THE COLLEGE OF MAASIN

“Nisi Dominus Frustra”

College of Nursing and Allied Health
Sciences

A Case Study
Of
Status Epilepticus

Submitted to:

Ms.Nina Piao,RN
CM-CI

Submitted by:
Butron , Charity Bless
DEFINITION OF TERMS

Status epilepticus is define as a continuous seizure lasting more than 30 min, or two or more seizures
without full recovery of consciousness between any of them. Seizures can either be a tonic- clonic type
with a regular pattern of contraction and extension of the arms and legs.

Classification of status epilepticus

Convulsive Status Epilepticus

This term is used to describe the more common form of emergency situation that can occur with
prolonged or repeated tonic-clonic (also called convulsive or grand mal) seizures. Most tonic-clonic
seizures end normally in 1 to 2 minutes, but they may have post-ictal (or after-effects) symptoms for
much longer. This makes it hard to tell when a seizure begins and ends.

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

Nonconvulsive Status Epilepticus

This term is used to describe long or repeated absence or complex partial seizures.

 The person may be confused or not fully aware of what is going on, but they are not
'unconscious', like in a tonic clonic seizure.
 These situations can be harder to recognize than convulsive seizures. Symptoms are more subtle
and it's hard to tell seizure symptoms from the recovery period.
 There is no consistent time-frame on when these seizures are called an emergency. It depends in
part on how long a person's typical seizures are and how often they occur.

When nonconvulsive status epilepticus occurs or is suspected, emergency medical treatment in a

hospital setting is needed. EEG testing may be needed to confirm the diagnosis first. People with this
type of status are also at risk for convulsive status epilepticus, thus quick treatment is required.

 If a person is having repeated seizures for 30 minutes or longer

Cherian and Thomas;Status epilepticus;https://www.ncbi.nlm.nih.gov/pmc/article

Status epilepticus ( acute prolonged seizure activity) is a series of generalized seizures that occur
without full recovery of consciousness between attacks.The term has been broadened to include
continuous clinical or electrical seizures (on EEG) lasting at least 30 minutes,even without impairment
of consciousness.

Brunner and Suddarth; Medical- Surgical Nursing 13th Edition Vol.2

Status Epilepticus is a medical emergency. A seizure that lasts more than 10 minutes, or three
seizures in a row without the person coming to between them.

Stages of Status Epilepticus

Doctors categorize three stages of status epilepticus (SE).

 Premonitory stage in which seizures increase in number and frequency prior to the onset of SE
 Established stage requiring immediate emergency treatment
 Refractory stage when the seizure resists initial treatment requiring more aggressive measures.

In the first phase of SE, convulsions are accompanied by increased muscle tension, high blood sugar
(hyperglycemia), sweats, salivation, high fever and increased blood flow to the brain. The second phase
begins about 30 minutes after seizures start. It is marked by a decrease in blood flow to the brain,
increased pressure in the skull, and abnormally low blood pressure. However, neuron damage may begin
much sooner.

Papadakis and McPhee;Current Medical Diagnosis and Treatment

ANATOMY AND PHYSIOLOGY

Nerve cells within the brain are called neurons,commonly communicate with each other through cell
called synapses.One nerve cells sends a chemical signal to neighboring cell which then activate an
electrical nerve impulse within the receiving neuron.Together the series of electrical impulses allow for
proper brain functioning.

The brain has two halves called hemispheres. Each half has four parts called lobes: the occipital,
parietal, temporal and frontal lobes.

Abnormalities in the temporal or frontal lobes of the brain are the most common reason for memory
problems in people with epilepsy.

The left temporal lobe is important for verbal memories such as learning names and remembering facts
for exams. If you have seizures that start in this area you may have problems remembering words, and
get stuck mid-sentence.

The right temporal lobe is important for visual memories like remembering a person’s face or finding
your way around a place.

The frontal lobe is important for prospective memory. Seizures in this area can cause problems
remembering to do things in the future.

The occipital lobe is the visual processing center of the mammalian brain containing most of the
anatomical region of the visual cortex.

