status epilepticus

Status Epilepticus

STATUS EPILEPTICUS

Status epilepticus is a seizure lasting for more than 30 minutes or one another without restoration of consciousness in between the fits.

Status epilepticus is defined as a generalized convulsion lasting 30 minutes or longer, or
repeated tonic-clonic convulsions occurring over a 30-minute period without recovery of consciousness between each convulsion.

This is considered as a complication of grand mal epilepsy rather than a certain type of epilepsy. It is both a medical and psychiatric emergency. This condition is life threatening and getting treatment started fast is vital.

Diagnosis

  1. Observation of a fit i.e. >  Body temperatures increases
    >   There is increased heart rate.
    >   Brain metabolic demand increases.
  2. History of a fit
  3. Neurological examination to check the reflexes
  4. Electro encephalogram may reveal epileptiform activity
  5. CT scan to reveal brain function
  6. Skull X-ray may indicate evidence of lesions
  7. Additional laboratory tests; >  Do random blood and sugar levels
    >   Blood slide for malaria.
    >   Urinalysis  >  Renal and liver function.
    >   Electrolytes.
    >   Calcium and magnesium. 

Triggers of an epileptic fit

  • Fevers in childhood
  • Sleep; convulsions during sleep may occur soon after the child wakes up from bed
  • Daylong or overnight fast
  • Emotional arousal e.g fear, anger, excitement etc
  • Flickering lights
  • Intoxication with alcohol
  • Alcohol withdrawal
  • Fatigue and boredom
  • High altitude
  • Discontinuation of anti convulsions
  •  Dehydration
  •  Infections
  •  Look for associated injuries.

Treatment and management of a Status Epilepticus.

An epileptic seizure is usually sudden and time to prepare for it is not there. It can occur at any time in any place.

Aims of management

  1. Avoid injury to the patient
  2. To prevent complications

Emergency management (First Aid)

  • Stay calm and speak calmly if you are to give instructions or when reassuring bystanders
  • Remove the person from danger or vice versa if the patient is safe, don’t move them.
  • Note the time the seizure starts and continue checking if it does not stop in 5 minutes, call for an ambulance.
  • Loosen ties, necklaces or any cloth around the neck that may make it hard to breathe
  • Support the head with a soft flat material under like a folded jacket so as to protect it from injury during jerking
  • Clear space to and minimise any form of crowdness such that the patient receives fresh air.
  • As soon as the fit stops, Make the patient lie down in a lateral position so as to ensure he does not choke on his own saliva
  • Check that breathing is returning to normal if their breathing sounds difficult after the seizure has stopped call for an ambulance
  • Check gently to see that nothing is blocking their airway such as false teeth.
  • Stay with the patient until when the patient is fully awake
  • After recovery, reorient the patient and reassure incase he is embarrassed

The following should not be done

  1. Don’t put any hard object like spoon in the mouth this can injure teeth or jaw.
  2. Don’t hold his limbs tightly because that prevents contraction and relaxation of muscles
  3. Don’t give anything to eat or drink until he is fully alert
  4. Do not try to give mouth to mouth breaths, people usually start breath again on their own after a seizure

Emergency Management (In hospital)

  1. Give oxygen to support respiration
  2.  If hypoglycaemia is suspected, give a bolus of 50ml of 50% glucose IV
  3.  Consider giving parenteral thiamine if alcohol abuse is suspected
  4.  Give anticonvulsants such as diazepam IV, lorazepam IV, clonazepam, midazolam
  5.  Give diazepam 5 — 10mg IV start. You may repeat after 10 —20 minutes. Do not exceed 30mg in 8 hours. Refer immediately if no improvement. For children, give 0.05 —0.3 mg per doze over 2
    — 3 minutes. Do not exceed 10 mg. Refer if no improvement.
  6.  Stow intravenous injection of Phenytoin may be given if seizures recur or fail to respond to Diazepam 30 minutes after it began
  7.  Phenytoin by Intravenous infusion should be given at a dose of I 5mg/kg body weight at a rate not greater than 50mg! minute.
  8.  Monitoring of blood pressure and ECG is necessary and phenytoin should be diluted with sodium chloride (normal saline) at a ratio of 1 mg of phenytoin 1 ml of normal saline
  9.  Supportive care and prompt termination of electrical seizure
  10.  Care is individualized
  11.  Supportive care including ABC’s should be provided.
  12. Establish aetiology. This is a common neurological
    problem in the elderly, with an underlying etiology of stroke. Status epilepticus is associated with a high mortality.
  13. Identify and treat medical complications:

Monitoring

  1.  Regular neurological observations and measurements of
    pulse, blood pressure, temperature.
  2.  ECG, blood gases, clotting, blood count, drug levels.
  3.  EEG monitoring is necessary for refractory status. Consider
    the possibility of non-epileptic status.

