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seizures without intervening consciousness.2. Status epilepticus is a medical emergency requiring immediate treatment.3. The longer the seizure activity lasts, the more difficult it is to control the seizure.IV. DiagnosisA. Obtain a thorough history from the patient, the family, and/or the observers of the eventB. Twenty-four-hour continuous EEG is an important test for supporting the diagnosis ofepilepsy, differentiating between types of seizures, and providing a guide to prognosis.1. Focal abnormalities indicate partial seizures2. Generalized abnormalities indicate primary generalized seizures3. A normal EEG does not rule out a seizureC. CT scan or MRI of the head—performed for allnew-onset seizures, especially after age 30, because of the possibility of an underlying neoplasm
MRI preferred over CT scan to identify specific lesions in non-emergent casesD. Lumbar puncture (if indicated) is performed to assess for an infectious process after CT scanor MRI has been used to rule out expanding mass that may increase intracranial pressure(ICP).E. Twenty-four-hour EEG to document seizure activityF. Blood analysis1. Complete blood count2. Glucose, liver, and renal function tests3. Venereal Disease Research Laboratory test4. Electrolytes5. Magnesium6. Calcium7. Antinuclear antibody8. Erythrocyte sedimentation rate9. Arterial blood gasesG. Urinalysis, drug screenH. Serum prolactin rises two to three times above normal for 10-60 minutes after occurrence of 80% of tonic-clonic or complex partial seizuresV. ManagementA. Initial management is supportiveB. Most seizures are self-limiting1. Maintain open airway2. Place patient in left lateral decubitus position3. Protect the patient from injury4. Administer oxygen if the patient is cyanotic5. Do not force airways or objects (e.g., tongue blade) between the teeth until the muscles have relaxed because this may cause the tongue to occlude the airway or teeth to break off and cause a partial obstruction6. Start with intravenous (IV) normal saline7. Perform ECG, and monitor respiration and blood pressureC. For status epilepticus:1. Benzodiazepines are first-line treatment, as these are able to rapidly control seizures2. Lorazepam (Ativan), 0.1 mg/kg (4-8 mg with a maximum dose of 10 mg) at 2 mg/minute; IV diazepam (Valium), 0.1 mg/kg at 5 mg/minute (maximum, 20 mg); or midazolam (Versed), 0.1-0.3 mg/kg IV for a maximal dose of 10 mg (if IV lorazepam is not available)3. If IV access is not available, nurse practitioner may prescribe midazolam 10 mg IMin patients greater than 40 kg or 5 mg IM for body weight between 13 and 40 kg4. Monitor for respiratory depression after medications are given; intubation may become necessary5. Increase normal saline if the patient becomeshypotensive6. Phenytoin (Dilantin) should be administered simultaneously with lorazepam or diazepam and saline at 50 mg/minute until a loading doseof 20 mg/kg is reacheda. Fosphenytoin (Cerebyx) does not irritate the veins and can be given with all common IV solutions; it may be administered more quickly than phenytoin (150 mg/minute vs. 50