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Status Epilepticus

ByDr. M. Tahaa Basheer

(MBBS)

Epilepsy“A neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions, associated with abnormal electrical activity in the brain.”

• A disorder of the nervous system that can cause people to suddenly become unconscious and to have violent, uncontrolled movements of the body.

ComplicationsTreatmentInvestigationsClassificationEtiologyDefinitionsStatus Epilepticus

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Status Epilepticus

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Basic “ State of continuing or recurring seizures in which recovery is incomplete.”

Official “Status epilepticus is a condition resulting either from the failure of the mechanisms responsible for seizure termination or from the initiation of mechanisms, which lead to abnormally, prolonged seizures (after time point t1). It is a condition, which can have long-term consequences (after time point t2) including neuronal death, neuronal injury, and alteration of neuronal networks, depending on the type and duration of seizures.”

Pathophysiologic “ any seizure activity lasting longer than 30 minutes”

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Status epilepticus occurs when….• The active part of a tonic-clonic seizure lasts 5 minutes

or longer• A person goes into a second seizure without recovering

consciousness from the first one• If a person is having repeated seizures for 30 minutes or

longer

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50% of seizures/SE are acute symptomatic–Stroke –Trauma–Cerebral hypoxia–Infection–Tumor

AED noncompliance or use of drugs that lower seizure threshold

Substance withdrawal

Metabolic derangements

Infectious cause

Autoimmune/Paraneoplastic

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1. Generalized Convuslive SE• Tonic-Clonic SE• Tonic SE• Clonic SE• Myoclonic SE

2. Generalized Nonconvulsive SE • Absence SE

3. Simple Partial (Focal) SE• Somatomotor SE

I. Epilepsia Partialis Continua• Sensory SE

I. SomatosensoryII. Special Sensory

• Aphasic SE• Autonomic SE

4. Complex Partial (Focal) SE

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1. Blood Glucose2. Blood Urea Nitrogen3. Serum Electrolytes4. LFTs5. Ca and Mg levels6. Anti epileptic drug levels7. Clotting Screen8. Full blood count9. MRI changes are evident in FLAIR and diffusion weighted sequence.10. EEG shows

• discrete seizures with interictal slowing

• Waxing and waning of ictal discharge

• Continuous ictal discharge• Continuous ictal discharge

punctuated by flat periods• Periodic epileptiform discharges on

a flat background

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0—5 min

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Obtain vital signs, establish airway, administer oxygen if needed.Observe seizures briefly to ascertain that patient is really in status.Draw baseline blood work (CBC, chemistry panel, antiepileptic drug levels), draw ABGs (for pO2 and pH), draw toxicology screen.Quickly assess patient for signs of cardio-respiratory compromise, hyperpyrexia, focal neurologic signs, head trauma, CNS infection.

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Start IV infusion with saline solution.Administer 100 mg thiamine, IV, if malnutrition and alcoholism are potential Factors.Administer 50 ml of 50% glucose solution, IV, if blood sugar is low or unobtainable. Do not give glucose if blood sugar is normal or high.Always have CPR equipment at bedside of a patient in status.

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To rapidly suppress the seizures, we have useddiazepam intravenously at a rate of about 2 mg/minuntil the seizures stop or a total of 20 mg has been given;alternatively, lorazepam, 0 . 1 mg/kg given by intravenouspush at a rate not to exceed 2 mg/min, is now favored,being marginally more effective than diazepam becauseof its clinically longer duration of action (see Table 1 6-8) .

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• Immediately thereafter, a loading dose (20 mg/kg)of phenytoin is administered by vein at a rate of less than 50 mg/ min. More rapid administration risks hypotension and heart block; consequently, it is recommended that the blood pressure and electrocardiogram be monitored during the infusion.• An alternative to phenytoin is fosphenytoin that can

be injected with twice the rate of phenytoin so help to stop seizure rapidly .

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• If phenytoin alone is not able to control the seizures then give high doses of midazolam (0.2 mg / kg loading dose followed by an infusion of 0 . 1 to 0.4 mg/kg/h along with phenytoin.

• Propofol given in a bolus of 2 mg/kg and then as an intravenous drip of 2 to 8 mg I kg /h is an effective alternative to midazolam, but after 24 h the

drug behaves like a high dose of barbiturate and theremay be hypotension. Prolonged use of propofol may precipitatehypertriglyceridemia-associated pancreatitis or afatal shock and acidosis ("propofol syndrome") .

