City Ambulance: Seizing deep into the lineup

Dispatched for witnessed seizures by a male in his 50s – we find a man supine on a couch unconscious and breathing, with nystagmus. Family on scene reports PMH includes seizures and alcohol abuse. No present trauma, unknown EtOH or drugs. While moving him to the unit he begins to exhibit clonic activity with inadequate breathing and cyanosis. With suctioning, O2, and 2.5 mg Valium we achieve respiratory adequacy and desisted seizures for transport. At the hospital he resumes status epilepticus with tonic-clonic activity. He receives 3.0 mg of Ativan which has negligible effect, and subsequently a Phenobarbital, which succeeds in breaking the seizure.

Learning point: Barbiturates were once the most common first-line treatment for seizures but have now been widely replaced by benzodiazepines. Barbiturates and anesthetics (typically Propafol) are common used second- or third-line for refractory status epilepticus. Phenobarbital is still the most widely-used anti-seizure medicine globally, and is on the WHO Essential Medicine list (along with Glyburide and Metformin).