The parietal lobe carries out some very specific functions. As a part of the cortex, it has a lot
of responsibilities and has to be able to process sensory information within seconds. The parietal lobe is
where information such as taste, temperature and touch are integrated, or processed. Humans would not
be able to feel sensations of touch, if the parietal lobe was damaged.
ETIOLOGY

Predisposing Factors Rationale

Genetic influence Certain genes may make a person more sensitive
to environmental conditions that trigger seizures

Prenatal injury Before birth, babies are sensitive to brain damage

that could be caused by several factors, such as an
infection in the mother, poor oxygen deficiencies.
This brain damage can result to seizures.

Family history If you have a family history of epilepsy, you may

be at an increased risk of developing a seizure
disorder.
Precipitating Factors Rationale
Head injuries A brain injury can cause seizure(s) because of the
unusual amount of energy that is discharged across
of the brain when the injury occurs and thereafter.

Stroke and other vascular diseases In the first few weeks following a stroke some
stroke survivors will experience a seizure. Seizures
are a sign of brain injury and are caused by sudden
disorganized electrical activity in the brain.
Brain infections Infections such as meningitis, which causes
inflammation in your brain or spinal cord, can
increase the risk.
Fever In children between the ages of 6 months and 5
years, a fever of 38 °C (100.4 °F) or higher may
lead to a seizure known as a febrile seizure.

Additionally, in some, gastroenteritis, which

causes vomiting and diarrhea, can lead to
diminished absorption of anticonvulsants, thereby
reducing protection against seizures
Sleep Deprivation The reason for which sleep deprivation can trigger
a seizure is unknown. One possible thought is that
the amount of sleep one gets affects the amount of
electrical activity in one's brain.
Missed anticonvulsants Missed doses are one of the most common reasons
for a breakthrough seizure. A single missed dose is
capable of triggering a seizure in some patients.

Incorrect dosage amount: A patient may be

Abrupt withdrawal from seizure medications
receiving a sub-therapeutic level of the
anticonvulsant.
Sudden withdrawal from anticonvulsants may lead
to seizures. It is for this reason that if a patient's
medication is changed, the patient will be weaned
from the medication being discontinued following
the start of a new medication.

Alcohol There are varying opinions on the likelihood of

alcoholic beverages triggering a seizure.
Consuming alcohol may temporarily reduce the
likelihood of a seizure immediately following
consumption. However, after the blood alcohol
 content has dropped, chances may increase.

Lights Can be responsible for the onset of a seizure This

condition is known as photosensitive epilepsy, and
in some cases, the seizures can be triggered by
activities that are harmless to others, such as
watching television or playing video games, or by
driving or riding during daylight along a road with
spaced trees, thereby simulating the "flashing
light" effect. Some people can suffer a seizure
because of blinking one's own eyes.
SYMPTOMATOLOGY

Signs and Symptoms Rationale

Muscle spasms The muscle during seizure is tighter and

floppy.It is develop when multiple cells misfire
at the same time depending on the severity and
location in the brain.

Falling Lack of oxygen and blood In the brain

Confusion Abnormalities in the temporal or frontal lobes

of the brain

Unusual Noises Consequence of the activation of functional

cortex by abnormal, unilateral, and brief
neuronal discharge

Loss of bowel and bladder control Increased pressure on the bladder and bowel
causes urinary incontinence and soiling.

Clenched teeth Induced by temporal lobe seizures

Seizures Disruptions in electrical activity in the central

nervous system, clusters of neurons in the
electrical system of the brain generate
abnormally high numbers of spontaneous and
asynchronous electrical discharges. The
threshold of excitability or the seizure
threshold becomes too low

Irregular breathing The autonomic nervous system regulates body

functions like breathing. Seizures can disrupt
this system, causing breathing to temporarily
stop. Interruptions in breathing during seizures
can lead to abnormally low oxygen levels, and
may contribute to sudden unexpected death in
epilepsy (SUDEP).

Loss of consciousness Abnormal increased activity in fronto-parietal

association cortex and related subcortical
structures. Abnormal decreased activity in
these same networks may cause loss of
conscious-ness in complex partial seizures.
Thus, abnormally increased or decreased
activity in the same networks can cause loss of
consciousness. Information flow during normal
conscious processing may require a dynamic
balance between these two extremes of
excitation and inhibition.
LABORATORY AND DIAGNOSTICS

The presence of SE should prompt a search for its etiology, and in particular for potentially reversible
conditions. Clinical information should guide the ordering of laboratory tests.

