STATUS EPILEPTICUS

A. Definition
Status epilepticus is when a seizure lasts longer than 5 minutes or when
seizures occur close together and the person doesn't recover between seizures.
There are different types of status epilepticus: convulsive and non-convulsive.
Convulsive status epilepticus requires emergency treatment by trained medical
personnel in a hospital setting. It can be life-threatening.

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

Nonconvulsive Status Epilepticus

This term is used to describe long or repeated absence or focal impaired
awareness (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.

B. Pathophysiology.
●You may be wondering what exactly happens that prolongs the seizure activity.
the nerve cells in the brain send electrical or excitatory signals to other nerve
cells. There are also cells that send inhibiting messages. Between the two they
balance out the activity within the brain.

●But during status epilepticus, there is a sustained excess of excitatory signals

and reduced inhibitory signals. It is believed that the reduced inhibitory signals
are the main reason for status epilepticus.

●On neurochemical level seizures are sustained by excess excitation and

reduced inhibition.

●Glutamate is the most common excitatory neurotransmitter and NMDA( N-

Methyl-D-Aspartate) Subtype is involved

●Gamma -aminobutyric acid(GABA)is the most common inhibitors

neurotransmitter. Failure of inhibitory processes is increasingly thought to be the
major mechanism leading to status epilepticus

●Neuronal death probably results from the inability to handle large increases in
intracellular calcium brought about by prolonged exposure to excitatory
neurotransmitter
 The process that usually stops a seizure and why it doesn't happen in status
epilepticus is not clearly understood

C. Causes/ Risk Factors

RISK FACTORS:
• Poorly controlled epilepsy
• Low blood sugar
• Stroke
• Kidney failure
• Liver failure
• Encephalitis (swelling or inflammation of the brain)
• HIV
• Alcohol or drug abuse
• Genetic diseases such as Fragile X syndrome and Angelman syndrome
• Head injuries

ETIOLOGY:
• Epileptic patients are the group at highest risk, especially if they fail to
maintain inadequate anti-epileptic drug levels in the blood. They make up 42% of
patients with SE, while on the other hand, up to a fifth of patients with epilepsy
develop SE at least once.
• Prior trauma to the central nervous system (CNS)
• History of stroke
• Alcohol abuse
• Metabolic disease
• Hypoxia of the CNS which is also associated with a mortality rate of 60-
70%
• Tumors of the brain
• Infections of the brain accompanied by fever, especially in children below
2 years who have no prior history of epilepsy
• Cerebrovascular involvement is seen in more than half of all cases and is
especially marked in the elderly.
• Recurrent SE is highest in children with CNS disease of any etiology, but
only 4% of children who develop SE following high fever or because of unknown
causes are likely to develop recurrences.
• Genetic factors may account for a higher concordance for SE among
monozygotic twins. For instance, the composition of the GABA-receptor may
confer a predisposition to CSE in some patients upon exposure to certain risk
factors.
D. CLINICAL MANIFESTATIONS

DURING (TONIC CLONIC PHASE)

• Loss of consciousness

• Short, loud cry

• Urinary and fecal incontinence

• The child may bite his/her tongue, which may cause bleeding

• Jerking and twitching movements

• Froth of saliva at the mouth

• Irregular breathing

AFTER (POST-ICTAL STATE)

• Fatigue

• Confusion

• Disorientation

• Hypotonia

E. Diagnostic Test
General Diagnostic Test for patients with status epilepticus
Stat laboratory to be obtained:
• Glucose and electrolyte levels Complete blood count
• Renal and liver function test
• Toxicologic screening and anticonvulsant drug levels
• Arterial blood gas results
Other test appropriate for clinical setting:
• Electroencephalography
- Is a criterion standard for diagnosing status epilepticus; however,
neurologic consultation is usually required
• Blood cultures
• Urinalysis and/or cerebrospinal fluid analysis
Imaging modalities used to evaluate status epilepticus
• CT scanning and/or MRI of the brain
• Chest radiography
 F. Managements

TYPES OF MANAGEMENT

1. SURGICAL MANAGEMENT
Surgical intervention for status epilepticus is a last resort and rarely
performed. By removing the seizure focus in the brain, epilepsy surgery can, in
most cases, successfully and safely stop seizures. Some people may need a
second surgery to become seizure free. Although many people are permanently
seizure free after surgery, seizures can come back in some people. Operative
procedures depend on the etiology of this condition and may consist of:
a. Ablating a structural abnormality - process of destroying abnormal or
malfunctioning tissues
b. Hemispherectomy, - surgical procedure which involves total, or partial
removal of an affected cerebral hemisphere or disconnecting the affected
cerebral hemisphere from the unaffected side.
c. Subpial resection - a technique of ascertaining the location of a point by
taking bearings from the point on two other points of known location
d. Placement of a vagus nerve stimulator - Vagus nerve stimulation prevents
seizures by sending regular, mild pulses of electrical energy to the brain via
the vagus nerve. It is sometimes referred to as a "pacemaker for the brain." A
stimulator device is implanted under the skin in the chest. A wire from the
device is wound around the vagus nerve in the neck.

2. MEDICAL MANAGEMENT

The treatment of status epilepticus involves the use of potent intravenous

medications that may have serious adverse effects. Therefore, the first step in
managing the condition is to ascertain that the patient has tonic-clonic status
epilepticus, and that prolonged or repetitive seizures have occurred. A single
generalized seizure with complete recovery does not require treatment. Once the
diagnosis of status epilepticus is made, however, treatment should be initiated
immediately. Necessary interventions include maintaining oxygenation and circulation,
assessing the etiology and laboratory evaluations, obtaining intravenous access, and
initiating drug therapy.

