Snapshot A 79-year-old man presents to the emergency department after a fall complicated by a head strike. He underwent a non-contrast CT head, which demonstrate bilateral subdural hematoma without evidence of cerebral herniation. Neurosurgery was consulted and determined the intracranial bleeds were small and his neurological exam was unremarkable. He was also found to have a complicated urinary tract infection, requiring hospital admission for treatment with intravenous antibiotics. On hospital day 3, the patient has a generalized tonic-clonic seizure that lasted 6 minutes. He is started on intravenous lorazepam and is loaded with levetiracetam. His seizures eventually clinically abort and he is placed on electroencephalography. Introduction Definition seizures that lasts ≥ 5 minutes OR incomplete recovery of consciousness between ≥ 2 discrete seizures Etiology Structural abnormalities stroke (most common in older adults) brain malignancy intracranial bleed head trauma arteriovenous malformations Infections meningitis encephalitis Metabolic abnormalities hypo- or hyperglycemia hepatic encephalopathy hypo- or hypernatremia hypocalcemia and hypomagnesemia uremia sepsis Medications/toxins antiepileptic drug nonadherence alcohol, benzodiazepine, or barbiturate withdrawal other medications that lower the seizure threshold certain antibiotics (e.g., imipenem and high-dose penicillin) tricyclic antidepressants bupropion Pathogenesis Uncontrolled neuronal excitation and reduced neuronal inhibition Presentation Symptoms/physical exam symptoms depend on the location of the seizure generalized tonic-clonic seizures with diffuse seizure activity Imaging CT head without contrast indication performed once the patient is stabilized to determine the presence of a stroke, intracranial bleed, or intracranial abnormality MRI brain indication more sensitive imaging modality to visualize any underlying structural lesion; however, not necessary to be performed the patient must be well enough to tolerate the length of the MRI Studies Electroencephalogram indication determins the presence of seizures and whether they terminated patients can still have seizures without convulsions (called non-convulsive status epilepticus) Serum studies calcium, phosphorous, magnesium, and glucose level antiseizure drug level toxicology studies Treatment Medical lorazepam or diazepam indication initial therapy to be administered in status epilepticus in 1 intravenous line other medications midazolam if intravenous access cannot be obtained fosphenytoin, phenytoin, valproic acid, or levetiracetam indication initial therapy to be administered in status epilepticus in the other intravenous line correcting underlying medical problem e.g., correcting hypoglycemia provide thiamine midazolam, phenobarbitol, or pentobarbitol drip indication used in refractory status epilepticus Complications Cardiac arrhythmias Hypoxia Aspiration pneumonitis and respiratory failure