Case 38 of 40
Repeated similar episodes during delirium may be seizures
Example case for staff education
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Page 1
Panel 1: Day 1
An infection and acute confusion bring her to hospital.
Dan: She also has epilepsy, usually well controlled.
Panel 2: Day 1
Vomiting has interrupted antiseizure medication.
Pharmacist Samir: We need to confirm which doses stayed down.
Panel 3: Day 1
The team treats the infection and arranges reliable medication delivery.
Ward doctor Amira: Check for other causes of this acute change too.
Panel 4: Day 2
Her apparent fluctuation includes brief, repeated pauses.
Nurse Tom: That started suddenly, just like the earlier episode.
Panel 5: Day 2
The same subtle movement accompanies another pause.
Nurse Tom: I will record exactly what happens and how long it lasts.
Panel 6: Day 2
Glucose, oxygenation and other urgent causes are assessed.
Ward doctor Amira: These repeated events need neurological assessment.
Panel 7: Day 2
Stereotyped episodes and epilepsy history raise concern for seizures.
Neurologist Mira: Arrange an urgent EEG.
Panel 8: Day 2
EEG identifies recurrent seizures without major convulsions.
Ward doctor Amira: The electrical recordings explain these episodes.
Panel 9: Day 2
Antiseizure treatment and monitoring proceed under specialist care.
Nurse Tom: We are watching her breathing and response closely.
Page 2
Panel 10: Day 3
The electrographic seizures stop after treatment.
Neurologist Mira: Continue checking whether the altered mental state has another contribution.
Panel 11: Day 3
Treatment effects and the underlying illness still affect arousal.
Nurse Tom: She needs close observation while these effects change.
Panel 12: Day 4
Seizure control does not mean immediate cognitive recovery.
Dan: The pauses have stopped, but she is still confused.
Panel 13: Day 5
Infection, medication effects and residual delirium are reviewed.
Ward doctor Amira: We need to follow the whole course, not one result.
Panel 14: Day 7
Practical support continues as attention improves.
Nurse Tom: We can take this one step at a time.
Panel 15: Day 10
She is stronger but still needs prompts.
Physiotherapist Lin: Pause before the turn, then follow me.
Panel 16: Week 3
The plan includes what to do if oral doses cannot be taken.
Neurologist Mira: Contact the clinical team promptly if this problem happens again.
Panel 17: Week 4
She needs supervision while daily function recovers.
Dan: I will stay until the support visits are established.
Panel 18: Week 6
No further events are reported; cognitive recovery is still being assessed.
Vera: I am clearer, but I still tire very quickly.
Sources
- [G03] Herman ST, Abend NS, Bleck TP, et al. Consensus statement on continuous EEG in critically ill adults and children, part I: indications. Journal of Clinical Neurophysiology. 2015;32:87–95.
- [S21] Whittam, D., Matthews, R., Nimeri, R. and Shaik, S. (2024) ‘Antibiomania: clarithromycin-induced neurotoxicity mimicking autoimmune limbic encephalitis’, Practical Neurology, 24(3), pp. 226–230.
- [S31] Temple, M. (2003) ‘Use of atypical anti-psychotics in the management of post-traumatic confusional states in traumatic brain injury’, Journal of the Royal Army Medical Corps, 149(1), pp. 54–55.
- [G01] National Institute for Health and Care Excellence. Delirium: prevention, diagnosis and management in hospital and long-term care. CG103.
Commentary
Delirium symptoms commonly vary, but Vera’s episodes have additional features. Each pause starts abruptly, lasts a similar time and includes the same small facial movement. Her epilepsy and missed doses increase concern. Record the events precisely, check urgent physical causes and seek neurological assessment.
An urgent EEG, a recording of the brain’s electrical activity, identifies repeated seizures. Treatment and monitoring stop the seizures, while her thinking improves more slowly. Seizures, sedation from treatment and continuing delirium may all affect how she appears, so assess them separately. Continue EEG assessment according to the neurological findings and treatment response [G03].
The American Clinical Neurophysiology Society consensus statement covers continuous EEG in critically ill patients with relevant changes in mental state. It does not recommend EEG for every uncomplicated episode of delirium. Vera’s repeated similar events and epilepsy provide additional reasons for investigation. The source reports describe related neurological and psychiatric presentations, but do not describe Vera’s life [S21, S31].
Describe the events before assigning a diagnosis. Record onset, responsiveness, eye or facial movements, duration, recurrence and how Vera is between events. Her thinking improves, but she still needs support. Seeing no further episode does not by itself establish that all seizures have stopped or that delirium has resolved.