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The treatment of epilepsy: treatment of special situations, status epilepticus THE TREATMENT OF EPILEPSY: TREATMENT OF SPECIAL SITUATIONS, STATUS EPILEPTICUS
Occasionally, a single, generalized tonic-clonic (grand mal) or generalized absence (petit mal) seizure may be prolonged (lasting more than 30 minutes) or the seizures may follow each other in rapid succession without full recovery between each one. When this happens, it is called status epilepticus. There are a number of different types of status epilepticus, the most common are:
convulsive status — prolonged tonic-clonic seizure
non-convulsive status — repeated myoclonic seizures
(non-convulsive means that — prolonged absence seizure
there are no jerks or abnormal — prolonged complex partial seizure
movements)
epilepsia partialis continua — continuous twitching of
one arm/leg
(this is rare) or one side of the face, or both.
The EEG is not usually helpful in convulsive status, but may be extremely valuable in
non-convulsive status. In this type of status, the diagnosis of epilepsy may not be immediately obvious. The patients may just appear confused or bewildered, with some inappropriate behaviour. An EEG recorded at this time will confirm the diagnosis.
Convulsive status epilepticus is a medical emergency which requires prompt treatment. When a convulsion is prolonged, or a patient does not recover fully between seizures there is a danger that a lack of an adequate oxygen supply to the brain may cause brain damage. There is also the risk of vomiting with aspiration of the vomit into the lungs. Although rare, patients may die in status epilepticus.
The longer the patient has been in status epilepticus, the harder it is to stop it.
Treatment consists of giving a fast-acting anti-epileptic drug as quickly as possible. This is usually given into a vein, or if this is difficult (which may be the case in young children), into the rectum. The most commonly used drug is diazepam (also called Valium, Diazemuls, or in a rectal tube preparation, Stesolid). Stesolid may be given by parents at home. This is useful as it means that treatment can be given early and before waiting for a doctor to arrive, or for the child to be taken to hospital. Other drugs that are sometimes used include lorazepam (Ativan), chlormethiazole (Heminevrin), and paraldehyde. This drug is usually given via the rectum but may, rarely be administered as an intramuscular injection into the buttocks. Paraldehyde is a very effective anticonvulsant but its main disadvantage is its unpleasant smell.
If the first dose of either diazepam, lorazepam, or paraldehyde does not terminate the status, then a second dose may be given. If this is not successful then the patient must be treated more urgently, and admitted to the intensive care unit. This is because the suppression of the seizure may require such considerable amounts of drugs that normal breathing may also be suppressed. In this situation, patients may require ventilator-assisted respiration, and intensive nursing. The longer-acting drugs which are most commonly used include phenytoin and phenobarbitone. They are usually given by a 'drip' intravenously to ensure that they work quickly. As the seizure comes under control, drugs can be given again by mouth.
Once the patient has recovered and is stable, any factors which may have caused the status epilepticus must be identified to try and prevent a recurrence. In many situations, this will involve a review of the usual oral anti-epileptic medication, and ensuring that patients take their medication regularly.
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Epilepsy
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