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.
- Observation of a fit i.e. > Body temperatures increases
> There is increased heart rate.
> Brain metabolic demand increases.
- History of a fit
- Neurological examination to check the reflexes
- Electro encephalogram may reveal epileptiform activity
- CT scan to reveal brain function
- Skull X-ray may indicate evidence of lesions
- Additional laboratory tests; > Do random blood and sugar levels
> Blood slide for malaria.
> Urinalysis > Renal and liver function.
> 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
- 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
- Avoid injury to the patient
- 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
- Don’t put any hard object like spoon in the mouth this can injure teeth or jaw.
- Don’t hold his limbs tightly because that prevents contraction and relaxation of muscles
- Don’t give anything to eat or drink until he is fully alert
- Do not try to give mouth to mouth breaths, people usually start breath again on their own after a seizure
Emergency Management (In hospital)
- Give oxygen to support respiration
- If hypoglycaemia is suspected, give a bolus of 50ml of 50% glucose IV
- Consider giving parenteral thiamine if alcohol abuse is suspected
- Give anticonvulsants such as diazepam IV, lorazepam IV, clonazepam, midazolam
- 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.
- Stow intravenous injection of Phenytoin may be given if seizures recur or fail to respond to Diazepam 30 minutes after it began
- Phenytoin by Intravenous infusion should be given at a dose of I 5mg/kg body weight at a rate not greater than 50mg! minute.
- 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
- Supportive care and prompt termination of electrical seizure
- Care is individualized
- Supportive care including ABC’s should be provided.
- 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.
- Identify and treat medical complications:
- Regular neurological observations and measurements of
pulse, blood pressure, temperature.
- ECG, blood gases, clotting, blood count, drug levels.
- EEG monitoring is necessary for refractory status. Consider
the possibility of non-epileptic status.
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
Specific Nursing Care for a patient with Status Epilepticus
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.
- 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.
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.
- Establish and maintain IV access to administer medications and fluids.
Monitoring Blood Glucose:
- Check blood glucose levels to rule out hypoglycemia, which can trigger seizures.
- Maintain accurate records of seizure activity, including the start and stop times, characteristics, and any associated symptoms.
Support and Reassurance:
- Provide emotional support and reassurance to the patient and their family.
- Explain the ongoing care and treatment plan.
- Pad side rails and protect the patient from self-inflicted injuries during seizures.
- Utilize soft restraints if necessary for safety.
- Continuously assess the patient’s neurological status, including pupil size, response to stimuli, and motor function.
Consultation and Referral:
- Consult with a neurologist or epilepsy specialist for further evaluation and management.