Snapshot 23 year old man, history of two traumatic brain injuries and subsequent epilepsy which present as an unresponsive staring spell with automatism of his left hand opening and clenching lasting two to five minutes, brought in by family after they noticed an episode at dinner. Family concerned that even though his automatism has not been constant, he remains unreponsive Introduction Definition more than 5 minutes of generalized convulsive seizure two or more seizure episodes without recovery of consciousness in between seizures maybe convulsive or non-convulsive A medical emergency with high mortality 13% in young adults 30% in elderly Evaluation Possible etiologies intracranial bleeding, ischemic infarction, arterio-venous malformations, venous sinus thrombosis, amyloid angiopathy meningitis, meningoencephalitis, abcess trauma CNS vasculitis, lupus gross electrolyte abnormalities cocaine, PCP, amphetamines, ethanol medications or lack of medications tumor Differential diagnosis hypoglycemia stroke, transient ischemic attack myoclonus, distonia narcolepsy, cataplexy complicated migraine panic attack transient global amnesia pseudoseizures, psychogenic malingering Immediate work up ABCs, oxygen sat, coma exam, blood glucose ABG, ECG, place on cardiac monitor CBC, Chem 10, LFT, Troponin, AED levels, tox screen Treatment Pharmacologic have IV lorazepam in syringe handy Avoid impulse to give benzos at onset! maintain patient in lateral decubitus position clear area of potentially injurous objects, place down protective padding administer O2 via nasal cannula, place two IVs, finger stick glucose if episode <5 minutes, wait 1-2 minutes majority of seizures resolve spontaneously draw labs and do immediate work up (see above) thiamine IV, 50% dextrose IV watch for respiratory suppression onset of lorazepam ~ 3minutes if seizure still persistent in 10-20 minutes - IV fosphenytoin, phenytoin, or valproate 21-60 minutes - IV midazolam, propofol, phenobarbital, or more valproate all of the above except valproate require intubation >60 minutes - IV phenobarbital Prognosis and Complications Prognosis 15.6% mortality in those with first episode 4.8% in those with repeated episodes length of episodes predisposes patient to complications Complications lactic acidosis hypoxia hyperthermia rhabdomyolysis cerebral edema hypotension