Status epilepticus is a condition in which epileptic seizures are repeated or continuous over a fairly long period of time (about 30 minutes). The patient does not have time to recover from the previous seizure before the next one overtakes him. The patient's consciousness is unclear, breathing is difficult, and signs of a coma are observed.
Causes of status epilepticus
The action of medications taken by a patient with epilepsy is aimed at inhibiting seizures. If the patient independently refuses medications prescribed for treatment, then this action can trigger the occurrence of ES.
Epistatus can also occur, for example, with brain pathologies:
- Malignant neoplasms;
- Withdrawal syndrome;
- Infections, intoxications, hematomas and encephalopathy;
- Peripheral circulation disorders.
Status epilepticus can also occur in patients with diabetes. Diabetes is scary because of its complications, including ES.
Worth a try
There is evidence that lorazepam is more effective than diazepam in epistatus. A parenteral dosage form of valproic acid (Depakine) has appeared, specifically intended for the treatment of epistatus.
Work has been carried out indicating the prospects of using hemosorption in the treatment of severe forms of epistatus.
There are observations that intravenous laser irradiation of blood increases the effectiveness of other measures for epistatus.
There is evidence of the effectiveness of electroconvulsive therapy for intractable forms of epistatus.
Types and stages of status epilepticus
The variability and diversity of types of epileptic seizures is the main basis for the formation and identification of forms of epileptic seizures, characterized by general signs of the clinical picture of the disease. They are divided into two groups: non-convulsive and convulsive. Classifying the types of ES, we can distinguish:
- Generalized non-convulsive seizure. In this case, a short-term loss of consciousness is observed. The patient seems to freeze with interrupted activities (eating, talking, writing...), or thinking about something. In this case, the eyes are focused on one point, the face becomes pale, and the connection with the outside world is interrupted. The absence seizure stops as suddenly as it started.
- Incompletely generalized status epilepticus is characterized by muscle cramps, the patient completely loses consciousness, cardiovascular activity is disrupted, and breathing becomes unstable.
- Tonic SE is typical for children of different ages with rare and severe forms of epilepsy.
- Clonic ES, accompanied by high fever and convulsions in children and infants.
- Myoclonic ES is expressed in episodic twitching of muscle tissue.
Epileptic seizures are characterized by short duration. Usually a seizure lasts several seconds, or several tens of seconds, less often - a minute. After status epilepticus, relief occurs spontaneously, without outside intervention. Therefore, they are called self-limited epileptic seizures. Serial attacks following one after another are often encountered.
In medicine, each stage of epistatus, which is a complication of epileptic syndrome, has its own name:
- The duration of the pre-status stage can last from 1 to 10 minutes;
- The initial stage is characterized by the duration of the attack from 10 to 30 minutes;
- Expanded - from 30 to 60 minutes;
- The stage, which lasts more than an hour, is called refractory.
Epistatus is a state of a person when he does not regain consciousness during alternating epileptic seizures. Before one attack has finished, the next one begins. The second variant of epistatus is no less dangerous, and is a seizure lasting more than 30 minutes.
Features of the condition in children
Very often, epistatus that occurs in children is a sign of the onset of epilepsy, but it happens that convulsive attacks appear already in the later stages of the course of this disease.
In newborns, a seizure occurs with partial loss of consciousness, while the reaction to external stimuli remains intact.
Generalized SE can manifest itself as tonic-clonic, clonic, myoclonic convulsions.
In nonconvulsive SE, electroencephalography is used to detect peak-wave stupor and slow waves, which reflect a state of epileptic stupefaction. Partial ES can be simple, somatomotor, or dysphasic.
In complex partial epistatus, stable preservation of epileptic twilight of consciousness is observed.
With generalized SE, the main property of an epileptic seizure is disrupted - it does not go away on its own.
The number of attacks can reach several tens or even hundreds per day. In this case, respiratory function and hemodynamics are disrupted, metabolic processes in the brain are disrupted, and the coma state can deepen until death occurs.
Symptoms of status epilepticus
Symptoms of epistatus are expressed in circulatory disorders, disturbances of consciousness (the person “switches off”), and disruption of the respiratory system. Symptoms of status epilepticus are a consequence of previous seizures from which the patient does not recover.
Epistatus can be characterized by a frequency of attacks up to 20 per hour. The patient does not regain consciousness at the onset of the subsequent seizure; his condition can be described as numbness bordering on coma.
The comatose state worsens in direct proportion to the duration. Tonic spasms affect the muscles of the back, arms and legs. High blood pressure suddenly drops. Increased reflexivity is also unexpectedly replaced by a complete lack of reaction.
Respiratory and circulatory disorders become obvious. When the seizures disappear, epileptic prostration occurs.
The duration of the epistatus is at least 30 minutes. Usually, as expected, we draw a line between this condition and episodic seizures with partial restoration of physiology and consciousness (full or partial).
There are two phases that characterize epileptic convulsive status with the following features:
- Compensatory changes in the circulatory and metabolic system, expressed in high blood pressure, vomiting and nausea, uncontrolled urination and defecation.
