit, Famotidine, iron sulfate, folic acid, and multivitamins. Neurology was consulted because of “persistent altered mental status”. The patient was examined by your colleague and was found to be awake, alert, and fully oriented with intact ability to name, repeat, and engage in some conversation (although she is distracted by pain). Memory recall was 0/3 at 2 minutes and at 5 minutes. She could not remember circumstances preceding the fall. The rest of the neurological exam was normal. At some point during the examination, she stopped answering questions and became quiet for about 30 seconds. Her eyes were open and she blinked; no limb movement was observed. Bedside EEG was requested. A representative segment of the tracing is shown below. The same pattern is present throughout the record. The patient appeared to be “in a daze” during EEG acquisition but she correctly answered all of the questions that were asked by the EEG technologist.

Describe the EEG findings. Is the patient in status epilepticus? If so, what type of status epilepticus? What will you tell the consulting neurologist?

STATUS EPILEPTICUS VIGNETTE 6 J.R., an 80-year-old man with type-2 diabetes, hypertension, and tremor, was admitted to University Hospital five days ago because of asymptomatic ST elevation in the EKG. Dobutamine stress echo revealed inducible myocardial ischemia. Three days ago, he developed arrhythmias (bradycardia → pulseless electrical activity → ventricular tachycardia) which required resuscitation, intubation, and transfer to the ICU. He was placed on hypothermia protocol. This morning, 4 hours after the hypothermia protocol was discontinued, the patient’s limbs started jerking prompting the ICU team to consult Neurology. When you examined him, he was already off sedation and anesthesia (off fentanyl ≥6hr and vecuronium ≥12hr). He opened his eyes to voice and was able to follow simple commands (e.g. show thumbs up with right hand then left hand). You noted repetitive jerking of his arms and, to a lesser extent, his legs. His temp was 37.3, HR 91, BP 134/51 and he was “breathing over the vent” (ventilator rate 12, breathing rate 20) with SaO2 of 96%. Cranial nerve deficits were not detected. He moved all of his extremities spontaneously and with command. He had mild paratonia but his reflexes were normal and symmetric; clonus and Babinski sign were absent. The EEG tech arrived and bedside EEG recording was started. A representative segment of the tracing is shown below. The same pattern is present throughout the record. Repetitive jerking of the arms (± slight leg jerking) was present throughout the study. The timing of the jerks is shown below by upward-pointing arrows.

Describe the EEG findings. Is the patient in status epilepticus? If so, what type of status epilepticus? What will you recommend to the physician(s) who consulted you?

STATUS EPILEPTICUS VIGNETTE 7 D.R. is a 46-year-old male with known coronary artery disease and stent placement seven months ago. He presented with chest pain to an outside hospital. Cardiac cath showed severe coronary artery disease prompting transfer to University Hospital where repeat catheterization showed 90% stenosis of the left anterior descending artery proximal to the stent and 50% stenosis of the left circumflex artery. Coronary artery bypass grafting was performed the day after admission. After the procedure, the patient was transferred back to the ICU. Three hours after transfer, he developed ventricular fibrillation followed by pulseless electrical activity. In addition, to routine measures, open cardiac massage was performed and intracardiac epinephrine was administered. His vital signs were stabilized and he was transferred back to the operating room. Blood test revealed hyperkalemia which was treated aggressively. Cardiac re-exploration was performed and intra-aortic balloon pump was placed. The patient was transferred back to the ICU where he remained hemodynamically stable with the help of pressors. Unfortunately, he never regained consciousness and he continued to require mechanical ventilation. Sporadic twitches were noted on his face and arms. EEG was recorded on the fifth post-op day. A representative segment of the tracing is shown below. This pattern persisted throughout the study.

Describe the EEG findings. Is the patient in status epilepticus? If so, what type of status epilepticus? What will you recommend to the ICU physician(s)?

STATUS EPILETICUS VIGNETTE 8 41-year-old man without significant past medical history was found down by his family at home. Paramedics called to the scene found that the patient bit his tongue and urinated on himself. Although his vital signs were stable, he remained confused and drowsy. With diagnosis of new-onset generalized tonic-clonic seizure the patient was brought to the ER of a local hospital. Within minutes of arrival at the ER, the patient developed another tonic-clonic seizure. Patient’s clonic convulsions and unresponsiveness have continued for five minutes. Questions:

1) Should the ER staff consider the patient to have developed convulsive status epilepticus?

2) Is the patient in life-threatening danger? 3) What should be the initial actions of the ER department? 4) Are you aware of AAN guidelines specific for management of status epilepticus

in adults? 5) Are you surprised that the patient did not have past history of seizures or

neurological disease? Answer: 30-50% of patients never had seizures before status epilepticus developed

References:

1) Samuel’s Manual of Neurologic Therapeutics. 8th edition, 2010 2) Merritt’s Neurology. 12th Edition, 2010. 3) Continuum. Epilepsy, 2010.

STATUS EPILETICUS VIGNETTE 9

A 40-year-old man with idiopathic generalized epilepsy is brought to the emergency department in convulsive status epilepticus. His wife believes that he had missed at least two doses of phenytoin over the previous 36 hours because he had neglected to refill his prescription on time. He has no other history of illness and takes no other medications. On admission to the emergency department, his vital signs are normal. An airway is established, and supplemental oxygen is administered. IV access is obtained, and IV lorazepam 4 mg is administered. Convulsions stop promptly, and 10 mg/kg IV fosphenytoin is administered. A phenytoin level drawn prior to the administration of IV fosphenytoin is 9 µg/mL. Initial serum electrolytes are normal. Four hours later, the patient remains unconscious with no convulsive activity. He withdraws all four limbs in response to pain, and brainstem reflexes are intact. Which of the following is the most appropriate next step in management?

A. administer an additional 10 mg/kg phenytoin B. administer 20 mg/kg phenobarbital C. CT head scan D. EEG E. repeat serum electrolyte levels