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A 16-Year-Old With Recalcitrant Seizures

A 16-year-old girl arrives in the emergency department (ED) by ambulance after having had a seizure at home. The seizure lasted 3 minutes and was described as generalized with rhythmic contractions of both arms and legs, ‘‘foaming at the mouth,’’ and urinary incontinence. Intravenous access was obtained in the prehospital setting, and it is reported that her blood glucose concentration was 210 mg/dL. The girl utters some incomprehensible sounds and occasionally opens her eyes, but she does not fix her gaze or respond to voice. Her heart rate is 118 beats/minute, her blood pressure is 120/55 mm Hg, and her respiratory rate is 28 breaths/minute and deep. She is afebrile, and her hemoglobin oxygen saturation is 97% as measured by transcutaneous pulse oximetry. Her scalp has no bruises or soft tissue swelling; her pupils are round, 6 mm in diameter, and reactive; and her mucous membranes are moist. The thyroid gland is normal in size and texture, and meningismus is not present. Breath sounds and heart sounds are normal to auscultation. The girl’s abdomen is soft with normally active bowel sounds. Pulses feel slightly bounding on palpation, but the skin is warm and moist. Deep tendon reflexes are normal in the lower extremities, but the girl cannot cooperate with strength or cerebellar examinations. The girl experiences another generalized tonic-clonic seizure in the ED and, after 2 minutes, is administered lorazepam, 1 mg, intravenously. Two minutes later, another 1-mg dose of lorazepam is administered with cessation of the seizure. Computed tomographic scan of the brain is normal. An electrocardiogram is obtained displaying sinus tachycardia with normal QRS and QTc intervals. Blood glucose is checked again and is 200 mg/dL, 1 L of 0.9% saline is administered intravenously, and blood is sent for laboratory evaluation. A urine catheter is placed, and result of a urine pregnancy test is normal. The girl’s family reports that she appeared normal in the morning and had no antecedent viral symptoms. She had been home all day and had no known head trauma. The girl has no known drug allergies and no medical history of epilepsy. She is troubled by chronic abdominal pain and has been treated for pelvic inflammatory disease several times, but her only current medication is an oral hormonal contraceptive. Her family believes that she has used alcohol and marijuana in the past but do not believe that she is a regular user and do not believe that she has tried any ‘‘harder’’ drugs. She lives in a household with an extended family with household members being treated for chronic back pain, depression, diabetes, hypertension, and a lung infection. She has not attempted suicide in the past, but her family reports that she has been acting more withdrawn lately and has been performing poorly at school. Earlier in the day, she had gotten into an argument with a family member about being ‘‘lazy.’’ A generalized seizure begins again and another 1 mg of lorazepam is administered, and 15 mg/kg of phenytoin is loaded via intravenous infusion. A complete blood cell count is unremarkable, but serum chemistries are remarkable for metabolic acidosis with a CO2 j = 10 mEq/L with a wide anion gap, normal renal function, and a mild elevation of hepatic transaminases. Result of serum testing for ethanol, acetaminophen, and salicylate is negative, and a urine drug immunoassay is negative for amphetamines, cannabis, cocaine, and opiate drugs. The convulsive activity continues, and in consultation with a regional poison control center, another anticonvulsant drug is given.