This section provides the monthly papers presented by the specialists of   RMCH for spreading knowledge amongst medical professionals  practicing, especially, in peripheries.   

With a view to spread knowledge and academics on the basis of practical experience of established consultants in treating diseases in this area, another interesting article is being presented on STATUS EPILEPTICUS. The author of this article, Dr. Yogendra Raj, is a practicing Neurologist of this area. the article discusses the latest advances on the topic as experienced by the author in USA and UK for 11 years and adaptation of the same to local conditions . The purpose of the article is not to bore you with the textbook details of Status Epilepticus, rather it concentrates on practical management of SE (Status Epilepticus).

Season Greetings

STATUS EPILEPTICUS

I would focus on management of generalized convulsive SE only, which generally refers to abnormal electrical activity involving areas of the cortex.

Traditionally, SE was defined as 30 minutes of continuous seizure activity or a series of seizures without return to full consciousness between the seizure. Many believe that a shorter period of activity causes neuronal injury and that seizure self- termination becomes unlikely after 5 minutes. For practical purposes, a duration of 5 minutes of continuous generalized convulsive activity is used arbitrarily as part of the definitions of GCSE.

•  In roughly one third of cases, an exacerbation of an idiopathic seizure.
•  In another third of cases, the first onset of a seizure disorder may be SE.
•  Stoppage of regular anti- convulsants.
• Other conditions like stroke, tumour, trauma, hypoxia, infections, toxic, (e.g. alcoholwithdrawl), electrolyte abnormalities, metabolic (e.g. hepatic encephalopathy) etc.
  

The overall mortality rate is about 20% death often is related to an underlying causes of brain injury. It is highest in neonatal status, in infancy and in the elderly.

•  A history of epilepsy frequently is elicited.
•  A history of systemic or CNS neopiasms, infections, metabolic disorders, toxic ingestions, alcohol cessation, and many other conditions may give clue to the precipitating causes of seizures.
• In roughly one third of cases, SE is the initial presentation of a seizure disorder.
•  Non- compliance with medications is the rule rather than the exception.
•  The history may suggest associated injuries, such as fall or involvement in a motor vehicle accident.

• GSCE often is recognizable  to the clinician at the beside when typical rhythmic tonic- clonic activity is present.
•  In roughly one third of cases, SE is the initial presentations of a seizure disorder
•  Non- compliance with medication is the rule rather than the exception.
•  The history may be suggest associated injuries, such as fall or involvement in a motor vehicle accident.

• GSCE often is recognizable to the clinician at the beside when typical rhythmic tonic- clonic activity is present.
•  Consciousness is impaired.
•  Rarely, SE may present as a persistent tonic seizure.
•  Psychogenic seizures (pseudo SE) may, at time, be in distinguishable from GSCE by appearance alone.

Frequently seen presentation of pseudo SE include asynchronous extremity movement, forward pelvic thrusting, the eyes deviating towards the ground in a non- physiological manner whether he head is turned left or  right, vocalization is common, as is bizarre behaviors, explosive emotional expression and resistance to examination.

If mistaken for true SE, I.V. anti- convulsants are given which are in-effective, seizure persist and more drugs are administered to the point of unconsciousness.

Suspect SE in any patient who does not regain consciousness within 20-30 minutes of cessation of generalized seizure activity.

Association injuries that may be present in patient with seizure include tongue laceration shoulder dislocation, head trauma, and vertebral fractures.

1.  Maintain airway administer oxygen by nasal cannula or face mask, prevent aspirations of gastric contents by left lateral positioning of patient.
2. .Draw blood to check glucose. if you suspect hypoglycemia, give 50% glucose 50ml I.V.
3. If there is any history or suspicion of alcoholism, give thiamine 100mg.I.V.mixed with 50% dextrose 50ml. Check skin sensitivity first.
4. Administer diazepam 5-10 mg. I.V. push over 2-3 minutes. Diazepam is best given is normal saline to avoid precipitation. An Ambu bag with face mask should be at the beside because it can cause respiratory depression. If the seizure persist, 5mg dose of diazepam may be repeated every 5 minute upto a maximum of 20mg.
5.  Recently,lorazepam2-4mg I.V. bolus has become popular as the drug of choice in the early stages of SE. A single injection is highly effective and the drug has a longer duration of action and a smaller risk of cardio respiratory depression than diazepam.
6. Administer I.V. phenytoin after giving either diazepam or lorazepam.. Usual dosage is 15-18mg/kg I.V. infusion over 30-45 minutes, not to exceed 50mg/min, hypotension and arrhythmias can occur. Therefore, use a  cardiac monitor if 
   possible. Diazepam is a short acting drug, whilst phenytoin has a prolonged action therefore it would prevent further seizures.
   P.S. I. V. phenytion must be administered in a saline; if given in dextrose it would precipitate
7. If SE Is not controlled by the above measures, it would be best to transfer the Patient to a neurologist or a hospital for ICU admission, where I.V. phenobarbitone, general anesthesia or propofol may given. Also ,CT scan of head, MRI, EEG etc. will be done.

SE is a neurological emergency, which must be immediately managed with airway clearance, oxygen, left lateral positioning, I.V. glucose and thiamine, diazepam or lorazepam plus I.V. phenytoin, If the above measures fail the patient should be sent either to a neurologist or a hospital with ICU facility.