Seizures in the critically ill

Critically ill patients with seizures are either admitted to the intensive care unit because of uncontrolled seizures requiring aggressive treatment or are admitted for other reasons and develop seizures secondarily. These patients may have multiorgan failure and severe metabolic and electrolyte disarrangements, and may require complex medication regimens and interventions. Seizures can be seen as a result of an acute systemic illness, a primary neurologic pathology, or a medication side-effect and can present in a wide array of symptoms from convulsive activity, subtle twitching, to lethargy. In this population, untreated isolated seizures can quickly escalate to generalized convulsive status epilepticus or, more frequently, nonconvulsive status epileptics, which is associated with a high morbidity and mortality. Status epilepticus (SE) arises from a failure of inhibitory mechanisms and an enhancement of excitatory pathways causing permanent neuronal injury and other systemic sequelae. Carrying a high 30-day mortality rate, SE can be very difficult to treat in this complex setting, and a portion of these patients will become refractory, requiring narcotics and anesthetic medications. The most significant factor in successfully treating status epilepticus is initiating antiepileptic drugs as soon as possible, thus attentiveness and recognition of this disease are critical.