Continuous seizure activity >= 5 min, or >= 2 seizures without full recovery; emergency IV Lorazepam (0.1 mg/kg) then IV Levetiracetam/Fosphenytoin.
Focal (originates in 1 hemisphere, may be aware or impaired awareness); Generalized (simultaneous bilateral hemispheres, e.g., Absence, Tonic-Clonic).
Antibodies to post-synaptic ACh receptors; fatigable weakness worsens with use; thymoma association; treat with Pyridostigmine.
Antibodies to pre-synaptic P/Q-type calcium channels; weakness improves with repetitive use; Small Cell Lung Cancer association.
Stepwise Status Epilepticus Emergency Resuscitation Protocol
Status epilepticus leads to permanent neuronal injury and systemic acidosis if seizure duration exceeds 30 minutes. The resuscitation protocol is structured into time-critical phases:
Airway, breathing, circulation. Check bedside capillary fingerstick blood glucose immediately. Administer IV dextrose + thiamine if hypoglycemic. Obtain IV access.
IV Lorazepam (Ativan): 4 mg IV over 2 min (repeat once at 5-10 min). If IV access unavailable: IM Midazolam 10 mg (or rectal diazepam).
Administer non-sedating IV antiepileptic: IV Levetiracetam (Keppra) 60 mg/kg (max 4500 mg), IV Fosphenytoin 20 mg PE/kg, or IV Valproate sodium 40 mg/kg.
Endotracheal intubation and continuous general anesthetic infusion: Propofol, Midazolam, or Ketamine with continuous bedside EEG monitoring for burst suppression.
Neuromuscular Junction Disorders: Myasthenia Gravis vs. Lambert-Eaton
| Feature | Myasthenia Gravis (MG) | Lambert-Eaton Myasthenic Syndrome (LEMS) |
|---|---|---|
| Target Antigen | Post-synaptic Nicotinic Acetylcholine Receptors (AChR) or MuSK | Pre-synaptic Voltage-Gated P/Q-type Calcium Channels (VGCC) |
| Effect of Repetitive Use | Muscle weakness worsens with use (fatigability) | Muscle strength improves with exercise (facilitation) |
| Ocular Involvement | Ptosis and diplopia common initial presentation (> 50%) | Ocular involvement rare; proximal limb weakness dominates |
| Autonomic Symptoms | Absent | Present: Dry mouth, erectile dysfunction, constipation |
| Deep Tendon Reflexes | Normal | Decreased or absent (may return after brief exercise) |
| Underlying Neoplasm | Thymoma (15%) or thymic hyperplasia (65%); chest CT mandatory | Small Cell Lung Carcinoma (SCLC) (> 50%) |
- Post-Ictal Hypertonicity: Tonic-clonic seizures cause profound lactic acidosis and generalized myofascial hypertonicity. Gentle indirect myofascial release and rib raising aid in respiratory recovery.
- Cranial RTM Strains: Compression of the sphenobasilar synchondrosis (SBS) is common following head trauma associated with falls during seizure episodes. The CV4 technique and venous sinus drainage encourage normal CRI fluctuation.
- Contraindication: Never perform HVLA thrusting techniques in patients with active or uncontrolled seizure disorders.
- In myasthenic crisis or Guillain-Barré syndrome, never rely on pulse oximetry or arterial blood gas (ABG) to detect respiratory failure; pulse oximetry remains normal until terminal arrest. Measure Forced Vital Capacity (FVC) and Negative Inspiratory Force (NIF); intubate if FVC < 20 mL/kg or NIF < -30 cm H2O.
- Avoid aminoglycosides, fluoroquinolones, macrolides, beta-blockers, and magnesium in patients with Myasthenia Gravis; all severely impair neuromuscular transmission and can precipitate fatal myasthenic crisis.
- In patients presenting with new-onset status epilepticus, always check bedside glucose; hypoglycemia is rapidly fatal if untreated, whereas administering phenytoin alone will not terminate hypoglycemic convulsions.