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March 12, 2017

Nonconvulsive Status Epilepticus After Tonic-Clonic Seizures: A Seldom Mentioned Phenomenon

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Thanksgiving break, my severely-autistic son has a 43 second tonic-clonic seizure that presents off baseline, (meaning an unusual presentation of seizure activity).

It's an obvious tonic clonic seizure, because his entire body is shaking, eyes roll to back of head, oxygen (O2) levels drop, but what happens next isn't normal.

An hour later, three more brief seizures, about 10 minutes apart, under 40 seconds. Again, O2 applied. Ativan IM 2mg given.

About 45 minutes later, after the 4th seizure, I get a call he has had another seizure, but now "it's also stopped."

Something says go look. I fall out of bed, heart pounding. Half asleep, pumped with adrenaline, I stumble down stairs to observe. From the second I reach his room, I'm don't like what I'm seeing. My son shivering,  eyes still dilated, as if having sub-clinical seizures.  I tell nurse "Call 911".

Indeed, seizures hadn't stopped, the clearly recognized convulsive seizures had progressed into a different type of non-stop seizure called non-convulsive status epilepticus, which is something almost no RN or LVN is trained to recognize.

I only knew what it was from reading abstracts from Epilepsia and International Journals of Epilepsy because that's the kind of odd person I am. I don't read fiction. I read stuff like this. I have to read it. It's like an obsession. Or maybe a survival technique.

I recall one study says because a tonic-clonic seizure stops, doesn't mean seizure activity stops, especially when person is still shivering or eyes twitch, AFTER the last generalized seizure.

These prolonged non-convulsive seizures are called "persistent nonconvulsive seizures" and are considered STATUS Epilepticus, a MEDICAL EMERGENCY.


Non-convulsive seizures after a convulsive, generalized tonic clonic seizure are difficult to detect. Mainly, because everyone is so relived the convulsive seizure has stopped that they don't think about sub-clinical status epilepticus.

Oxygen levels drop quickly with a generalized tonic clonic seizure. It takes longer for O2 to drop during non-convulsive seizures.

One might think the patient recovering from a generalized tonic clonic seizure is just post-ictal. Nope.

Post-ictal means there's decreased tremoring, no shaking, no shivering, eyes aren't fluttering and there's an overall return to normal BASELINE.

Do NOT ignore nonconvulsive seizure activity. It can present as eye and face twitching, increased salivation, slightly dilated eyes.

Include TIME the tremoring/shaking/shivering occurs as a normal seizure. Seek immediate medical help if it doesn't stop.

AGAIN, here are a few signs someone is in non-convulsive status epilepticus AFTER a normal, general tonic clonic convulsive seizure stops:

1. Eyes fluttering.  THIS IS A MAJOR SIGN OF NON CONVULSIVE STATUS EPILEPTICUS.

2. Low oxygen, especially despite application of oxygen mask between 4lps-12lps.

3. Tremors (body not shaking but having visible mild tremors almost looking like the person is shivering).

4. Increased salivation,

5. Eyes still dilated, not returning to baseline.

6. Pupils different sizes (this sign alone is always a medical emergency requiring 911 during a seizure)

7. Abnormal respiratory sounds, grunts, as they struggle to breathe during subclinical status epilepticus.

8. Recurrent seizures without a return to baseline IN BETWEEN EPISODES. VERY IMPORTANT SIGN. Don't miss it.

9. Continuous high pulse rate (bad for heart!!! Call 911).

Never delay treatment for any seizure activity that appears to be compromising someone's health. Always, always, always seek medical help if you aren't sure what to do or what you're seeing in a patient/student/client with epilepsy. Never delay, especially if the person has additional special needs.

Unfortunately, nursing schools, medical schools and paramedic programs provide little education or training on how to recognize and treat seizures and no training on how to identify non-convulsive status epilepitcus in patients.

More emphasis on neurological emergencies should be taught in EMS training, medical and nursing schools.

Also to be noted are licensed group homes, nursing facilities, etc..that do not call 911 and attempt to treat these serious medical issues on their own because they 'don't want to raise any red flags' or 'fill out incident reports'.

This should be a crime. If you are someone who owns a state licensed group home or works in a state licensed school, nursing or group home, get your culo in gear and call 911 when a vulnerable elderly or disabled patient or student has a long seizure or any seizure that can't be treated with emergency medication and trained staff, as per a doctor's order.

Kim Oakley




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