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If seizures persist, intubate and give phenobarbital, 20 mg/kg, at 100 mg/min.Never use Valium and phenobarbital sequentially in the treatment of status, unless the patient is intubated and in an ICU. Their hypotensive and respiratory depressant actions synergize. Serious and abrupt side effects can occur with these two drugs when given together.

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If seizures persist, the patient should be placed in a drug induced coma with pentobarbital, a benzodiazepine, or other anesthetic agent to prevent life threatening lactic acidosis, hypoxia, hyperthermia, and permanent seizure-induced neuronal damage. The patient must be in an ICU, and outcome should be monitored and treatment guided by EEG with the goal being suppression of seizure activity on EEG

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If seizure still continues we will move further to stop all muscle activity by pancuroniumThat cause neuromuscular paralysis.Inahalational Anesthesia (isoflurane and halothane)Absence status should be managed by intravenouslorazepam, valproic acid, or both, followed by ethosuximide.Nonconvulsive generalized status is treated alongthe lines of grand mal status, usually stopping short ofusing anesthetic agents (see Meierkord)

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• Cardiac: Hypotension, tachycardia, arrhythmia

• Pulmonary: apnea, hypoxia, respiratory failure

• Hyperthermia• Metabolic derangement ( lactic

acidosis )• Cerebral: neuronal damage• Death

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ComplicationsTreatmentInvestigationsClassificationEtiologyDefinitionsStatus Epilepticus

Any Question ??

ByDr. M. Tahaa Basheer

(MBBS) Thankyou

Status Epilepticus

Status EpilepticusFor further description consult these websites

Epilepsy.com

WebMD.com

Wikipedia.com

Status Epilepticus

What is an absence seizure?An absence seizure causes a short period of “blanking out” or staring into space. Like other kinds of seizures, they are caused by abnormal activity in a person’s brain. You may also hear people call absence seizures petit mal (“PUH-tee mahl”) seizures, although that name is not common anymore.There are two types of absence seizures:Simple absence seizures: During a simple absence seizure, a person usually just stares into space for less than 10 seconds. Because they happen so quickly, it’s very easy not to notice simple absence seizures — or to confuse them with daydreaming or not paying attention.Complex absence seizures: During a complex absence seizure, a person will make some kind of movement in addition to staring into space. Movements may include blinking, chewing, or hand gestures. A complex absence seizure can last up to 20 seconds.Absence seizures can also happen with other kinds of seizures.

What is an atonic seizure?Muscle "tone" is the muscle's normal tension. "Atonic" (a-TON-ik) means "without tone," so in an atonic seizure, muscles suddenly lose strength. The eyelids may droop, the head may nod, and the person may drop things and often falls to the ground. These seizures are also called "drop attacks" or "drop seizures." The person usually remains conscious. These seizures typically last less than 15 seconds. They often start in childhood yet last into adulthood. Many people with atonic seizures are injured when they fall, so they may choose to use protection such as a helmet.Another name for this type of seizure is "akinetic" (a-kin-ET-ik), which means "without movement."

What is a clonic seizure?"Clonus" (KLOH-nus) means rapidly alternating contraction and relaxation of a muscle -- in other words, repeated jerking. The movements cannot be stopped by restraining or repositioning the arms or legs. Clonic (KLON-ik) seizures are rare. Much more common are tonic-clonic seizures, in which the jerking is preceded by stiffening (the "tonic" part). Sometimes tonic-clonic seizures start with jerking alone. These are called clonic-tonic-clonic seizures! These seizures tend to last for a few seconds to a minute.Brief and infrequent clonic seizures in infants usually disappear on their own within a short time. Other types may need prolonged treatment

What is a myoclonic seizure?Myoclonic (MY-o-KLON-ik) seizures are brief, shock-like jerks of a muscle or a group of muscles. "Myo" means muscle and "clonus" (KLOH-nus) means rapidly alternating contraction and relaxation—jerking or twitching—of a muscle. Usually they don't last more than a second or two. There can be just one, but sometimes many will occur within a short time.

What is a tonic seizure?Muscle "tone" is the muscle's normal tension at rest. In a "tonic" seizure, the tone is greatly increased and the body, arms, or legs make sudden stiffening movements. Consciousness is usually preserved. Tonic seizures most often occur during sleep and usually involve all or most of the brain, affecting both sides of the body. If the person is standing when the seizure starts, he or she often will fall. These seizures usually last less than 20 seconds.

