History

Fact Explanation
Continuous seizure lasting more than 30 minutes or two or more seizures without full recovery of consciousness between any of them. An epileptic seizure can be defined as a sudden synchronous discharge of cerebral neurons causing symptoms and signs that are apparent either to patient or observer. Status epilepticus occurs due to excess excitation and reduced inhibition at the neuro chemical level of the brain. It is a medical emergency associated with significant morbidity and mortality. When considering the etiology, it can represent an initial manifestation of a seizure disorder, an exacerbation of a seizure disorder which is pre existing, or an insult other than a seizure disorder. [1],[2],[3],[4],[7]
History of epilepsy If this is a representation of pre existing seizure disorder, their is positive a past medical history of seizures. Onset of seizure, pattern, post ictal phase, frequency, Previous treatments and compliance with anticonvulsants are important information in the history. [1],[2],[3],[4],[5],[6],[7]
History of taking systemic treatment for any other disease. Commonly used drugs that may predispose to status epilepticus by lowering the seizure threshold or by increasing the clearance of antiepileptic drugs. For example- Antibiotics, Antihistamines, Antipsychotics, Antidepressants, Theophylline. [2],[5],[6]
History of stroke. This can be an representation of insult to the brain due to acute or remote stroke. Therefore must ask for history of sudden onset of focal deficit of cerebral function. [1],[2],[7]
History of hypoglycemia. This can be an representation of insult to the brain due to hypoglycemia. Therefore history of diabetes mellitus, control of diabetes, anti diabetic or insulin abuse, prolong fasting and eating disorders are important information in the history. [1],[2],[7]
History of cerebral infection. This can be an representation of insult to the brain due to cerebral infection. History of fever, headache, photo phobia, delirium, contact history of meningitis, tuberculosis, Immunization history, history of syphilis, travel history to malaria endemic regions are important information in the history. [1],[2],[7]
History of head injury. This can be an representation of insult to the brain due to acute or remote head injury. Therefore history trauma, history of vomiting and headache, behavioral change are important information in the history. [1],[2],[7]
History of cerebral tumor. This can be an representation of insult to the brain due to cerebral tumor. Due to direct effect local progressive deterioration of function occur. Due to raised intracranial pressure early morning headache, vomiting occur. [1],[2],[7]
History of hypoxia. This can be an representation of insult to the brain due to hypoxia. History of ischemic heart diseases is an important information in the history. [1],[2],[7]
History of Drug overdose or withdrawal. This can be an representation of insult to the brain due to drug overdose. Example- Tricyclics. This can be an representation of insult to the brain due to drug withdrawal. Example- Chronic alcohol abuse. [1],[2],[5],[6],[7]
History of electrolyte disturbance. This can be an representation of insult to the brain due to electrolytes such as sodium, calcium or magnesium disturbance. For example recent thyroid or parathyroid surgery may cause hypocalcaemia. [1],[2],[7]
References
  1. KUMAR, Parveen and CLARK, Michael. KUMAR & CLARK'S Clinical Medicine. 8th Ed. ELSEVIER.2012,1115.
  2. THOMAS SANJEEVV, CHERIAN AJITH. Status epilepticus. Ann Indian Acad Neurol [online] 2009 December [viewed 03 June 2014] Available from: doi:10.4103/0972-2327.56312
  3. MISRA USHAKANT, BHOI SANJEEVKUMAR, KALITA JAYANTEE. Practice parameters in management of status epileptics. Ann Indian Acad Neurol [online] 2014 December [viewed 03 June 2014] Available from: doi:10.4103/0972-2327.128646
  4. SINGH SANJAYP, FAULKNER M, AGARWAL SHUBHI. Refractory status epilepticus. Ann Indian Acad Neurol [online] 2014 December [viewed 03 June 2014] Available from: doi:10.4103/0972-2327.128647
  5. BENNET, P.N. and BROWN, M.J. CLINICAL PHARMACOLOGY. 9th Ed. CHURCHILL LIVINGSTONE. 2003.
  6. KATZUNG, Bertram G. MASTERS, Susan B. and TREVOR, Anthony J. Basic and Clinical Pharmacology. 12th Ed. Tata McGraw-Hill. 2012.
  7. RAMRAKHA, Punit S. MOORE, Kevin P. and SAM, Amir. Oxford Handbook of Acute Medicine. 3rd Ed. OXFORD UNIVERSITY PRESS. 2010,390-393.

