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A Case Study
Of
Status Epilepticus
Submitted to:
Ms.Nina Piao,RN
CM-CI
Submitted by:
Butron , Charity Bless
DEFINITION OF TERMS
Status epilepticus is define as a continuous seizure lasting more than 30 min, or two or more seizures
without full recovery of consciousness between any of them. Seizures can either be a tonic- clonic type
with a regular pattern of contraction and extension of the arms and legs.
This term is used to describe the more common form of emergency situation that can occur with
prolonged or repeated tonic-clonic (also called convulsive or grand mal) seizures. Most tonic-clonic
seizures end normally in 1 to 2 minutes, but they may have post-ictal (or after-effects) symptoms for
much longer. This makes it hard to tell when a seizure begins and ends.
This term is used to describe long or repeated absence or complex partial seizures.
The person may be confused or not fully aware of what is going on, but they are not
'unconscious', like in a tonic clonic seizure.
These situations can be harder to recognize than convulsive seizures. Symptoms are more subtle
and it's hard to tell seizure symptoms from the recovery period.
There is no consistent time-frame on when these seizures are called an emergency. It depends in
part on how long a person's typical seizures are and how often they occur.
Status Epilepticus is a medical emergency. A seizure that lasts more than 10 minutes, or three
seizures in a row without the person coming to between them.
Premonitory stage in which seizures increase in number and frequency prior to the onset of SE
Established stage requiring immediate emergency treatment
Refractory stage when the seizure resists initial treatment requiring more aggressive measures.
In the first phase of SE, convulsions are accompanied by increased muscle tension, high blood sugar
(hyperglycemia), sweats, salivation, high fever and increased blood flow to the brain. The second phase
begins about 30 minutes after seizures start. It is marked by a decrease in blood flow to the brain,
increased pressure in the skull, and abnormally low blood pressure. However, neuron damage may begin
much sooner.
The brain has two halves called hemispheres. Each half has four parts called lobes: the occipital,
parietal, temporal and frontal lobes.
Abnormalities in the temporal or frontal lobes of the brain are the most common reason for memory
problems in people with epilepsy.
The left temporal lobe is important for verbal memories such as learning names and remembering facts
for exams. If you have seizures that start in this area you may have problems remembering words, and
get stuck mid-sentence.
The right temporal lobe is important for visual memories like remembering a person’s face or finding
your way around a place.
The frontal lobe is important for prospective memory. Seizures in this area can cause problems
remembering to do things in the future.
The occipital lobe is the visual processing center of the mammalian brain containing most of the
anatomical region of the visual cortex.
The parietal lobe carries out some very specific functions. As a part of the cortex, it has a lot
of responsibilities and has to be able to process sensory information within seconds. The parietal lobe is
where information such as taste, temperature and touch are integrated, or processed. Humans would not
be able to feel sensations of touch, if the parietal lobe was damaged.
ETIOLOGY
Stroke and other vascular diseases In the first few weeks following a stroke some
stroke survivors will experience a seizure. Seizures
are a sign of brain injury and are caused by sudden
disorganized electrical activity in the brain.
Brain infections Infections such as meningitis, which causes
inflammation in your brain or spinal cord, can
increase the risk.
Fever In children between the ages of 6 months and 5
years, a fever of 38 °C (100.4 °F) or higher may
lead to a seizure known as a febrile seizure.
Loss of bowel and bladder control Increased pressure on the bladder and bowel
causes urinary incontinence and soiling.
The presence of SE should prompt a search for its etiology, and in particular for potentially reversible
conditions. Clinical information should guide the ordering of laboratory tests.
Laboratory studies that should be obtained on an emergency basis include the following:
Electrolytes
Calcium
Magnesium
Glucose
Complete blood count
Renal function tests
Toxicologic screening
Anticonvulsant levels
Liver function tests
Emergent glucose assessment is particularly important because both hyperglycemia and hypoglycemia
can be associated with SE. Rapid turnaround of anticonvulsant drug levels may be particularly helpful in
guiding treatment choices in patients with well-established epilepsy who on long-term therapy.
Arterial blood gas (ABG) measurement may be useful to monitor oxygenation and ventilation efficacy
and to discover any unexpected acid-base abnormalities. An episode of generalized seizures will
typically result in a metabolic acidosis, but this should correct rapidly following seizure cessation as the
lactate generated by vigorous muscle contractions is metabolized. Profound metabolic acidosis and
continuing seizures might raise the possibility of isoniazid poisoning
Electroencephalography
EEG is the criterion standard for diagnosing EEG, and some authors believe that EEG should be a
routine part of management of SE.Nevertheless, EEG is rarely available in the acute-care setting;
normally, it is obtained through neurologic consultation. When EEG is unavailable for the acute workup,
presumptive treatment strategies must occasionally be started before EEG confirmation becomes
available.
Computed Tomography
CT scanning of the brain is often helpful in evaluating for a structural lesion (eg, brain tumor, infarction,
abscess, hemorrhage) that may underlie SE. Noncontrast CT is the imaging procedure of choice for
emergency department patients with SE. However, a neuroimaging study should never be allowed to
impede rapid and aggressive treatment of the disorder. Imaging is often deferred if the patient is known
to have epilepsy and the seizure pattern is not unusual for the individual.
