Epilepsy emergencies: the first seizure and status epilepticus

Patients experiencing a first seizure need a careful history and examination to confirm that the presenting seizure is truly the initial event and to identify other possible risk factors for recurrence. The decision of whether to start therapy should be made by the clinician and a fully informed patient. Status epilepticus presents in several forms, with generalized convulsive status epilepticus (GCSE) being the most dramatic. Management of GCSE requires life support and monitoring measures as well as timely administration of antiepileptic drugs (AEDs) to terminate the seizure and reduce the risks for morbidity and mortality. Benzodiazepines, phenytoin, and phenobarbital can all be used to treat GCSE. Clinicians need to be familiar with the dosage and administration, adverse events, time to onset, and duration of action of these drugs. Should seizures continue or recur despite AED administration, induction of coma with pentobarbital may be considered. This must be done with continuous EEG and other physiologic monitoring in an intensive care unit. Additional assessment of the patient who has experienced GCSE focuses on identification of the underlying cause.