Examination

Fact Explanation
Generalized tonic clonic convulsions. When seizure continues can identify the seizure type by observation. In the brain the most common excitatory neuro transmitter is glutamate, the most common inhibitory neuro transmitter is gamma aminobutyric acid. The status epilepticus occur due to excess excitation and reduced inhibition. It is now considered that any seizure that lasts more than 5 min probably needs to be treated as status epilepticus. [1],[2],[3],[4]
Focal unilateral parasthesias or numbness, focal visual changes, olfactory,gustatory hallucinations may be elicited. When insult involve only the sensory cortex non motor simple partial status epilepticus occur with these subjective sensory disturbance occur. [1],[2],[4]
Intermittent, involuntary twitching of the muscle groups. Commonly involve face and distal hand muscles can be observed. When acute insult occur to the motor cortex, epilepsy partialis continua occur. It can be a infection, neoplasm, trauma, metabolic disturbance or stroke. the signs are usually non progressive but rarely can be progressive progressive. [1],[2],[4]
Recurrent recognizable partial seizures or continous ongoing partial seizures. These two patterns suggest the presentation of complex partial seizures. Confusion, memory impairment and automatism such as lip smacking may be noticed during examination. [1],[2],[4]
Assess the level of consciousness Rapid assessment of the level of conciousness done with GCE score. [1],[2],[4]
Signs of head injury The skull should be examined for fractures. Extensive periorbital haematoma, bruising behind the ear, bleeding from ear, CSF rhinorrhoea, otorrhoea suggest basal skull fracture. [1],[2],[4]
Fever If the etiology is cerebral infection pyrexia is an important sign to narrow down the differential diagnosis. Also hyperthermia occur as a complication of status epilepticus. [1],[2],[4]
Papillodema Papillodema is a sign of increased intracranial pressure. It suggest a possible neoplastic lesion or brain infection. [1],[2],[4]
Needle rack marks or insulin injection sites The needle track marks of IV drug abuse or insulin injection sites suggest the etiology of seizure. [1],[2],[4]
Neurological examination Lateralized neurological signs such as increased tones, reduced power, asymmetrical reflexes are suggestive of seizures initiate at localized regions. [1],[2],[4]
Associated injuries due to seizure Bite marks of lateral sides of tongue, shoulder dislocations, facial and head injuries are common injuries associated with seizures. [1],[2],[4]
Signs of complications Hypo or hypertension, hyperthermia, hypoxia, dysrhythmia are common possible complications due to status epilepticus. Therefore monitoring the vital signs is important. [1],[2],[4]
References
  1. KUMAR, Parveen and CLARK, Michael. KUMAR & CLARK'S Clinical Medicine. 8th Ed. ELSEVIER.2012,1115.
  2. THOMAS SANJEEVV, CHERIAN AJITH. Status epilepticus. Ann Indian Acad Neurol [online] 2009 December [viewed 03 June 2014] Available from: doi:10.4103/0972-2327.56312
  3. MISRA USHAKANT, BHOI SANJEEVKUMAR, KALITA JAYANTEE. Practice parameters in management of status epileptics. Ann Indian Acad Neurol [online] 2014 December [viewed 03 June 2014] Available from: doi:10.4103/0972-2327.128646
  4. RAMRAKHA, Punit S. MOORE, Kevin P. and SAM, Amir. Oxford Handbook of Acute Medicine. 3rd Ed. OXFORD UNIVERSITY PRESS. 2010,390-393.

