Acute Seizures and Status Epilepticus

Questions

• 1.

  What are the vital signs? Is the airway secured?

• 2.

  Is the patient still seizing?

  • If yes, how long has it been going on?

  • If no, has the patient had multiple seizures without return to baseline?

    • Status epilepticus is a neurologic emergency defined as ≥ 5 minutes of continuous seizure or repeated seizures without return to baseline in between. Any patient seizing with no known time of onset should be considered to be in status epilepticus until proven otherwise.

• 3.

  What is the patient’s level of consciousness?

  • A patient may have a decreased level of consciousness because of ongoing nonconvulsive status epilepticus, postictal state, as a result of medications given to abort the seizures, or because of the underlying cause of the seizure. One should never assume an altered level of consciousness is caused by a postictal state or medications until nonconvulsive status epilepticus and underlying pathologies are excluded with further investigations, including an electroencephalogram (EEG).

• 4.

  What are the patient’s finger stick glucose level and vital signs?

  • Focal and generalized seizures can be caused by hyperglycemia or hypoglycemia, and they may remain refractory to antiepileptic drugs (AEDs) unless the glucose is corrected. Knowing the patient’s vital signs (even if no longer seizing) is crucial to assess the urgency of the situation.

• 5.

  Is this the first known seizure for this patient?

  • In patients with known epilepsy, there may be records available detailing their history, including AEDs that have worked/failed in the past, or allergies and complications from AEDs that should be avoided.

• 6.

  Is the patient on antiepileptic medications?

  • AED levels need to be checked for any seizure patient on medication. Noncompliance with medication in patients with epilepsy is the most common cause of status epilepticus. In some cases, AEDs may be epileptogenic at toxic levels.

Orders

• 1.

  Protect patient from potential harm. Place the patient in the lateral decubitus position to prevent aspiration, clear sharp or hard objects from the bed, put side rails up, and pad side rails.

• 2.

  Obtain a full set of vitals and place patient on monitors if possible.

• 3.

  Ensure that two working intravenous (IV) lines present.

• 4.

  Ensure that airway equipment such as oxygen, suction, oral airway, and Ambu bag are present at bedside.

• 5.

  For any seizure lasting ≥ 2 minutes Lorazepam 0.1 mg/kg should be given by IV push. For most patients, a total of 8 mg given in four repeated 2-mg boluses is required. Although the seizures may stop after the initial 2 mg is given, consider a full loading dose to minimize the chance of recurrent seizures during the next 6 to 12 hours.

• 6.

  Perform a bedside finger stick glucose test . If results are available and confirm hypoglycemia, then 100 mg IV thiamine followed by 50 mL of IV D50W should be administered.

• 7.

  Send stat labs including complete blood count, electrolytes, calcium, magnesium, phosphate, creatinine, and a liver panel. If the patient has depressed level of consciousness, then send an arterial blood gas (ABG). Depending on the clinical scenario, a tox panel or AED levels also may need to be sent.

Inform RN

“Will arrive at the bedside in…minutes.”

If the patient is still seizing, it must be considered an emergency. Even if the patient has stopped seizing, the patient may remain unstable because of aspiration or depressed level of consciousness, and another seizure may occur within minutes requiring urgent assessment.