Prognosis
Aetiology and conscious level predict outcome.
>   If the patient presents for the first time with status
epilepticus, the chance of a structural brain lesion is
greater than 50%.

Education of caretakers and persons with status epilepticus

The following should be taught to the patient and the community at large

  • Status epilepticus is an illness just like any other illness and on treatment a person gets better
  • People with status epilepticus should be encouraged to enjoy as much as possible
  • Isolating, stigmatizing and labelling an epileptic patient is very traumatizing to the patient, family and clan members so they should be avoided
  • Children with status epilepticus are encouraged to attend school
  • Teachers, school children and other school personnel should be educated about the illness so that they are enlightened
  • Adults with status epilepticus can marry and should be encouraged to do so
  • Persons with epilepsy should avoid dangerous activities such as driving, climbing height, operating heavy machines, swimming
  • People have to be taught that Status epilepticus is not contagious so patients should be treated fairly like other people
  • Epileptic seizures can effectively be controlled if drugs are taken as prescribed.

Status epilepticus becomes an emergency only when;

  • The person has never had a seizure before
  • The person has difficulty breathing or walking after the seizure
  • The seizure lasts longer than 5 minutes
  • The person has another seizure soon after the first one
  • The person is hurt during the seizure
  • The seizure happens in water
  • The person has a health condition like diabetes, heart disease or is pregnant

Prevention of Status epilepticus

  • Prevent head injury by wearing seat belts and bicycle helmets.
  • Seek medical help Immediately after suffering a first seizure.
  • Mothers should be encouraged to get good prenatal care to prevent brain damage to a developing fetus
  • Treatment of hypertension
  • Avoid excess alcohol abuse and alcohol intake
  • Treating high fevers in children
  • Treatment of any infections and proper nutrition including adequate vitamin intake

Complications of Status epilepticus

Status epilepticus complications

Specific Nursing Care for a patient with Status Epilepticus

  1. Assessment and Monitoring:

    • Regularly monitor the patient’s vital signs, including heart rate, blood pressure, and oxygen saturation.
    • Continuously observe and document the duration, frequency, and characteristics of seizures.
    • Assess the patient’s level of consciousness and neurological status.
    • Maintain a safe environment by ensuring there are no obstacles that could harm the patient during a seizure.
  2. Administering Medications:

    • Administer antiepileptic drugs (AEDs) as prescribed, which may include intravenous (IV) or intramuscular (IM) medications such as lorazepam or diazepam to stop seizures.
    • Ensure proper dosages and monitor for any adverse reactions.
  3. Airway and Breathing:

    • Position the patient on their side to prevent aspiration if vomiting occurs during or after a seizure.
    • Administer supplemental oxygen if the patient experiences respiratory distress.
  4. IV Access:

    • Establish and maintain IV access to administer medications and fluids.
  5. Monitoring Blood Glucose:

    • Check blood glucose levels to rule out hypoglycemia, which can trigger seizures.
  6. Seizure Documentation:

    • Maintain accurate records of seizure activity, including the start and stop times, characteristics, and any associated symptoms.
  7. Support and Reassurance:

    • Provide emotional support and reassurance to the patient and their family.
    • Explain the ongoing care and treatment plan.
  8. Preventing Injuries:

    • Pad side rails and protect the patient from self-inflicted injuries during seizures.
    • Utilize soft restraints if necessary for safety.
  9. Neurological Assessment:

    • Continuously assess the patient’s neurological status, including pupil size, response to stimuli, and motor function.
  10. Consultation and Referral:

    • Consult with a neurologist or epilepsy specialist for further evaluation and management.
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