From the Guidelines
The patient should be taken to the emergency department immediately for evaluation and management of their cluster of seizures, considering the recent study from 2024 1 that emphasizes the importance of early treatment in reducing morbidity and mortality. While the seizures individually did not meet the parameters for midazolam administration (being under one minute each), the occurrence of three seizures within a short timeframe constitutes a concerning pattern that requires urgent medical attention. The facial asymmetry (twisted mouth) during the last seizure could indicate focal seizure activity or postictal paralysis, which needs neurological assessment. Despite having taken their regular antiepileptic medications (Vimpat, Keppra, and phenytoin) at 7 pm, the breakthrough seizures and elevated blood pressure suggest either subtherapeutic medication levels or an evolving neurological condition. Some key points to consider in management include:
- The use of levetiracetam, fosphenytoin, or valproate in the setting of benzodiazepine-resistant status epilepticus, as these have been shown to result in cessation of seizures in approximately half of all patients 1.
- The potential benefits of valproate, which has been advocated as an alternative to phenytoin and even as first-line therapy for status epilepticus, with potentially fewer adverse effects 1. At the hospital, the patient will likely need:
- Blood work to check antiepileptic drug levels
- Possible loading doses of medication
- Continuous EEG monitoring
- Investigation for underlying causes such as infection, metabolic disturbances, or structural brain changes. This approach is guided by the principle of minimizing the risk of progression to status epilepticus, which becomes more difficult to control the longer it continues and can lead to neurological damage, as highlighted by the most recent clinical policy from 2024 1.
From the Research
Seizure Management
- The patient experienced seizures at 6:21,8:10, and 8:26, with jerking movements and elevated blood pressure 2.
- The patient did not meet the parameters for 5mg nasal spray midazolam for seizures lasting over a minute 2.
- The patient was administered Vimpat, Keppra, and Phenytoin at 7 pm 2.
Treatment Options
- Benzodiazepines, such as intravenous lorazepam, are commonly used as first-line treatments for status epilepticus 2, 3.
- Levetiracetam, valproate, and fosphenytoin are potential second-line agents for benzodiazepine-refractory status epilepticus 4, 5.
- Intramuscular midazolam is an effective alternative to intravenous lorazepam for pre-hospital treatment of seizures 3.
Considerations
- The patient's elevated blood pressure and seizure activity may require close monitoring and adjustment of treatment 2.
- The use of multiple antiepileptic drugs, such as Vimpat, Keppra, and Phenytoin, may increase the risk of adverse effects 4, 5.
- The patient's response to treatment should be closely monitored, and adjustments made as necessary to prevent recurrence of seizures 6.