It is a common neurological emergency that is associated with brain damage and death. Status epilepticus or SE is defined as continuous seizure episodes lasting more than 5 minutes or two or more seizures without recovery of full consciousness. Seizures are due to hyper firing of neurons in the brain.
Types of Status Epilepticus
1. Generalized convulsive status epilepticus : Involves the whole brain
Tonic-clonic SE, Clonic SE, Tonic SE and Myoclonic SE
2. Nonconvulsive status epilepticus: It is a continuous or near to continuous generalised seizure lasting for about 30 mins but without physical convulsions.
Etiology
- Infections
- Head injury
- Hypoxia
- CNS tumors
- Stroke
- Chronic alcoholism
- Electrolyte imbalances
- Genetics
- Certain drugs
- Withdrawal of anti-epileptics
Pathophysiology
- Seizure occurs due to the imbalance between excitatory NT such as glutamate, calcium, sodium, substance P, neurokinin B and the inhibitory NT such as GABA, adenosine, potassium, neuropeptide Y , opioid peptides and galanin neurotransmitters.
- Glutamate as already mentioned, an excitatory NT and stimulates postsynaptic NMDA receptors leading to neuronal depolarisation and if it is sustained then it can cause neuronal death.
- GABA, the primary inhibitory NT oppose excitation by stimulation of GABAA receptors leading to hyperpolarisation and inhibition of postsynaptic cell membrane.
- What happens in epilepsy is that GABA mediated inhibition becomes decreased and enhanced glutamate effects.
- Seizures lasting more than half an hour can cause significant injury and neuronal loss.
Stages of status epilepticus
Clinical features of status epilepticus
- During phase I, up to 30 mins there will be a marked increase in plasma NA and Adr and steroid conc. so the following occurs
- HTN, tachycardia, cardiac arrhythmias. Fever and sweating also seen.
- Muscle contraction and hypoxia occurs which in turn causes acidosis, hypotension, rhabdomyolysis, secondary hyperkalemia.
- Hypothermia
- During phase II, from 30-60 mins the following happens.
- Respiratory failure, pulmonary edema, cardiac failure, hypotensive with compromised cerebral blood flow, hyperthermia.
- Even multi-organ failure can occur if not taken care clinically.
Diagnosis
- EEG
- CT scan
- MRI
- Laboratory tests
- Spinal tap if CNS infection suspected.
Treatment
Non pharmacological treatment
- Ketogenic diet (KD): Dietary treatment by altering the ratio of fat to non-fat food in increasing ratios from 1:1 to 4:1. This is done with the aim of maximising the ketone production in a way that improves the seizure control.
- Vagal nerve stimulation (VNS): Used in the treatment of refractory epilepsy those who are not amenable to surgery. It is not a cure but can lower the seizure by 50%.
- Epilepsy surgery: Considered in case of people who can’t get a control of their seizure with medications. After the surgery is done there will be improved seizure control or even have complete seizure freedom.
Pharmacological treatment
- BZDs are the preferred initial drugs to stop seizure activity.
- Followed by anti-epileptic drugs.
- Anti-epileptics can be given I.V for immediate action, when I.V access not available then it may be given via I.M, rectally or nasally.
- If the patient is still does not respond (refractory SE) to any of these medications then patient will be sent to coma by continuous I.V anaesthetic drugs.
What should I do when somebody is having a seizure?
- Be calm
- Loosen the clothing of the person having seizure.
- Turn them on to their side to drain anything in his/her mouth to prevent choking.
- Put something that is flat or soft under their head if it is within your reach to prevent injuries.
- Move all sharp or any other objects or furniture so that they won’t injure themselves during the episode.
- Don’t try to hold their tongue down with anything. Nothing must be placed in their mouth during the seizure episode. It will cause obstruction in their airway and make breathing difficult.
- Do not give anything to drink.
- Do not shake or slap them so as to bring some sense in them as it is of no use. Just let them be and do not restrain them in anyway.
- Stay with them until their breathing is normal and awake again.
- Take a note on the type and duration of the seizure as it is important in diagnosing.
- Do keep in mind than the person can be irritated or tired after having an episode so make effort to be calm and calm them and also reassuring them.
- Bring them immediately to hospital if it is lasting more than 5 minutes or is having continuous seizure episodes, or occurred more than 1 time per day, has a stiff neck, appearing unwell or is their first episode.
– Written by Gayathri Gopinadh