What is a tonic-clonic seizure?This type is what most people think of when they hear the word "seizure." An older term for them is "grand mal." As implied by the name, they combine the characteristics of tonic seizures and clonic seizures. The tonic phase comes first: All the muscles stiffen. Air being forced past the vocal cords causes a cry or groan. The person loses consciousness and falls to the floor. The tongue or cheek may be bitten, so bloody saliva may come from the mouth. The person may turn a bit blue in the face.After the tonic phase comes the clonic phase: The arms and usually the legs begin to jerk rapidly and rhythmically, bending and relaxing at the elbows, hips, and knees. After a few minutes, the jerking slows and stops. Bladder or bowel control sometimes is lost as the body relaxes. Consciousness returns slowly, and the person may be drowsy, confused, agitated, or depressed.These seizures generally last 1 to 3 minutes.A tonic-clonic seizure that lasts longer than 5 minutes needs medical help. A seizure that lasts more than 10 minutes, or three seizures without a normal period in between, indicates a dangerous condition called convulsive status epilepticus. This requires emergency treatment.

What is a simple partial seizure?Simple partial seizures are usually divided into categories depending on the type of symptoms the person experiences:Motor seizures:These cause a change in muscle activity. For example, a person may have abnormal movements such as jerking of a finger or stiffening of part of the body.The movements may spread, either staying on one side of the body or extending to both sides. Other examples are weakness, which can even affect speech, and coordinated actions such as laughter or automatic hand movements. Sensory seizures:These cause changes in any one of the senses.People with sensory seizures may smell or taste things that aren't there; hear clicking, ringing, or a person's voice when there is no actual sound; or feel a sensation of "pins and needles" or numbness.Seizures may even be painful for some patients. They may feel as if they are floating or spinning in space.They may have visual hallucinations, seeing things that aren't there (a spot of light, a scene with people). They also may experience illusions—distortions of true sensations. For instance, they may believe that a parked car is moving farther away, or that a person's voice is muffled when it's actually clear.Autonomic seizures:These cause changes in the part of the nervous system that automatically controls bodily functions.These common seizures may include strange or unpleasant sensations in the stomach, chest, or head; changes in the heart rate or breathing; sweating; or goose bumps.Psychic seizures:These seizures change how people think, feel, or experience things.They may have problems with memory, garbled speech, an inability to find the right word, or trouble understanding spoken or written language.They may suddenly feel emotions like fear, depression, or happiness with no outside reason.Some may feel as though they are outside their body or may have feelings of déja vu ("I've been through this before") or jamais vu ("This is new to me"— even though the setting is really familiar).

What is a complex partial seizure?These seizures usually start in a small area of the temporal lobe or frontal lobe of the brain. They quickly involve other areas of the brain that affect alertness and awareness. So even though the person's eyes are open and they may make movements that seem to have a purpose, in reality "nobody's home." If the symptoms are subtle, other people may think the person is just daydreaming.Some people can have seizures of this kind without realizing anything has happened. The seizure can wipe out memories of events just before or after it.Some of these seizures (usually ones beginning in the temporal lobe) start with a simple partial seizure.Then the person loses awareness and stares blankly.Most people move their mouth, pick at the air or their clothing, or perform other purposeless actions. These movements are called "automatisms" (aw-TOM-ah-TIZ-ums).Less often, people may repeat words or phrases, laugh, scream, or cry. Some people do things during these seizures that can be dangerous or embarrassing, such as walking into traffic or taking their clothes off. These people need to take precautions in advance.Complex partial seizures starting in the frontal lobe tend to be shorter than the ones from the temporal lobe. The seizures that start in the frontal lobe are also more likely to include automatisms like bicycling movements of the legs or pelvic thrusting.Some complex partial seizures turn into secondarily generalized seizures. They usually last between 30 seconds and 2 minutes. Afterward, the person may be tired or confused for about 15 minutes and may not be return to normal function for hours.As for many other kinds of seizures, the outlook depends on whether the cause is known. They may be outgrown or controlled with medication. If medication is not effective, some can be eliminated by epilepsy surgery.

Epilepsia partialis continua (also called Kojevnikov's or Kozhevnikov's epilepsia) is a rare[1] type of brain disorder in which a patient experiences recurrent motor epileptic seizures that are focal (hands and face), and recur every few seconds or minutes for extended periods (days or years).