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This
section provides the monthly papers presented by the specialists
of RMCH for spreading knowledge amongst medical
professionals practicing, especially, in peripheries.
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Dear doctor,
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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
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Dr. D. Mohan
Director- Medical &
Administration, Raj Hospital
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STATUS EPILEPTICUS
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Dr.Yogendra Raj, M.D.,M.R.C.P.(Ireland)
Consultant Physician & Neurologist
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Status Epilepticus- Types
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1. Tonic- clonic SE or Generalized convulsive SE
(GCSE)
2. Typical absence status
3. Complex partials status
4. Epilepsia partials continua
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I would focus on management
of generalized convulsive SE only, which generally refers to abnormal
electrical activity involving areas of the cortex.
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Definition
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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.
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Causes
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- 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.
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Mortality
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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.
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History
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- 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.
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Examination
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- 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.
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Examination
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- 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.
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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.
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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.
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Suspect SE in any patient who does not regain consciousness within 20-30 minutes of cessation of
generalized seizure activity.
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Association injuries that may be present in patient with seizure include tongue laceration
shoulder dislocation, head trauma, and vertebral fractures.
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Treatments
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- Maintain airway administer oxygen by nasal cannula or face mask, prevent aspirations of gastric contents by left lateral positioning of patient.
- .Draw blood to check glucose. if you suspect hypoglycemia, give 50% glucose 50ml I.V.
- If there is any history or suspicion of alcoholism, give thiamine 100mg.I.V.mixed
with 50% dextrose 50ml. Check skin sensitivity first.
- 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.
- 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.
- 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
- 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.
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Conclusion
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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.
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