DRUG TREATMENT

Rapid treatment of status epilepticus is crucial to prevent neurologic and systemic

pathology. The goal of treatment always should be immediate diagnosis and termination
of seizures. For an anti-seizure drug to be effective in status epilepticus, the drug must
be administered intravenously to provide quick access to the brain without the risk of
serious systemic and neurologic adverse effects. Multiple drugs are available such as:
 BENZODIAZEPINES

The benzodiazepines are some of the most effective drugs in the treatment of acute
seizures and status epilepticus. The benzodiazepines most commonly used to treat
status epilepticus are diazepam (Valium), and lorazepam (Ativan).

DIAZEPAM

Diazepam is one of the drugs of choice for first-line management of status

epilepticus.

Despite its pharmacokinetic and adverse effects it remains an important tool in the
management of status epilepticus because of its rapid and broad-spectrum effect.

PHENYTOIN

Phenytoin (Dilantin) is one of the most effective drugs for treating acute seizures and
status epilepticus. In addition, it is effective in the management of chronic epilepsy,
particularly in patients with partial and secondarily generalized seizures. The main
advantage of phenytoin is the lack of a sedating effect.

PHENOBARBITAL

Phenobarbital typically is used after a benzodiazepine or phenytoin has failed to

control status epilepticus.

3. NURSING MANAGEMENT

General Nursing Interventions for status epilepticus

-Do not leave the patient during and after a seizure

Rationale:

Promote safety measure as the seizure is happening

-Evaluate the need for protective headgear

Rationale:

Headgear may provide extra protection in a patient with recurring or severe seizures

-Do not attempt to restrain. Instead, support head, place on soft area or assist to the
floor if out of bed

Rationale:

Supporting the extremities lessens the risk of physical injury when the patient lacks
voluntary muscle control. Restraining the patient during a seizure may cause erratic
movements and the patient may injure self or others.

-Educate the patient not to smoke except while supervised.

Rationale:

May cause burns if the cigarette is accidentally dropped during a seizure activity.

-Reorient patient following seizure activity

Rationale: Patient may be confused, disoriented, and possibly amnesic after the seizure
and need help to regain control and alleviate anxiety.

-Perform non-invasive airway positioning

Rationale:

Prevent airway obstruction

Nursing interventions done for patient

-Assess patient vital signs

Rationale:

To obtain baseline data

-Explore with the patient the various stimuli that may precipitate seizure activity

Rationale:

Drugs, loss of sleep, flashing light, alcohol, and other stimuli may increase potential
seizure activity

-Turn patient head sideway to suction as indicated

Rationale:

Helps maintain airway clearance

-Discuss seizure warning signs and usual seizure patterns

Rationale:

Protects patient from injury and recognize change that requires notification of physician
for further assessment

G. DRUG STUDY and NURSING CARE PLAN

Date Ordered: 1/27/20

GENERIC NAME: Phenobarbital

BRAND NAME: Solfoton

DOSAGE: 30mg/Tab

ROUTE & FREQUENCY: ORAL OD

ACTION & CLASSIFICATION:

BARBITURATE

It works by increasing the amount of chloride channel are open which in turn depresses
the central nervous system. This is done by acting on GABA a receptor subunate.
INDICATION:

Treatment for genaralized toniccloric and cervical local seizures. And in the emergency
of certain acutecobulasive episodes

Associated with status epilepticus, cholera, eclarpra, meningitis and reaction to local
anesthtics.

CONTRAINDICATION

Hypersensitivity to oter barbiturates, porphyria, dyspnea or obstruction, use in nephritic

pts. Severe Hepatic impairment, Pt’s with history of sedative/hypotonic addiction.

Nursing Action

Monitor CNS status

Seizure Activity

Hepatic/Renal Function

Monitor V/S & BP

DATE ORDERED: 1/27/20

GENERIC NAME: Carbamazepine

BRAND NAME: Tegretol

DOSAGE: 1/2 per tab

ROUTE & FREQUENCY: Oral BID

CLASSIFICATION & ACTION

Anticonvulsants

Decreases sodium ion influx into neuronal membranes, reducing post titanic
potentiation at synapse

INDICATION: Produces anticonvulsant effect

CONTRAINDICATION:

Concomitant use or within 14 days of use of MAOIs, myelosuppresion. Concomitant use

of delaviridne or other NNRT inhibitors, hypersensitivity to tricyclic antidepressants.

NURSING INTERVENTION:

Observe frequently for recurrence of seizure activity.

Monitor for therapeutic levels

Assess for clinical improvement(decrease in intensity, frequency of seizure)

Assess for clinical evidence of early toxicity(fever, sore throat, mouth ulcerations)
H. DISCHARGE HEALTH TEACHING

-Take your medicine every day at the same time. This will help prevent seizures. -Use
an alarm to help you remember to take your medicine. Do not skip any doses or take
less than directed.

-Identify and avoid your seizure triggers. Common triggers include alcohol, drugs,
flashing lights, and moving patterns. Talk to your healthcare provider if you need help to
quit using drugs or drinking alcohol.

-Drink plenty of liquids and eat a variety of healthy foods. Dehydration and poor nutrition
can trigger a seizure. Healthy foods include fruits, vegetables, whole-grain breads, low-
fat dairy products, beans, lean meats, and fish. Ask if you need to be on a special diet.
Also ask how much liquid you need each day and which liquids are best for you.

-Manage stress. A large amount of stress can increase your risk for a seizure. Do
activities that help relax you such as yoga, reading, or meditation. Talk to your
healthcare provider if you think you need therapy or other ways to manage your stress.

-Set a sleep schedule. A lack of sleep is a powerful trigger of seizures in some people.
Try to go to sleep and wake up at the same times every day. Keep your bedroom quiet
and dark. Talk to your healthcare provider if you have trouble sleeping.