What are the next best steps for an 81F with MS and hypothyroidism on comfort care presenting with a new seizure, hypertension, tachycardia, and mild hypoxia?

Management of New-Onset Seizure in an 81-Year-Old Patient on Comfort Care

For an 81-year-old female with MS and hypothyroidism on comfort care presenting with a new-onset seizure, the next best steps are to administer a benzodiazepine such as lorazepam 4 mg IV if the seizure is ongoing, while simultaneously addressing potential underlying causes such as metabolic derangements, medication effects, or infection, all within the framework of her comfort care goals. 1

Initial Seizure Management

1. Immediate seizure control (if still seizing or recurrent seizures):

   • Administer lorazepam 4 mg IV slowly (2 mg/min) 2
   • If seizures continue after 10-15 minutes, an additional 4 mg dose may be given 2
   • Monitor respiratory status closely as benzodiazepines can cause respiratory depression, especially in elderly patients 2

2. Airway and vital sign management:

   • Ensure patent airway and adequate oxygenation
   • Continue oxygen supplementation to maintain saturation >94%
   • Monitor vital signs closely - note that her current hypertension (161/93) and tachycardia (HR 115) may be post-ictal manifestations or indicate an underlying cause 1

Diagnostic Evaluation (Within Comfort Care Framework)

1. Essential laboratory tests (tailored to comfort care goals):

   • Serum glucose (rule out hypoglycemia)
   • Serum sodium (rule out hyponatremia)
   • Basic metabolic panel (assess for metabolic derangements)
   • Consider thyroid function tests (given her hypothyroidism history) 1

2. Focused evaluation for common seizure triggers:

   • Medication review (MS treatments, thyroid medications)
   • Assess for signs of infection (fever, though currently afebrile at 36.4°C)
   • Evaluate for signs of metabolic disturbances 1

Special Considerations for This Patient

1. MS and seizure relationship:

   • MS patients may have increased seizure risk due to cortical lesions
   • Consider if this represents disease progression 3

2. Thyroid function assessment:

   • Thyroid dysfunction can lower seizure threshold
   • Hypothyroidism management may need adjustment 4

3. Comfort care context:

   • Align all interventions with established goals of care
   • Focus on symptom management rather than extensive workup
   • Avoid unnecessary transfers or invasive procedures

Ongoing Management

1. Second-line treatment (if seizures persist despite benzodiazepines):

   • Consider levetiracetam, valproate, or phenytoin if consistent with comfort care goals 5, 1
   • The American College of Emergency Physicians recommends valproate, levetiracetam, or phenytoin/fosphenytoin for refractory seizures 5

2. Post-seizure care:

   • Monitor for return to neurological baseline
   • Provide supportive care for post-ictal symptoms
   • Consider maintenance anti-seizure medication only if recurrent seizures would compromise comfort 1

Communication and Documentation

1. Family discussion:

   • Explain the seizure event and its management within comfort care context
   • Review and confirm goals of care
   • Discuss seizure precautions and management plan for potential recurrence

2. Documentation:

   • Record seizure characteristics (duration, type, post-ictal state)
   • Document treatment provided and response
   • Update care plan to include seizure management within comfort care framework

Pitfalls to Avoid

• Overtreatment: Avoid extensive diagnostic workups inconsistent with comfort care goals
• Undertreatment: Don't withhold appropriate seizure management that would improve comfort
• Medication interactions: Be aware of potential interactions between anti-seizure medications and current treatments
• Age-related considerations: Elderly patients may experience more profound and prolonged sedation with benzodiazepines 1

Remember that the primary goal in this patient on comfort care is to manage symptoms effectively while maintaining dignity and quality of life, not necessarily to determine and address the underlying etiology of seizures unless doing so would improve comfort.