An Unusual Cause of Tachycardia: Focal Nonconvulsive Status Epilepticus Following Acute Head Trauma
Non-convulsive status epilepticus has traditionally been thought of as a rare condition. There is little data regarding its true incidence but evidence suggests it is far more common than once believed. Non-convulsive status epilepticus can have an array of presentations and can be a diagnostic enigma for those unaware of its existence or those who believe, as it was once taught, that this condition is isolated to critically ill patients in the intensive care unit. Herein, we discuss the case of a patient with a focal traumatic brain injury who was found to be in Non-convulsive status epilepticus. This condition is one that physicians need to consider, especially those physicians caring for patients with traumatic brain injury.
Non-convulsive Status Epilepticus (NCSE) is defined as a period of ongoing seizure activity which may present as an alteration in behaviour or mental status, albeit in the absence of motor activity. There are two recognized classifications of NCSE including absence status epilepticus (primary generalized) and complex partial (secondary generalized). NCSE has, in years past, been considered a rare condition. This is in large part the result of the fact that there have been very limited data from which to accurately describe the incidence of NCSE. Historically, most data have been drawn from single centre studies with small sample sizes. Nevertheless, the incidence has been estimated to be 15- 20/100,000 cases per year. These values may underestimate the true incidence. In one study of patients who presented to the Emergency Department (ED) with Altered Mental Status (AMS) and without convulsions who received EEG studies, 37% were found to have NCSE. Notably, nearly half of patients with NCSE will not have any history of epilepsy. While in years past NCSE was thought to have an incidence of 3%, subsequent studies have shown it to be more common ranging from 16-43% of all status epilepticus cases. This is notable as the morbidity and mortality of NCSE is estimated to be 39 and 18% respectively.
Herein, we present a case of a 49-year-old male who presented to the Emergency Department (ED) by Emergency Medical Services (EMS) after being found down outside. The patient was intoxicated with an ethanol level of 459 mg/dl. The patient was unable to clearly recall the preceding events but alleges he may have been kicked and/or struck in the head with a bottle. The patient’s chief complaint was rib pain and headache. His GCS was 15 and vitals were normal with blood pressures of 116/74, heart rate of 60 beats per minute, temperature 97.4 degrees F, respiratory rate 14 breaths per minute, SpO2 100% on room air. The patient had no significant medical history and specifically no history of seizures. He reported drinking alcohol and smoking tobacco and marijuana daily. On physical exam, there was tenderness to palpation of the left chest wall and generalized abdominal tenderness. His speech was slurred and he appeared clinically intoxicated.