- Coming in about half an hour/hour, it is a maladaptation of compensatory changes, which is expressed in acute renal failure (and liver failure), a sharp decrease in pressure, disruption of the respiratory system, and arrhythmia.
Epistatus, the course of which is not accompanied by convulsions, is characterized by complete immobility of the patient and a feeling of detachment. Usually the patient lies with his mouth open, his blank gaze does not express anything.
Further actions
Relief of status epilepticus is carried out through the following measures:
- ensuring airway patency;
- use of oxygen therapy;
- intravenous injection of Diazepam (maximum daily dose - 40 mg), a side effect of this drug may be respiratory depression.
Further therapy is carried out by administering medications depending on the stage of status epilepticus.
At the initial stage, the following drugs are used to relieve status epilepticus:
- Diazepam;
- Lorazepam;
- Depakine;
- Feniton;
- Oxybutyrate.
Among the side effects of treatment, the following consequences can be identified: arterial hypotension, acute toxic hepatitis, phlebosclerosis, hypokalemia.
At the advanced stage of ES the following is used:
- Diazepam;
- Lorazepam;
- Phenobarbital;
- Sodium thiopental.
At the refractory stage of ES, the following measures are carried out:
- Intubation, correction of electrolyte disturbances, transfer to artificial ventilation of the lungs
- to maintain vital functions of the body. - Barbiturate anesthesia
- intravenous injection of sodium thiopental for 20 seconds. 100-250 mg of the drug is administered. If the patient's condition does not improve, a dose of 50 mg is administered every few minutes until the seizure stops. Barbiturate anesthesia can last from 12 hours to a day. - Dexamethasone and Mannitol injections
are given to prevent cerebral edema. - Infusion dehydration therapy
is carried out to eliminate disorders of liquor dynamics and the metabolic process. For this purpose the following are used: Magenzia, Lasix, Cordiamin, Eufillin, Korglykon.
In the event that the epistatus is symptomatic, that is, it arose against the background of brain damage, a neurosurgical operation should be performed to compress the brain vessels.
Emergency care for status epilepticus
First aid for status epilepticus, before the arrival of doctors, is the need to protect the patient from receiving mechanical injuries. There is no need to crowd around the patient, blocking free access to clean air.
Our recommendations:
- Place the patient on a non-traumatic surface with something soft (jacket, sweater) under his head;
- To avoid choking on saliva, carefully turn your head to the side;
- Remove the tie, belt, unbutton the collar so that nothing interferes with the patient’s ability to breathe freely;
- Remove all sharp and traumatic objects located nearby;
- If your teeth are clenched, there is no need to unclench them;
- If your mouth is open, place any soft cloth between your teeth.
You should not place sharp, metal or other objects between your teeth that could cause injury to an unconscious person.
Emergency care for status epilepticus should be provided very carefully. You should not hold the patient too tightly so as not to damage his bones (in this condition the likelihood of fractures is very high).
Introduction
Doctors of various specialties deal with status epilepticus: neurologists, epileptologists, neurosurgeons, psychiatrists, general anesthesiologists and resuscitators, neuroreanimatologists, psychoreanimatologists, sometimes even obstetricians and infectious disease specialists.
There is no clear attribution of this condition to any medical discipline. Most often, the question of who will treat such a patient is determined by random reasons (for example, distance to the nearest medical facility). In this brief guide, attention is focused on the treatment of those patients who come to the attention of psychoreanimatology. The material is based on twenty years of experience in the intensive care unit (Moscow Regional Center for Psychoreanimatology) at the Moscow Regional Psychiatric Hospital No. 23. According to this unit, patients with status epilepticus make up no more than 3% of the total flow of emergency patients admitted there, but the severity of their condition, requiring intense and dramatic work of staff, are in one of the first places. These recommendations do not constitute exhaustive rules to which there is nothing to add. Each patient can, with his or her individuality, force us to make adjustments to treatment. Each unit of psychoreanimatology has its own differences in traditions, approaches and equipment. Therefore, the material presented here is best used as a story from experienced people about what and in what sequence they usually do when treating epistatus - a story that should in no way hinder the creativity of a practicing doctor.
Complications of status epilepticus
Epistatus is characterized by irreparable consequences. Statistics. With symptomatic ES, mortality is 30–50%. With ES in patients with epilepsy - 5%.
If ES lasts more than an hour, then patients will face serious consequences:
- Diffuse saturation of brain tissue with fluid, called cerebral edema and accompanied by oxygen starvation;
- Critically low blood pressure;
- Excessive levels of lactic acid, called lactic acidosis;
- Violation of water-salt balance;
- For children, characteristic signs are delays in the development and formation of the psyche, which can lead to mental retardation.
Non-convulsive epistatus is considered less dangerous compared to generalized epistatus. Nevertheless, complications of status epilepticus often find expression in disturbances of perception, attitude, thinking, memory, and understanding.
