Horace Gunner,* a 65-year-old man with hypertension and type 2 diabetes, is admitted to the hospital after a fall at home. His computed tomography (CT) scan shows a moderate intracerebral hematoma, and he undergoes a craniotomy to remove the clot. Two days after surgery, he’s moved to the progressive care unit.

History and assessment hints

Mr. Gunner, who has a subgaleal drain in his left temporal area, is sleepy but easy to awaken when Carol, his nurse, makes her first assessment. While he’s slow to respond, his speech is clear; he understands where he is but needs to be reminded about the time of day. Mr. Gunner’s extremity strength is 5/5, but 3/5 to his right arm. His pupils are round and 4 mm in diameter.

Call for help

When Carol returns to Mr. Gunner’s room a few minutes later, she notes minor trembling in his right hand. His eyes are open and slowly deviating to the left. Carol asks him if he’s okay, but he doesn’t respond. The trembling generalizes to the right side of his body, and within seconds he’s having a tonic-clonic seizure. After Carol places Mr. Gunner on his side, she calls the rapid response team (RRT).

On the scene

Mr. Gunner’s oxygen saturation is 92%, so Carol starts oxygen at 4 L by nasal cannula. By the time the RRT arrives, she isn’t able to obtain vital signs. Carol summarizes Mr. Gunner’s status for the team. The RRT nurse uses suction to clear secretions from the patient’s mouth, making sure not to force the suction tip past Mr. Gunner’s teeth during the seizure so he doesn’t bite it. The RRT nurse also orders 2 mg lorazepam I.V. per seizure protocol. A bedside blood glucose is normal. After a phone consult 3 minutes into the seizure, Mr. Gunner’s neurosurgeon orders 20 mg/kg of the antiseizure drug fosphenytoin.

Outcome

While fosphenytoin is infused, the patient‘s I.V. fluids are increased from 50 mL/hr to 75 mL/hr. The RRT physician orders a complete metabolic profile and CT scan to determine if the patient may have a new intracerebral bleed. During infusion of fosphenytoin, the patient’s seizure ends at 4 minutes. After the seizure, Mr. Gunner’s vital signs return to his preseizure status, and his oxygen saturation is now 96%. Carol documents a description of his seizure, including duration and treatment. The CT scan shows no expansion of the intracerebral bleed, but Mr. Gunner is transferred to the intensive care unit for neurologic monitoring and continuous encephalography (EEG). He has no further seizures.

Education and follow-up

Any patient with a traumatic brain injury is at risk for seizures. Precautions include keeping oxygen and suction available at the bedside. If the patient has a known seizure history, continue prescribed anti-seizure medication. Emergent care of a seizing patient focuses on safety. Place the patient on his side to prevent aspiration. If he’s in bed, keep his arms and legs clear of the siderails. If the patient is on the floor, place something under his head to prevent injury. Administer oxygen if breathing is altered.

Blood tests are drawn to check if hypoglycemia or an electrolyte imbalance caused the seizure. A CT scan or magnetic resonance imaging of the brain may show a structural cause such as pressure created by hemorrhaging into the brain’s confined space.

Only clinical seizures are treated with anti-seizure medications; prophylactic use of these drugs isn’t recommended. In addition, continuous EEG is warranted for patients who experience clinical seizures.

Carol’s prompt action kept Mr. Gunner safe from injury and enabled him to receive quick treatment. Her predischarge education includes explaining that if another seizure occurs, Mr. Gunner will need to follow up with his primary care provider to determine if further testing and medical management is required.

*Names in clinical scenarios are fictitous.

Misti Tuppeny is a clinical nurse specialist for neuroscience, behavioral health, and rehab at Florida Hospital Orlando in Orlando, Florida.

Selected references

Hemphill JC, Greenberg SM, Anderson CS, et al. Guidelines for the management of spontaneous intracerebral hemorrhage. A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2015;46(7):2032-60.

Krumholz A , Wiebe S, Gronseth GS, et al. Evidence-based guideline: management of an unprovoked first seizure in adults. Report of the Guideline Development Subcommittee of the American Academy of Neurology and the American Epilepsy Society. Neurology. 2015;84(16):1705-13.

Trinka E, Hofler J, Leitinger M, et al. Pharmacotherapy for status epilepticus. Drugs. 2015;75(13):1499-521.