Seizures in a Patient With Medication Non-Compliance

Case Study

A rapid response event was initiated by a floor nurse for a patient having persistent seizure-like activity. On arrival of first responders, the patient was non-arousable and was having generalized tonic-clonic movements. Per the bedside nurse, she had just administered 2 mg of IV lorazepam to no effect. Per the report, the patient was a 24-year-old male with a past medical history of seizure disorder and type 2 diabetes. He was admitted one day prior to the surgical service for small bowel obstruction. The patient had been nil per os (NPO) with a nasogastric (NG) tube placed for bowel decompression. Upon medication review, it was noted that his home medications had been held, including his oral levetiracetam. He was only receiving a low dose sliding scale insulin while NPO with Q6h glucose checks. The nurse reported continuous tonic-clonic jerking movements for approximately 4 min.

Vital Signs

Temperature: 98.4 °F, axillary
Blood Pressure: 115/86 mmHg
Heart Rate: 104 beats per min (bpm) – sinus tachycardia on telemetry
Respiratory Rate: 18 breaths per min
Pulse Oximetry: 94% oxygen saturation on room air

Focused Physical Examination

A quick exam showed a well-developed young male lying in bed with generalized tonic-clonic movements of all four extremities and rapid eye twitching. He was non-arousable to tactile or vocal stimuli. The rest of his physical exam was not conducted because of active seizures.

Interventions

Due to persistent seizure-like activity approaching 5 min, the most likely diagnosis was status epilepticus, secondary to not receiving his antiepileptic medications. After securing the airway by placing an oral airway, the patient was turned to his lateral side (to prevent aspiration). A pulse oximetry probe was placed on his finger to monitor oxygen saturation. Capillary blood glucose was checked to rule out hypoglycemia, which revealed a glucose level of 130 mg/dL. A basal metabolic panel (BMP) was drawn to rule out electrolyte abnormalities. The patient was given an additional dose of lorazepam (4 mg IV) followed by a loading dose of 1500 mg levetiracetam. The patient’s seizure failed to resolve by benzodiazepines and levetiracetam, and he started to get hypoxic; thus, he was intubated for airway protection and started on a propofol drip. This stopped the seizures, and the patient was transferred to the intensive care unit (ICU) for further monitoring and management.

Final Diagnosis

Status epilepticus secondary to sudden discontinuation of antiepileptic therapy.

Status Epilepticus

Generalized convulsive status epilepticus is defined as >5 min of continuous seizure episode or more than two seizures for which in-between there is incomplete recovery to baseline mentation.

The classification of status epilepticus per the International League Against Epilepsy is given in Table 45.1 .

Table 45.1

Classification of status epilepticus (SE)

Convulsive
Generalized convulsive SE • Primary generalized convulsive SE • Generalized convulsive with focal onset	Focal motor SE

Convulsive

Generalized

Focal

Generalized convulsive SE

•

Primary generalized convulsive SE
•

Generalized convulsive with focal onset

Focal motor SE

Non-convulsive
• Typical absence SE • Other primarily generalized non-convulsive status epilepticus (NCSE) • Atypical absence SE • Other generalized NCSE, with focal onset	• Complex partial SE, with prolonged or repeated focal seizures (i.e., focal onset seizures with impaired or altered awareness) • Other focal SE with non-motor features (i.e., focal onset seizures with dyscognitive features) (e.g., aphasic or sensory)