Brain MRI is rarely indicated in the acute phase of generalized convulsive SE. Although MRI provides
more information than CT, it is more time consuming, and the additional information rarely affects
immediate treatment and evaluation.
In contrast, in a patient with simple partial SE that does not match previous seizures, the search for an
epileptic focus should include brain imaging, preferably with MRI (or CT if MRI is unavailable) to look
for a new lesion (eg, new stroke, mass lesion). Currently, many centers offer advanced MRI, such as
diffusion-weighted, perfusion, and susceptibility-weighted imaging. [56] These newer methods can be
particularly helpful in identifying acute cerebral ischemia.
Nevertheless, MRIs may be problematic in focal SE because the SE itself can cause a wide range of
MRI abnormalities, many of which are transient. Repeat imaging over weeks to months may be helpful
to clarify their interpretation.
Chest Radiography
Chest radiography may be used to assess for aspiration or endotracheal tube positioning.
If clinically indicated, other plain radiographs may be useful to assess fractures or dislocations.
Lumbar Puncture
If CNS infection is in the differential diagnosis, consider a lumbar puncture (after appropriate head
imaging to ensure safety).
Succinimides
Immostilbenes
• Carbamazepine ( Tegretol) is effective in treating refractory seizure disorders that have not
responded top other anticonvulsant therapies.
• It is used for grand mal and partial seizure
• An interaction occurs when taken with grapefruit juice causing possible toxicity
• Therapeutic serum range is 5-12 mcg/ml
• Dosage: PO 200 Mg BID, increasing dosage as needed
Benzodiazepines
Aka : anxiolytics
- Clonazepam
- Chlorazepate Dipotassium
- Diazepam
Clonazepam – effective in controlling petit mal seizures,but tolerance may occur 6 months after drug
therapy
Valproate
• Valproic Acid (Depakene) has been prescribed for petit mal,grand mal and mixed type of
seizures.
• Hepatoxicity is one of its adverse reactions (given with caution in children and clients with liver
disorder.
• Liver enzymes should be monitored i.g SGPT/SGOT
• Therapeutic serum range is 40-100 mcg/ml
• Dosagez; PO 15mg/kg;max 60 mg/kg/day in divided doses
Diazepam (Valium)
• Primarily prescribed for treating acute status epilepticus (drug of choice) and administered IV to
achieve the desired response
• Has a short term effect thus other anticonvulsant i.e phenytoin are given after administration of
diazepam
• Dosage: IV-5mg;repeat if needed at 10-15 mins intevals;max 30mg
SURGICAL MANAGEMENT
Common surgical procedure for treatment of seizure is cortical exicision i.e lobectomy
When temporal lobe epilepsy, then resection of the antero-medial temporal lobe called mesial temporal
lobectomy
If scar tissue or other focal epileptogenic area exists the identified lesion (lesionectomy) can be removed
A corpus callosotomy has been helpful in patients with tonic clonic seizures
A hemispherectomy is reserved for selected catastrophic infant and early childhood epilepsies
An electrode is surgically placed around the left vagus nerve in the neck. It is connected to a battery
placed beneath the skin in the upper chest. This device is programmed to deliver intermittent electrical
stimulation to the brain to reduce the frequency and intensity of seizures. Exact mechanism is unknown.
JOURNAL READING
Scientists in the US have conducted a study that offers new insights into predictive factors for young
patients affected by status epilepticus, a particularly serious and long-lasting form of epilepsy that is
more difficult to treat.
Conducted by Boston Children's Hospital, the research not only aimed to identify risk factors of
paediatric convulsive status epilepticus, but also to determine whether defining status epilepticus as
seizures lasting either five minutes or more or in excess of 30 minutes would modify the risk factors
identified.
To determine this, the team conducted a retrospective case-control study including patients between the
ages of one month and 21 years at the time of convulsive status epilepticus. The characteristics of
patients who did and did not experience status epilepticus were then compared using both of the chosen
seizure duration thresholds.
In total, 1,062 patients were enrolled, with the median age at the time of the epileptic episode being 6.4
years.
According to data published in the medical journal Seizure, 444 patients, or 41.8 per cent, had seizures
lasting for at least five minutes, while 14 per cent of the group – 149 patients – experienced seizures
lasting at least half an hour.
Subsequent analysis revealed that risk factors for status epilepticus were not markedly different when
considering a five or 30-minute threshold. Compared to their respective control groups, patients in both
of these categories were shown to be younger at the age of seizure onset and at the age of status
epilepticus.
They were also generally receiving more antiepileptic drugs at baseline, had a higher rate of changes in
therapy regimens in the three months prior to the episode, were more likely to experience developmental
delays and were affected by a higher mortality rate.
Meanwhile, a higher baseline seizure frequency and a more pronounced increase in seizure frequency
prior to the index episode was seen only in the five-minute patient group.
Such findings could improve understanding and future treatment of status epilepticus.
Explanation
On a neurochemical level, seizures are sustained by excess excitation and reduced inhibition. Glutamate
is the most common excitatory neurotransmitter and the NMDA (N-methyl-D-aspartate) receptor
subtype is involved. Gamma-aminobutyric acid (GABA) is the most common inhibitory
neurotransmitter. Failure of inhibitory processes is increasingly thought to be the major mechanism
leading to status epilepticus.
Most seizures terminate spontaneously. Which processes are involved in seizure termination and why or
how these processes fail in status epilepticus are active areas of inquiry.