Status Epilepticus, Seizures, and EEG Monitoring
Definitions and treatment ladder
Status epilepticus is continuous seizure activity ≥5 min or recurrent seizures without recovery. Treat time-critically: benzodiazepines first (lorazepam, midazolam), then a second-line antiseizure medication (levetiracetam, fosphenytoin, valproate), then anesthetic agents (midazolam, propofol, pentobarbital) for refractory disease. Nonconvulsive status epilepticus is common in ICU patients and requires EEG to detect.
EEG fundamentals
Know the patterns: periodic discharges, rhythmic delta activity, and the ictal-interictal continuum. Recognize that some patterns are treated (clinical or electrographic seizures) while others are monitored. Burst suppression is a target for refractory status, often titrated to EEG.
Traps
- Underdosing benzodiazepines; adequate weight-based dosing is essential.
- Missing nonconvulsive status because the patient is "just encephalopathic."
- Confusing postictal state with ongoing seizure; EEG resolves ambiguity.
- Forgetting to identify and correct the precipitant (hypoglycemia, hyponatremia, infection, drug withdrawal).
Rule of thumb
"Time is neurons": benzodiazepine within minutes, second-line within ~20 min, anesthetic within ~40 min for refractory cases.
Worked example
A comatose patient with unexplained altered mental status and subtle eye twitching: obtain urgent EEG. If electrographic seizures are found, treat as status epilepticus and search for a cause.