A case report on status epilepticus

Vijaya Bharathi1, Sheetal. J2

1Neuro ICU Staff Nurse Kauvery Hospital, Tirunelveli, Tamil Nadu

2Nursing Supervisor, Kauvery Hospital, Tirunelveli, Tamil Nadu

Abstract

Status epilepticus is a neurological emergency requiring immediate evaluation and management to prevent significant mortality and morbidity. Previously, status epilepticus was defined as a seizure with a duration equal to or greater than 30 min or a series of seizures in which the patient does not regain normal mental status between seizures. The Neuro critical care Society guidelines from 2012 revised the definition to a seizure as 5 minutes or more of continuous clinical and/or electrographic seizure activity or recurrent seizure activity without recovery between seizures. This article reviews the evaluation and management of status epilepticus and highlights the role of the inter professional team in the care of affected patients.

Objectives

  • Describe a typical presentation of status epilepticus.
  • Identify the treatment and management options available for status epilepticus.
  • Explain nursing team strategies for improving coordination and communication to advance the treatment of status epilepticus and improve patient outcomes.

Introduction

Status epilepticus (SE) is a medical emergency defined as continuous seizures lasting more than 5 minutes or a series of seizures without full recovery between them. Its characterized by prolonged and potentially debilitating seizure activity, with significant risks of brain injury and mortality. Status epilepticus may be convulsive, non-convulsive, focal motor, myoclonic, and any can become refractory. Convulsive status epilepticus consists of generalized tonic-clonic movements and mental status impairment. Non-convulsive status epilepticus is defined as seizure activity identified on an electroencephalogram (EEG) with no accompanying tonic-clonic movements. Focal motor status epilepticus involves the refractory motor activity of a limb or a group of muscles on one side of the body with or without loss of consciousness is myoclonic status epilepticus. Refractory status epilepticus refers to continuing seizures (convulsive or non-convulsive) despite appropriate antiepileptic drugs. Status epileptics is the most common pediatric neurological emergency. Management focuses on early and aggressive treatment to stop seizures, stabilize the patient, and address the underlying cause.

Background

In ED-based series, when status was mentioned, it represented 6% to 7% of seizures. In 1995, DeLorenzo and colleagues72 estimated 195,000 status events in 152,000 patients per year in the United States, with 42,000 deaths. The highest rate was in infants, followed by the elderly. Fewer than half of the cases were managed by neurologists, and the majority (58%) occurred in patients with no prior history of epilepsy. Overall mortality was 22%, with an age-related increase from 3% in children to 38% in the elderly. Whites were affected less frequently (23 per 100,000) than nonwhites (71 per 100,000), but mortality in whites was 31% versus 17% in nonwhites. In adults, risk factors were: low antiepileptic drug levels (34%), remote insults (24%), stroke (22%), metabolic derangement (15%), ethanol (13%), hypoxia (13%), infection, tumor, anoxia, central nervous system infection, trauma, and idiopathic. In children, risk factors were: infection (52%), remote insult (39%), low antiepileptic drug levels (21%), stroke, metabolic, hypoxia, idiopathic, trauma, and ethanol.

Nonconvulsive status is electrical status without predominant motor activity. Whether it is very harmful, is a subject of debate. It accounts for about a quarter of status episodes, and has been observed to persist in 48% of cases after control of convulsive status. Nonconvulsive status has been found in 8% of comatose patients, leading some neurologists to recommend screening for occult status epilepticus among patients in coma of unclear etiology.

Case Presentation

A 13 years’ male was admitted with the complaints of fever, seizures and altered sensorium for 3 days. Initially he was evaluated at an outside hospital and treated with anti-epilepticus, antibiotics and sedation drugs. His CT Brain with MRI screening was normal.

On Examination

  • GCS – 7/15
  • Temp – 101.2° F
  • PR – 110/bts/min
  • RR – 20brs /min
  • Spo2 – 100% with 5 liters of O2 (on guedel airway)
  • Ryles Tube, CBD and CVC (Right subclavian) in situ

Family Background

Patient is the second child of their family. Patient’s elder brother was born as MR child and expired at the age of 13 due to febrile seizures.

Investigations

 

 

Provisionally, diagnosed to have 5 febrile induced refractory status epilepsy/encephalitis syndrome. For which, pulse steroid therapy started.

Treatment

  • Initially patient drowsy, not obeying, pupils were 3mm equally reacting to light, rigidity present. GCS-6/15.
  • Patient was intubated and initiated mechanical ventilation on pressure control mode.
  • Midazolam infusion was started, continued with antiepileptic, antibiotics, antiviral and anti-fungal therapy. However, he had continuous fever and seizures.
  • His EEG report shows slow background intermittent attenuation with occasional triphasic waves.
  • On day 3 patient need more Fio2 support, chest x-ray revealed left minimal pneumothorax, and need for closer observation.
  • On day 4 patient had seizure episodes in-between, hence ketamine was added to midazolam infusion.
  • As clinical symptoms stopped for 24 hr, ketamine was gradually stopped followed by midazolam.
  • Intermittently had focal seizures and continuous high-grade fever spikes. Need continuous antipyretics, antibiotics and tepid sponging. For focal seizure started Tablet phenobarbitone and stopped sedation.
  • Symptoms settled down intermittently. Steroid dose tapered and rituximab started.
  • On day 10 patient was extubated, eye contact-maintained, GCS improved.
  • He needed physiotherapy, oral intake improved hence Ryle’s tube removed.
  • On day 21 patient was discharged. On discharge patient was alert, awake, taking oral feeds, self-voiding and had good communication.

Pictorial Representation of Occurrence of Seizure

Medications

Nursing Challenges

  • During seizure need to prevent tongue bite and bleeding
  • Due to steroid patient was immune compromised so we have to prevent hospital acquired infections.
  • After extubation patient had reduced swallowing reflex so needed close monitoring to prevent aspiration and proper positioning, Suctioning and mouth care done.
  • For pyrexia patient needed continuous tepid sponging & analgesics.
  • Drug administration
  • Ryle’s tube feeding
  • Required monitoring and management for non-convulsive status epilepticus

Discharge Medications

Family Education

  • Educate the family members on recognizing symptoms of seizure
  • Educate about triggers e.g., Fever, Dehydration, behavioral activity
  • Educate to continue medication regularly.
  • Advice to follow-up and review neurologists regularly.

References

Nightingale Journals

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