Hi there! I'm writing a story fanfic about a main character with epilepsy. Her meds don't control it very well, and she has absence and tonic-conic seizures. One night she goes into status epilepticus and 911 is called. Could you give me some insight as to what the paramedics would do when they arrive on scene? And if they couldn't get her to stop seizing at the ER what could the ICU stay be like? And how long roughly would it be? I'm love to get a better idea of this in addition to my research.
Hey there nonny! Yes! Status epilepticus is a really scary thing to watch, and I’ve come across it several times.
First, upon arrival, paramedics are going to try to determine:
- How long she’s been seizing
- Does she usually seize once or multiple times, when she seizes?
- Has she ever been in the ICU for her seizures?
All this is going to be while they’re making sure she’s lying on her side, that she has a pillow under her head, and while one of them is drawing up a medication (either Ativan / lorazepam, 2mg, or Versed / midazolam, 10mg) to give intramuscularly into a thigh.
They’ll also apply an oxygen mask and may check a blood sugar level, especially if she’s diabetic.
If the first line of medication doesn’t work, it’s time to scoop and run, because many EMS systems don’t have good backup plans for “what if first-line benzodiazepines fail?”.
If they have it on hand, an excellent second-line medication is ketamine, given at high doses (4mg/kg IM, so a 70kg person might get 300mg intramuscularly). That should stop the seizing.
Once we get beyond that point it’s down to general anesthesia and intubation, which, hopefully the ketamine is enough to get that done.
Somewhere along the line, probably en route to the hospital, they’ll try to get an IV, but I have to say, getting an IV on a seizing patient in a moving vehicle isn’t easy. I’ve done it, but I’ve never LIKED doing it. (The medic will likely stabilize the arm against the medic’s leg to keep it “still” while performing the IV).
Other systems might try more benzos – additional Ativan or Versed or Valium / diazepam – but this probably won’t work, because the longer someone seizes, the more GABA receptors shut down – the same receptors hit by benzodiazepines. (This is why I suggested ketamine above!)
This is a patient the ER will get a heads-up about. If EMS hasn’t intubated her, the ER is going to. They’ll put her on a drip of either midazolam or (preferably) propofol and fentanyl until her brainwaves have been completely flatlined, as evidenced by EEG monitoring. She’ll also be loaded with an antiepileptic like Keppra or Dilantin IV.
This character is getting an emergent CT of the head, to make sure that the issue isn’t because of a bleed or a tumor or some other intracranial catastrophe.
If it truly is her epilepsy, she’ll be admitted to the neuro ICU, which may be at another hospital, so they may need someone like me to come and do the transfer.
At the Neuro ICU…. well, honestly, she’ll likely get another CT, and probably an MRI if they suspect a physical cause.
As for the experience of being in a Neuro ICU, you’re in luck. I have not one, but TWO excellent masterposts – interviews, really – about this very topic. M was kind and brave enough to come on the blog and talk with me about her husband’s 3-month coma that was due to intractable seizures.
Her posts are here (part 1): http://scriptmedic.tumblr.com/post/155822695067/nothing-like-a-lightswitch-ms-husbands-3-month
Part 2 even contains her direct advice for writers, which I appreciate immensely.
I hope this helped your story!