Differential Diagnoses

Fact Explanation
Psychogenic status epilepticus Usually there are bizarre limb movements. It is triggered by psychological problems, and frequently occur in conversion disorder. But there can be extreme difficulty in separating these attacks from true seizure. [1],[2],[3],[4]
Encephalitis Possible presentations are behaviour and personality changes, photophobia, neck pain, neck stiffness, focal neurological lesions are ataxia. [1],[2]
Encephalopathy The hallmark of encephalopathy is an altered mental state. Depending on the type and severity of encephalopathy symptoms vary. Common neurological symptoms are loss of cognitive function, subtle personality changes, inability to concentrate, lethargy, and depressed consciousness. [1],[2]
Hypoglycemia Causes attacks of loss of consciousness, some times with convulsions. There is often warning signs such as hunger, malaise, shaking and sweating. Prolonged hypoglycemia causes wide spread cerebral damage. [1],[2]
Drug reactions Acute dystonic reactions such as oculogyric crises are some times mistaken for status epilepticus. Consciousness is preserved. [1],[2]
Withdrawal syndromes Is a set of symptoms occurring in discontinuation or dosage reduction of some types of medications. The risk of a discontinuation syndrome occurring increases with dosage and length of use. Eg: In alcohol withdrawal syndrome, symptoms seen when an individual reduces or stops alcohol consumption after periods of excessive alcohol intake. [1],[2]
Hyponatremia Medical conditions such as congestive heart failure, liver or renal failure or pneumonia associated with hyponatremia. Commonly these patients present with symptoms of primary medical problem. [1],[2]
Neuroleptic malignant syndrome Neuroleptic malignant syndrome is a life-threatening neurological disorder most often caused by an adverse reaction to antipsychotic drugs. It typically consists of muscle rigidity, fever, autonomic instability, and cognitive changes. [1],[2]
Hyperventilation Is common and over breathing cause alkalosis. This leads to dizziness, anxiety, circumoral, peripheral tingling and tetany. Occasionally there is loss of consciousness. [1],[2]
Tetanus The first sign is trismus, or lockjaw, and the facial spasms called risus sardonicus, followed by stiffness of the neck, difficulty in swallowing, and rigidity of pectoral and calf muscles. Other symptoms include elevated temperature, elevated blood pressure, sweating, and episodic rapid heart rate. Spasms may occur frequently and last for several minutes with the body shaped into a characteristic form called opisthotonos. [1],[2]
References
  1. KUMAR, Parveen and CLARK, Michael. KUMAR & CLARK'S Clinical Medicine. 8th Ed. ELSEVIER.2012.
  2. THOMAS SANJEEVV, CHERIAN AJITH. Status epilepticus. Ann Indian Acad Neurol [online] 2009 December [viewed 03 June 2014] Available from: doi:10.4103/0972-2327.56312
  3. MISRA USHAKANT, BHOI SANJEEVKUMAR, KALITA JAYANTEE. Practice parameters in management of status epileptics. Ann Indian Acad Neurol [online] 2014 December [viewed 03 June 2014] Available from: doi:10.4103/0972-2327.128646
  4. RAMRAKHA, Punit S. MOORE, Kevin P. and SAM, Amir. Oxford Handbook of Acute Medicine. 3rd Ed. OXFORD UNIVERSITY PRESS. 2010,390-393.

Investigations - for Diagnosis

Fact Explanation
Capillary blood sugar level Most healthy adults maintain fasting glucose levels above 4.0 mmol/L (72 mg/dl), and develop symptoms of hypoglycemia when the glucose falls below 4 mmol/L. Usually prompt recovery occurs with IV glucose. Prolonged hypoglycemia causes wide spread cerebral damage. [1],[2],[3],[4]
Serum electrolytes, Serum calcium and Serum magnesium Electrolyte disturbance such as hypo and hypernatremia, Hypocalcemia, Hypomagnesemia are possible etiology of status epilepticus. [1],[2],[3],[4]
Full blood count It may show features of acute or chronic infection which affects the brain. [1],[2]
Renal function tests As a result of renal failure hyponatremia can occur. [1],[2],[4]
Liver function tests As a result of liver failure hyponatremia can occur. [1],[2],[4]
Toxicologic screening Etiology of status epilepticus can be a drug overdose or withdrawal. Therefore toxicologic screening performed. [1],[2],[4]
Anticonvulsant levels Finding anticonvulsant level in blood is important to treatment decisions in patients with epilepsy and on long term treatments. [1],[2],[4]
Arterial blood gas This is helpful to detect complications such as hypoxia and acidosis and to identify Isoniazid poisoning. [1],[2],[4]
EEG If available EEG is useful to identify focal status epilepticus, subtle seizures and to confirm the diagnosis. [1],[2],[4]
CT scanning When their is a history of head injury or suspect a structural lesion. [1],[2],[4]
Brain MRI This is not commonly indicated. Brain MRI provides more information than CT, but for acute management rarely useful. [1],[2],[4]
Lumbar Puncture After ensuring safety by imaging lumbar puncture performed if cerebral infection is a differential diagnosis. [1],[2],[4]
References
  1. KUMAR, Parveen and CLARK, Michael. KUMAR & CLARK'S Clinical Medicine. 8th Ed. ELSEVIER.2012,1115.
  2. THOMAS SANJEEVV, CHERIAN AJITH. Status epilepticus. Ann Indian Acad Neurol [online] 2009 December [viewed 03 June 2014] Available from: doi:10.4103/0972-2327.56312
  3. MISRA USHAKANT, BHOI SANJEEVKUMAR, KALITA JAYANTEE. Practice parameters in management of status epileptics. Ann Indian Acad Neurol [online] 2014 December [viewed 03 June 2014] Available from: doi:10.4103/0972-2327.128646
  4. RAMRAKHA, Punit S. MOORE, Kevin P. and SAM, Amir. Oxford Handbook of Acute Medicine. 3rd Ed. OXFORD UNIVERSITY PRESS. 2010,390-393.