Laboratory studies that should be obtained on an emergency basis include the following:

 Electrolytes
 Calcium
 Magnesium
 Glucose
 Complete blood count
 Renal function tests
 Toxicologic screening
 Anticonvulsant levels
 Liver function tests

Emergent glucose assessment is particularly important because both hyperglycemia and hypoglycemia
can be associated with SE. Rapid turnaround of anticonvulsant drug levels may be particularly helpful in
guiding treatment choices in patients with well-established epilepsy who on long-term therapy.

Arterial Blood Gases

Arterial blood gas (ABG) measurement may be useful to monitor oxygenation and ventilation efficacy
and to discover any unexpected acid-base abnormalities. An episode of generalized seizures will
typically result in a metabolic acidosis, but this should correct rapidly following seizure cessation as the
lactate generated by vigorous muscle contractions is metabolized. Profound metabolic acidosis and
continuing seizures might raise the possibility of isoniazid poisoning

Electroencephalography

EEG is the criterion standard for diagnosing EEG, and some authors believe that EEG should be a
routine part of management of SE.Nevertheless, EEG is rarely available in the acute-care setting;
normally, it is obtained through neurologic consultation. When EEG is unavailable for the acute workup,
presumptive treatment strategies must occasionally be started before EEG confirmation becomes
available.
Computed Tomography

CT scanning of the brain is often helpful in evaluating for a structural lesion (eg, brain tumor, infarction,
abscess, hemorrhage) that may underlie SE. Noncontrast CT is the imaging procedure of choice for
emergency department patients with SE. However, a neuroimaging study should never be allowed to
impede rapid and aggressive treatment of the disorder. Imaging is often deferred if the patient is known
to have epilepsy and the seizure pattern is not unusual for the individual.

Magnetic Resonance Imaging

Brain MRI is rarely indicated in the acute phase of generalized convulsive SE. Although MRI provides
more information than CT, it is more time consuming, and the additional information rarely affects
immediate treatment and evaluation.

In contrast, in a patient with simple partial SE that does not match previous seizures, the search for an
epileptic focus should include brain imaging, preferably with MRI (or CT if MRI is unavailable) to look
for a new lesion (eg, new stroke, mass lesion). Currently, many centers offer advanced MRI, such as
diffusion-weighted, perfusion, and susceptibility-weighted imaging. [56] These newer methods can be
particularly helpful in identifying acute cerebral ischemia.

Nevertheless, MRIs may be problematic in focal SE because the SE itself can cause a wide range of
MRI abnormalities, many of which are transient. Repeat imaging over weeks to months may be helpful
to clarify their interpretation.

Chest Radiography

Chest radiography may be used to assess for aspiration or endotracheal tube positioning.

If clinically indicated, other plain radiographs may be useful to assess fractures or dislocations.

Lumbar Puncture

If CNS infection is in the differential diagnosis, consider a lumbar puncture (after appropriate head
imaging to ensure safety).

Initiate antibiotic therapy if CNS or systemic infection is strongly suspected.

NURSING MANAGEMENT

1. Promote compliance to medication regimen

2. Advise client not to drive or perform other hazardous activities when beginning
anticonvulsant therapy.
3. Inform client that alcohol and other CNS depressants can cause an added depressive
effect
4. Encourage client to obtain a medical alert identification card or medical alert bracelet,
which indicates a health problem and a drug taken.
5. Teach client not to abruptly stop drug therapy to prevent rebound seizure or status
epilepticus.
6. Supportive care in patients with status epilepticus includes the following:

 Maintenance of vital signs

 Airway, breathing, circulation (eg, hemodynamic/cardiac monitoring)
 Respiratory support, with intubation and/or mechanical ventilation if necessary
 Periodic neurologic assessments
MEDICAL MANAGEMENT

Succinimides

• They are used to treat absence or petit mal seizures

• May be used in combination with other anticonvulsants to treat seizures
• Therapeutic range is 40/100 mcg/ml

Ethosuxinimide(Zarontin) is the succinamide of choice.

