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LEARNING OBJECTIVES

After completing this case study, the reader should be able to:

  • Define status epilepticus and its precipitating causes.

  • Identify measures that should be taken in the ED for a patient in status epilepticus.

  • Recommend appropriate drug treatment for status epilepticus.

  • Recommend an optimal care plan for a patient with status epilepticus.

PATIENT PRESENTATION

Chief Complaint

As given by a friend of the patient: “I walked back into the room after getting breakfast and Josh was having a seizure. He kept shaking for a couple of minutes so I went to get the RA and he said we needed to get him to the ED.”

HPI

Joshua Banch is a 20-year-old man brought to the university hospital emergency department by his college roommate and dormitory resident assistant (RA). The roommate reported that he and Joshua went out partying the night before because all the fraternities were throwing rush parties. The roommate left Joshua partying at the Delta Tau Chi fraternity house at about 2:00 AM. He heard Joshua return to the room at approximately 4:30 AM and he was clearly intoxicated.

PMH

Medical records revealed that the patient developed generalized tonic–clonic seizures in childhood. Phenobarbital was initiated and controlled the seizures for many years. Withdrawal of phenobarbital was attempted 10 years ago after several years of being seizure free. The drug was restarted when seizures occurred during the attempted taper. Phenobarbital was replaced, due to sedation and lethargy, with carbamazepine. Phenytoin was added 8 years ago because of frequent and prolonged breakthrough seizures. He has had occasional breakthrough seizures since his admission to the university 2 years ago. Breakthrough seizures are typically associated with Joshua’s nonadherence with medications or sleep deprivation due to prolonged study sessions. He is routinely followed in the university hospital neurology clinic.

FH

Negative for epilepsy; the patient has two siblings, all alive and well. No other information on family history was obtained.

SH

Single with no children; no tobacco use; reports drinking up to six beers per week

Meds

Carbamazepine 500 mg PO TID

Phenytoin 100 mg PO BID

All

NKDA

ROS

Unobtainable

Physical Examination

Gen

WDWN Caucasian man who is unarousable, continues to have intermittent jerking of his extremities; clothes are wet from urinary incontinence.

VS

BP 150/90 mm Hg, P 150 bpm, RR 25, T 37.5°C; ...

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