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  • Seizures are a relatively common occurrence in the intensive care unit (ICU), but may be difficult to recognize.

  • Seizures that persist longer than 5 minutes should be treated to prevent progression to status epilepticus (SE).

  • Three major factors determine outcome in SE: type of seizure, cause, and duration.

  • Electroencephalographic (EEG) monitoring to titrate therapy should be implemented in seizing patients who do not awaken promptly after institution of antiepileptics, even if tonic-clonic motor activity resolves.

  • Lorazepam is a preferred agent for initial treatment, followed by consideration of additional agents for long-term management or to “break” SE.

  • Patients with refractory SE require intubation, mechanical ventilation, and aggressive treatment with antiepileptics titrated to the EEG.

  • The underlying cause of the seizure disorder must be sought in tandem with treatment of the seizure disorder itself.


Seizures are a relatively common occurrence in the ICU, complicating the course of about 3% of adult ICU patients admitted for nonneurologic conditions.1 Status epilepticus (SE) may be the primary indication for admission, or it may occur in any ICU patient during a critical illness. Seizures are second to encephalopathy as a cause of neurological complications (28.1%).1 A seizure may be the first indication of a central nervous system (CNS) complication or the result of overwhelming systemic disease. Seizures in the setting of critical illness are often difficult to recognize and require a complex diagnostic and management strategy. Delay in recognition and treatment of seizures is associated with increased mortality2; thus, the rapid diagnosis of this disorder is mandatory. Conventionally, status epilepticus is referred to as a protracted seizure episode lasting 30 minutes or longer or multiple seizures without return to baseline consciousness between seizures. However, more recently, revised definitions have suggested to consider seizures lasting for 5 minutes or longer as SE,3–5 and newer guidelines define SE as 5 minutes or more of either continuous clinical and/or electrographic seizure activity, or recurrent seizure activity without recovery between seizures.6

While most seizures will terminate spontaneously within a few minutes,5 only half of seizure episodes lasting 10 to 29 minutes will stop spontaneously7 and aggressive treatment should be administered to prevent ongoing SE.8 SE is not a single process, and can be subdivided into convulsive and nonconvulsive SE (NCSE); NCSE can be seen in comatose patients and in ambulatory awake patients. Additionally, patients in the ICU could have acute repetitive seizures or EEG patterns that fall on an ictal-interictal continuum. Management should be customized to the underlying type and etiology of SE.9


Limited data are available on the epidemiology of seizures in the ICU. A 10-year retrospective study of all ICU patients with seizures at the Mayo Clinic revealed that seven patients had seizures per 1000 ICU admissions.8 Our 2-year prospective study of ...

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