• Mode of Action: decrease calcium influx through the calcium channels

• Dosage: PO 250 mg bid

Immostilbenes

• Carbamazepine ( Tegretol) is effective in treating refractory seizure disorders that have not
responded top other anticonvulsant therapies.
• It is used for grand mal and partial seizure
• An interaction occurs when taken with grapefruit juice causing possible toxicity
• Therapeutic serum range is 5-12 mcg/ml
• Dosage: PO 200 Mg BID, increasing dosage as needed

Benzodiazepines

Aka : anxiolytics

3 benzodiazepines that have anticonvulsant effects are:

- Clonazepam
- Chlorazepate Dipotassium
- Diazepam

Clonazepam – effective in controlling petit mal seizures,but tolerance may occur 6 months after drug
therapy

Dosage: po 0.5-1 mg tid

Clorazepate Dipotassium – frequently administered in adjunctive therapy for treating partial seizure

Dosage: PO 7.5 mg tid

Valproate

• Valproic Acid (Depakene) has been prescribed for petit mal,grand mal and mixed type of
seizures.
• Hepatoxicity is one of its adverse reactions (given with caution in children and clients with liver
disorder.
• Liver enzymes should be monitored i.g SGPT/SGOT
• Therapeutic serum range is 40-100 mcg/ml
• Dosagez; PO 15mg/kg;max 60 mg/kg/day in divided doses

Diazepam (Valium)

• Primarily prescribed for treating acute status epilepticus (drug of choice) and administered IV to
achieve the desired response
• Has a short term effect thus other anticonvulsant i.e phenytoin are given after administration of
diazepam
• Dosage: IV-5mg;repeat if needed at 10-15 mins intevals;max 30mg
SURGICAL MANAGEMENT

Common surgical procedure for treatment of seizure is cortical exicision i.e lobectomy

When temporal lobe epilepsy, then resection of the antero-medial temporal lobe called mesial temporal
lobectomy

If scar tissue or other focal epileptogenic area exists the identified lesion (lesionectomy) can be removed

A corpus callosotomy has been helpful in patients with tonic clonic seizures

A hemispherectomy is reserved for selected catastrophic infant and early childhood epilepsies

Vagal nerve stimulation

An electrode is surgically placed around the left vagus nerve in the neck. It is connected to a battery
placed beneath the skin in the upper chest. This device is programmed to deliver intermittent electrical
stimulation to the brain to reduce the frequency and intensity of seizures. Exact mechanism is unknown.
JOURNAL READING

New research highlights risk factors for status epilepticus

Posted May 28 2014 in Conditions related to epilepsy

Scientists in the US have conducted a study that offers new insights into predictive factors for young
patients affected by status epilepticus, a particularly serious and long-lasting form of epilepsy that is
more difficult to treat.

Conducted by Boston Children's Hospital, the research not only aimed to identify risk factors of
paediatric convulsive status epilepticus, but also to determine whether defining status epilepticus as
seizures lasting either five minutes or more or in excess of 30 minutes would modify the risk factors
identified.

To determine this, the team conducted a retrospective case-control study including patients between the
ages of one month and 21 years at the time of convulsive status epilepticus. The characteristics of
patients who did and did not experience status epilepticus were then compared using both of the chosen
seizure duration thresholds.

In total, 1,062 patients were enrolled, with the median age at the time of the epileptic episode being 6.4
years.

According to data published in the medical journal Seizure, 444 patients, or 41.8 per cent, had seizures
lasting for at least five minutes, while 14 per cent of the group – 149 patients – experienced seizures
lasting at least half an hour.

Subsequent analysis revealed that risk factors for status epilepticus were not markedly different when
considering a five or 30-minute threshold. Compared to their respective control groups, patients in both
of these categories were shown to be younger at the age of seizure onset and at the age of status
epilepticus.

They were also generally receiving more antiepileptic drugs at baseline, had a higher rate of changes in
therapy regimens in the three months prior to the episode, were more likely to experience developmental
delays and were affected by a higher mortality rate.

Meanwhile, a higher baseline seizure frequency and a more pronounced increase in seizure frequency
prior to the index episode was seen only in the five-minute patient group.
Such findings could improve understanding and future treatment of status epilepticus.

Posted by Anne Brow

Explanation

On a neurochemical level, seizures are sustained by excess excitation and reduced inhibition. Glutamate
is the most common excitatory neurotransmitter and the NMDA (N-methyl-D-aspartate) receptor
subtype is involved. Gamma-aminobutyric acid (GABA) is the most common inhibitory
neurotransmitter. Failure of inhibitory processes is increasingly thought to be the major mechanism
leading to status epilepticus.

Most seizures terminate spontaneously. Which processes are involved in seizure termination and why or
how these processes fail in status epilepticus are active areas of inquiry.