Date: 14 Sep 2017

Noticing

The patient was admitted from ED to the NSICU for status epilepticus 45 mins.
Patient has a history of stage 4 lung cancer w/ mets to the brain and vasoedema. He also
has a history of drug & alcohol abuse. Upon assessment the patient seemed very
somnolent, not following commands, and responsive only to painful stimuli on right
side of body. The patients left upper extremity showed constant spastic movement &
tremors. His lower extremity movement was sporadic and non-purposeful. His CT
(head) scan showed lesions on right parietal hemisphere and left frontal hemisphere.
The lesions were confirmed to be malignant neoplasms. Seizure precautions are in place
and the patient is on continuous EEG monitoring, pulse oximetry, NPO with tube feeds,
and receiving Lorazepam (Ativan) injection q4h & Levetiracetam (Keppra) 2g IV
infusion.
My nurse had cared for this patient the day before so, and she informed me that he had
multiple seizures even while on the Keppra. My nurse also explained to me that her
patients are often very agitated after the Ativan wears off. When we assessed him that
the morning, she noted a decrease neurological status with some agitation. She stated he
was alert & oriented x 3 yesterday, he followed commands, and he was even speaking
although incoherent. She believed the Keppra & Ativan we had been administering as
ordered for prevention of seizures might be hindering an accurate neuro assessment.
Interpreting

Our patient was being followed by USF Neurology & Gulf to Bay Internal Medicine to
assist in both monitoring and getting seizures under control. Oncology also came
onboard to evaluate the origin and stage of cancer. When Neurology stopped by, my
nurse asked if they would consider discontinuing Keppra changing Ativan his
administration to 2mg prn instead of 2mg q4h because it was affecting the patients
neuro assessment and increasing agitation. Neurologist explained that although his EEG
indicated No seizure activity he was still at a high risk for a seizure; if we discontinued
the Ativan. The neurologist would eventually agree to change the frequency of Ativan to
prn and also ordered Phenytoin(Dilantin) 50mg in 100ml IVPB followed by
Lacosamide(Vimpat) 50mg in 100ml IVPB. The neurologist did not want to discontinue
Keppra at this time.
Responding

At first I wondered why he wasnt receiving Phenytoin(Dilantin) initially, but my nurse

explained that Dilantin can be very toxic; patients must have labs drawn after each dose
to monitor for toxicity. Lacosamide(Vimpat) was an anti-seizure medication I had never
heard of. The drug Vimpat is fairly new, but research suggest that it may be the new
add-on drug of choice for patients with cancer-related seizures versus Levetiracetam.
Reflecting

After a being off of the Ativan for a few hours, our patient became more alert but
disoriented to time and situation. He would open his eyes spontaneously, follow
commands, speech was garble, movement was purposeful, and without agitation. He
remained seizure free for the day and the neurology team from USF was able to assess
him more adequately. However, Oncology also came by and discussed his poor
prognosis with my nurse. His lung cancer was stage 4 and with mets to the brain it was
untreatable. I feel that, even in light of our patients poor prognosis, we were able to
collaborate with Neurology and find the best course of treatment.