| ID | 394 |
|---|---|
| Name | STATUS EPILEPTICUS |
| Cause | Stroke. Imbalance of substances in the blood, such as low blood sugar. Drinking too much alcohol or having alcohol withdrawal after previous heavy alcohol use. Withdrawal from medicines to treat seizures. |
| Signs Symptoms | Muscle spasms. Falling. Confusion. Unusual noises. Loss of bowel or bladder control. Clenched teeth. Irregular breathing. Unusual behavior. |
| Diagnosis | A seizure with 5 minutes or more of continuous clinical and/or electrographic seizure activity or recurrent seizure activity without recovery between seizures |
| Investigations | Electrocardiography, blood pressure, and blood gas monitoring are usually necessary. Other investigations depend on the clinical circumstance |
| Management | Continuous infusion of an antiepileptic drug. Choices include an intravenous (IV) infusion of midazolam, pentobarbital, thiopental, or propofol (propofol infusion should not be used in children due to the risk of propofol infusion syndrome) |
| Introduction | Status epilepticus is a clinical or electrical seizure lasting at least 30 minutes, or a series of seizures without complete recovery over the same period of time. After 30 minutes, the brain begins to suffer from hypoxia and acidosis, with depletion of local energy stores, cerebral oedema and structural damage. Eventually, high fever, hypotension, respiratory depression and even death may occur. Thus, status epilepticus is a relative medical emergency |
| History | |
| Etiology | Etiologic types Currently, in children ‘status epilepticus’ is classified etiologically in three major subtypes- 1. Prolonged febrile seizure (febrile convulsive status): The most common cause of ‘status epilepticus’ particularly in children younger than 3 years. Seizure usually lasts for 50mins. with convulsive tonic-clonic or grand mal variety. 2. Idiopathic status epilepticus: In this type, no underlynig CNS lesion or cause is found, status epilepticus usually followed sudden withdrawal of anticonvulsant drugs. Epileptic children who are irregularly treated or noncompliant, are more prone to develop this variety of status epilepticus. 3. Symptomatic status epilepticus: In this, seizure occurs as a result of an underlying neurologic disorder or a metabolic abnormality. |
| Clinical Features | Jerking motions, grunting sounds, drooling, and rapid eye movements |
| Preventions | Medicines as directed may help you avoid status epilepticus |
| Treatment | Treatment: Immediate general measure: The patient must be under continuous observation and should be kept in semiprone position. The following measures should be taken immediately- 1. ABCs a. Airway: maintain oral airway; intubation may be necessary. b. Breathing: O2 by mouth by using face mask (if available), c. Circulation: assess pulse, blood pressure; support with i.v fluids, drugs. Monitor vital signs. 2. Start i.v fluid, containing glucose; draw dextrostix / blood glucose; evaluate electrolytes, HCO3-, CBC, BUN, anticonvulsant levels. 3. Arterial blood gases, pH. 4. Give 10% glucose if blood glucose is low (at the rate of 5ml/kg). 5. Begin i.v drug therapy to control status in 20-60 minutes (as below). Drug therapy for controlling status-Treatment should be prompt and energetic. 1. Inj. diazepam- initially 0.2-0.3mg/kg or Img per year of age by i.v injection and then repeat once only after 15 minutes or lorazepam 2mg i.v. 2. If the fits continue after 30 mins. patient should be transferred to the hospital with intensive care arrangement, if available. 3. Then start anticonvulsant drug, any one of the following- Phenytoin, a loading dose of 15mg/kg by i.v infusion at a rate of not faster than 50mg/min, Or, Fosphenytoin, a loading dose of 15mg/kg by i.v infusion at a rate of not faster than lOOmg/min, Or, Phenobarbital, a loading dose of lOmg/kg by i.v infusion at a rate of not faster than l00mg/min. 4. If seizures yet not controlled after 30-60 mins. with above measures- start medication for refractory status with intubation and ventilation, and general anesthesia using thiopental or propofol. Thiopentone 100-250mg as a bolus over 20 sec, then repeat 50mg boluses every 2-3 mins until seizures are controlled; then continue infusion at 3-5mg/kg/hour if needed. 5. If seizure still continue- investigate for underlying causes, a. Structural disorders or trauma. Consider CT scan, b. Infection: spinal tap, blood culture, antibiotics, c. Metabolic disorders: correct it (if any e.g low-sodium, acidosis). d. Investigate for toxins, uremia. May need HCO3- medication, toxin screen, judicious fluid administration. 6. Once status controlled start longer-term anticonvulsant medication with one of the following-Sodium valproate lOmg/kg i.v over 3-5 minutes and then 800-2000mg/day. Or, Phenytoin (if not used as above), a loading dose of 15mg/kg by i.v infusion at a rate of not faster than 50mg/min, then 300mg/day. Or, Carbamazepine 400mg by nasogastric tube, then 400-1200mg/day. 7. Regular checking of vital signs, neurological conditions; recording of blood pressure, pulse, respiration & analysis of blood gases should be done. 8. To combat brain edema (if any), by- Mannitol 20%, 7.5ml/kg dose i.v over 30 minutes. Or, Dexamethasone 0.lmg/kg/dose i.v stat, and 0.05mg/kg every 6-hourly. 9. To prevent recurrence- Diazepam 50mcg/kg/hour in continuous i.v infusion, should be given. |
| Complications | Cardiac arrhythmia, cardiac damage because of catecholamine surge, respiratory failure, hypoventilation, hypoxia, aspiration pneumonia, pulmonary edema, fever, and leukocytosis |
| Prognosis | Prognosis of epilepsy: 1. A severe prolonged seizure of 1 hour or more may deplete stores of glucose, interfere with oxygena-tion, and causes secondary cerebral damage, but there is reason to believe that the usual convulsive episode does not cause irreversible damage. 2. The anticonvulsant drug should be continued for 3 years from the date of last convulsion. Then start to discontinue slowly and gradually. 3. 80% or more children with epilepsy can expect to lead useful lives. 4. Anticonvulsant treatment is associated with an approximately 3-fold increase in foetal malforma-tion. Phenytoin, for example, may cause facial clefts, cogenital cardiac defects, & other dysmor-phic defects, and valproate may result in neural tube defects. |
| Types | Convulsive, non-convulsive, focal motor, myoclonic, and any can become refractory |
| Classification | Convulsive SE or nonconvulsive SE (NCSE) |
| Observation | A seizure with 5 minutes or more of continuous clinical and/or electrographic seizure activity or recurrent seizure activity without recovery between seizures |
| Pathology | Occurs due to the failure of mechanisms that terminate seizures |
© Pakistan Drug Directory. All Rights Reserved.
Designed By: Pakistan Drug Directory Team