Investigations - Followup

Fact Explanation
Follow up Clinic visits Assess response to treatment, compliance and side effects of treatments. [1],[2],[3]
Periodic monitoring. When patients are on long term therapy monitor liver function tests and full blood count periodically due to the possibility of liver toxicity and agranulocytosis of anti epileptic drugs. [1],[2],[3]
References
  1. KUMAR, Parveen and CLARK, Michael. KUMAR & CLARK'S Clinical Medicine. 8th Ed. ELSEVIER.2012,1115.
  2. THOMAS SANJEEVV, CHERIAN AJITH. Status epilepticus. Ann Indian Acad Neurol [online] 2009 December [viewed 03 June 2014] Available from: doi:10.4103/0972-2327.56312
  3. RAMRAKHA, Punit S. MOORE, Kevin P. and SAM, Amir. Oxford Handbook of Acute Medicine. 3rd Ed. OXFORD UNIVERSITY PRESS. 2010,390-393.

Management - General Measures

Fact Explanation
Secure airway, breathing and ciculation Ensure an adequate airway and to provide respiratory support. Open the airway by laying the patient on side in semiprone position with head slightly lower to prevent aspiration. Usually an oral airway will suffice and ET tube is rarely necessary. Give oxygen via face mask. Monitor pulse rate, Blood pressure. Get IV access with wide bore cannula. Take blood for lab investigations. Correct hypotension with colloid if necessary. Obtain ECG if patient is hypotensive. [1],[2],[3],[4],[5]
IV Thiamine Thiamine 250mg IV should be given if alcoholism or other malnourished states appear likely. [1],[2],[3],[4],[5]
IV Dextrose If hypoglycemia is suspected 50ml of 50% Dextrose should be administered IV. Because glucose increase the risk of Wernicke's Encephalopathy, thiamine 1-2mg/Kg IV should administered beforehand in any patient suspected of alcohol excess. [1],[2],[3],[4],[5]
Patient education after recovery. Advise regarding importance of compliance with prescribed medication. Advise patient to avoid conditions such as swimming, climbing trees, handling fire to avoid possible life threatening accidents. Educate family members how to take care of patient. [1],[2],[3],[4],[5]
References
  1. KUMAR, Parveen and CLARK, Michael. KUMAR & CLARK'S Clinical Medicine. 8th Ed. ELSEVIER.2012,1115.
  2. THOMAS SANJEEVV, CHERIAN AJITH. Status epilepticus. Ann Indian Acad Neurol [online] 2009 December [viewed 03 June 2014] Available from: doi:10.4103/0972-2327.56312
  3. MISRA USHAKANT, BHOI SANJEEVKUMAR, KALITA JAYANTEE. Practice parameters in management of status epileptics. Ann Indian Acad Neurol [online] 2014 December [viewed 03 June 2014] Available from: doi:10.4103/0972-2327.128646
  4. RAMRAKHA, Punit S. MOORE, Kevin P. and SAM, Amir. Oxford Handbook of Acute Medicine. 3rd Ed. OXFORD UNIVERSITY PRESS. 2010,390-393.
  5. SIRVEN JI, WATERHOUSE E. Management of status epilepticus. Am Fam Physician [online] 2003 Aug 1, 68(3):469-76 [viewed 05 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/12924830

