Status epilepticus


Status epilepticus

Description, Causes and Risk Factors:

Abbreviation: SE.

Status epilepticus is a common medical and one of the most serious neurological emergency associated with high mortality and morbidity. Status epilepticus refers to a condition in which there is a failure of the "normal" factors that serve to terminate a typical seizure. Status epilepticus may be classified based solely on the presence or absence of convulsions into convulsive status epilepticus (CSE) and non­convulsive status epilepticus (NCSE).

In the United States, approximately 40 cases of status epilepticus occur annually out of every 100,000 members of the population. This includes about 10-20% of all first seizures.

Certain factors can cause status epilepticus depending on the person's age. These precipitating factors include:

    Systemic infections (infections affecting large portions of the body).

  • Febrile (fever-related) disease.

  • Head trauma.

  • Stroke.

  • Certain cancers.

  • Abrupt withdrawal of anticonvulsant medications.

  • Abrupt withdrawal of alcohol or illicit drugs.

  • Metabolic disorders (low sodium, low calcium low or high blood sugar).

  • Low concentration of antiepileptic drug in blood.

Several types of status epilepticus exist. Clinically, the most important distinction to make is between convulsive and nonconvulsive status epilepticus, based on whether or not rhythmic jerking of the extremities is observed. Typically, patients who present with generalized convulsive status epilepticus (GCSE) are expected to awaken gradually after the motor features of seizures disappear. If the level of consciousness does not improve by 20 minutes after cessation of movements, or the mental status remains abnormal 30 to 60 minutes after the convulsions cease, NCSE must be considered and urgent electroencephalogram (EEG) is advised. In a study by DeLorenzo and colleagues, 14% of patients treated successfully for convulsive status epilepticus were in NCSE when EEG was begun; of the patients who underwent continuous EEG monitoring (cEEG) after convulsive status epilepticus was controlled, 48% had nonconvulsive seizures.

Status epilepticus can be deadly and should not be taken lightly. One study noted that the death rate for the population diagnosed with epilepsy was as high as 22%, with a mortality rate of 3% in children and 26% in adults. Therefore, quick action is very important.

In order to prevent status epilepticus, individuals should be compliant with their antiepileptic medications. Additionally, regular visits to their healthcare provider should be made to ensure that the medication is working properly, no other medications have been added that could reduce the effectiveness of their antiepileptic medications, and to assess for any other conditions (such as alcoholism, uncontrolled diabetes, metabolic disturbances) that could interrupt seizure control.

Symptoms:

The following symptoms may indicate someone has SE.

    A convulsion with or without a fever.

  • Short periods of blackout or confused memory.

  • Occasional "fainting spells" in which bladder or bowel control is lost, followed by extreme fatigue.

  • Episodes of blank staring.

  • Brief periods of no response to questions or instructions.

  • Sudden stiffening or falls for no apparent reason.

  • Episodes of blinking or chewing at inappropriate times.

  • Dazed behavior; being unable to talk or communicate for a short time.

  • Repeated movements that look out of place or unnatural.

  • Sudden fear, anger or panic for no reason.

  • Odd changes in the way things look, sound, smell or feel.

  • Muscle jerks of arms, legs or body.

  • Clusters of swift jerking movements in babies.

Diagnosis:

Laboratory studies that should be obtained on an emergency basis include the following:

    Electrolytes.

  • Calcium.

  • Magnesium.

  • Glucose.

  • Complete blood count (CBC).

  • Renal function tests.

  • Toxicologic screening.

  • Anticonvulsant levels.

  • Liver function tests.

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.

The approach to potential status epilepticus should be conducted similarly to that for any self-limited seizure, but clearly in an expeditious fashion. Prompt diagnosis facilitates medical intervention to abort or limit status epilepticus.

The workup should include stat laboratory work. Fever should prompt a thorough search for sources of infection, with blood culture and urinalysis. Lumbar puncture (after neuroimaging to rule out potential cerebral herniation) is indicated if a CNS infection is suspected. Fever, stiff neck, headache, and photophobia are signs and symptoms that may suggest such infection.

The primary means of diagnosing SE is the electroencephalogram (EEG). The EEG is a device that measures electrical activity in the brain. The results obtained from an EEG test are recorded on graph paper as a pattern of wavy lines. A doctor is able to read the lines on the paper and determine whether or not the brain is functioning normally. Seizure disorders produce characteristic patterns in an EEG test.

Doctors may try to schedule an EEG test during a seizure. They know that flashing lights (like strobe lights) or forcing the patient to breathe very deeply can trigger a seizure in patients with SE. Or the patient may simply be kept in the hospital until an attack occurs. In such cases, the electrical activity of the brain during an attack can be observed and recorded.

Treatment:

The treatment of status epilepticus involves the use of potent intravenous medications that may have serious adverse effects. Therefore, the first step in managing the condition is to ascertain that the patient has tonic-clonic status epilepticus, and that prolonged or repetitive seizures have occurred. A single generalized seizure with complete recovery does not require treatment. Once the diagnosis of status epilepticus is made, however, treatment should be initiated immediately. Necessary interventions include maintaining oxygenation and circulation, assessing the etiology and laboratory evaluations, obtaining intravenous access, and initiating drug therapy.

Physicians first should assess the patient's airway and oxygenation. If the airway is clear and intubation is not immediately required, blood pressure and pulse should be checked and oxygen administered. In patients with a history of seizures, an attempt should be made to determine whether medications have been taken recently. A screening neurologic examination should be performed to check for signs of a focal intracranial lesion.

Obtaining intravenous access is the next step, and blood should be sent to the laboratory for measurement of serum electrolyte, blood urea nitrogen, glucose, and antiepileptic drug levels, as well as a toxic drug screen and complete blood cell count. Isotonic saline infusion should be initiated. Because hypoglycemia may precipitate status epilepticus and is quickly reversible, 50 mL of 50 percent glucose should be given immediately if hypoglycemia is suspected. If the physician cannot check for hypoglycemia or there is any doubt, glucose should be administered empirically. Thiamine (100 mg) should be given along with the glucose, because glucose infusion increases the risk of Wernicke's encephalopathy in susceptible patients.

After administration of oxygen, blood gas levels should be determined to ensure adequate oxygenation. Initially, acidosis, hyperpyrexia, and hypertension need not be treated, because these are common findings in early status epilepticus and should resolve on their own with prompt and successful general treatment. If seizures persist after initial measures, medication should be administered. Imaging with computed tomography is recommended after stabilization of the airway and circulation. If imaging is negative, lumbar puncture is required to rule out infectious etiologies.

Pharmacotherapy for SE: First-line medications control SE in 80% of patients when initiated within 30 minutes, but in only 40% if started after 2 hours of onset. Benzodiazepines are the preferred initial therapy. Most experts recommend IV lorazepam (0.1 mg/kg) as the ?rst-line therapy. Patients who respond to ?rst-line agents will usually require maintenance therapy with a second-line agent. Additional treatment must be provided quickly when patients continue to seize. The longer SE persists, the higher the risk for developing refractory SE. There is a lack of prospective data for second-line agents, but phenytoin (PHT) or fosphenytoin is used most frequently.

NOTE: The above information is for processing purpose. The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition.

DISCLAIMER: This information should not substitute for seeking responsible, professional medical care.

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