Management - Specific Treatments

Fact Explanation
Lorazepam IV Lorazepam IV 4mg bolus (0.007mg/kg) which may be repeated once after 10 min. Because lorazepam does not accumulate in lipid stores and has strong cerebral binding and a long duration of action, it has distinct advantages over diazepam in early status of epilepticus. Buccal midazolam is an alternative. [1],[2],[3],[4],[5],[6],[8]
Phenytoin IV With a benzodiazepine, start an infusion of phenytoin 15mg/kg, at rate of 50mg/min in to a large vein. 5% glucose is not compatible with phenytoin. ECG monitoring is required because phenytoin may induce cardiac arrythmias. Pulse,BP, and respiratory rate must be monitored. IV phenytoin is relatively contraindicated in patients with heart disease, specially patients with conduction abnormalities. [1],[2],[3],[4],[5],[6],[8]
Phenobarbital IV If seizure continues give Phenobarbital IV 10mg/kg at a rate of 100mg/min. [1],[2],[3],[4],[5],[6],[8]
Fosphenytoin IV An alternative is fosphenytoin given as infusion of 15mg PE (phenytoin equivalents) at a rate of 100mg PE/min. This is a pro drug of phenytoin and can be given faster than phenytoin. [1],[2],[3],[4],[5],[6],[8]
In refractory status (seizure continuing for 60-90 min after initial therapy) patient Should be transferred to intensive care. General anesthesia with either propofol or thiopental should be administered. Paraldehyde is an alternative but requires glass syringe as it corrodes rubber and plastic. Continous EEG monitoring used to assess efficacy of treatments, aim for EEG burst suppression pattern. The anasthetic agent Should be continued for 12-24h after the last clinical or electrographic seizure; The dose should be then tapered down. [1],[2],[7]
Initiate long term therapy. If this patient was on anti epileptic previously check adequacy of dose, compliance and manage accordingly. Other conditions such as alcohol withdrawal or repeated status epilepticus in multi infarct dementia need anticonvulsant for a short while. Sodium valporate is now considered first choice tratment, with carbamazapine as an alternative. [1],[2],[3],[4],[5],[6],[8]
References
  1. KUMAR, Parveen and CLARK, Michael. KUMAR & CLARK'S Clinical Medicine. 8th Ed. ELSEVIER.2012,1115.
  2. THOMAS SANJEEVV, CHERIAN AJITH. Status epilepticus. Ann Indian Acad Neurol [online] 2009 December [viewed 03 June 2014] Available from: doi:10.4103/0972-2327.56312
  3. MISRA USHAKANT, BHOI SANJEEVKUMAR, KALITA JAYANTEE. Practice parameters in management of status epileptics. Ann Indian Acad Neurol [online] 2014 December [viewed 03 June 2014] Available from: doi:10.4103/0972-2327.128646
  4. RAMRAKHA, Punit S. MOORE, Kevin P. and SAM, Amir. Oxford Handbook of Acute Medicine. 3rd Ed. OXFORD UNIVERSITY PRESS. 2010,390-393.
  5. BENNET, P.N. and BROWN, M.J. CLINICAL PHARMACOLOGY. 9th Ed. CHURCHILL LIVINGSTONE. 2003.
  6. KATZUNG, Bertram G. MASTERS, Susan B. and TREVOR, Anthony J. Basic and Clinical Pharmacology. 12th Ed. Tata McGraw-Hill. 2012.
  7. SINGH SANJAYP, FAULKNER M, AGARWAL SHUBHI. Refractory status epilepticus. Ann Indian Acad Neurol [online] 2014 December [viewed 03 June 2014] Available from: doi:10.4103/0972-2327.128647
  8. SIRVEN JI, WATERHOUSE E. Management of status epilepticus. Am Fam Physician [online] 2003 Aug 1, 68(3):469-76 [viewed 05 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/12924830