Status Epilepticus - Types, Causes, Complications, and Emergency Management

What Is Status Epilepticus?

A seizure attack is caused by a sudden abnormal electrical activity among brain cells. This results in temporary alterations in an individual's state of mind, muscular activity, and senses. When one suffers more than one seizure attack on different occasions, it is termed epilepsy. Seizure attacks may be mild and momentary; or intense, accompanied by violent jerks and loss of consciousness. However, if a seizure lasts for more than five minutes or if one suffers a cluster of seizure attacks in a short period without recovering in between the attacks, the condition is known as status epilepticus. It is a life-threatening situation that requires urgent medical care.

What Are the Causes of Status Epilepticus?

The most important cause of status epilepticus is an existing history of epilepsy. Those with a longstanding history of untreated epilepsy seem to have a tendency to develop status epilepticus. Stopping an antiseizure drug suddenly or missing the regular doses may very well trigger an attack. Other causes of status epilepticus are:

• Trauma from a head injury.

• Heavy alcohol abuse.

• Withdrawal from alcohol without medical assistance.

• Substance abuse; cocaine and other illegal drugs.

• Human immunodeficiency syndrome (HIV).

• Low blood sugar levels.

• Imbalance of chemicals in the blood.

• Kidney failure or liver failure.

• Stroke.

• Brain tumor.

• Infection or inflammation inside the brain.

• Neurologic disorders such as Angelman syndrome or Fragile X syndrome.

What Are the Two Types of Status Epilepticus?

Status epilepticus affects a person in two different ways. They are:

1. Convulsive Status Epilepticus (Grand Mal Seizure) - This is the most commonly seen type among the two. It is characterized by tonic-clonic (alternating stiffness and jerking) seizures lasting more than five minutes. Additionally, before recovering from the first attack, another one sets out. They keep coming for thirty minutes or more. In a grand mal seizure, one may experience:

   1. Violent jerking of arms and legs.

   2. Stiffening of muscles and body going rigid.

   3. Clenching the teeth.

   4. Irregular breathing.

   5. Eyes roll back into the head.

   6. Drooling of frothy saliva.

   7. Tend to bite the tongue due to the jerky head movements.

   8. Produces grunting noises.

   9. Lose bowel control and bladder control.

   10. Fall unconscious.

2. Non-convulsive Status Epilepticus - This one is hard to identify because there are no jerky movements or convulsions, but the individual goes into an altered mental status. A non-convulsive status epilepticus may be particularly at risk of developing a convulsive type of status epilepticus later. Though there is no loss of consciousness:

   1. The person lacks time-place-person awareness and stays confused for a long time.

   2. The individual may not respond to others around them and appears to be ‘daydreaming.’

   3. One might mistake the condition for a psychiatric illness or the influence of drugs.

What Are the Complications From Status Epilepticus?

Ordinary seizures may not last more than two minutes. When it keeps going for more than five minutes, it is not likely to stop without administering medicines. Status epilepticus poses a risk of causing permanent brain damage in individuals. This may be from repeated electrical discharges and the resulting stress on the brain. The person may fall into a stage of coma or even death; rarely does a status epilepticus cause breathing troubles and abnormal heart rhythm, and one might encounter a condition called sudden unexpected death in epilepsy (SUDEP). Apart from that, one may suffer complications from aspirating saliva into the lungs resulting in serious lung problems. Hence, if the seizure does not end in five minutes or another seizure starts right after one attack is over, one must be rushed to the hospital without further delay.

What Is the Immediate Course of Action for Status Epilepticus?

Stopping the ongoing seizure before it causes long-term brain damage is the first line of action. The treatment should start before reaching the emergency room. Expert management involves:

1. Intubating the affected individual and providing adequate oxygen by mechanical ventilation.

2. Assess the airway, breathing, blood pressure, and blood flow and do the needful to stabilize the patient’s heartbeat and respiration.

3. Establish intravenous fluid support through the blood vessels to maintain the biochemical balance of the body.

4. Drugs are given into the vein to control the ongoing seizure attack. They include antiseizure drugs such as; Diazepam, Lorazepam, Midazolam, Phenobarbital, Valproate, or Phenytoin.

5. The individual may be put in a drug-induced coma to stop the seizures.

6. This is followed by tests to find the underlying cause of status epilepticus.

How Is Status Epilepticus Diagnosed?

The doctor will ask for a medical history, including current medications and details on alcohol or substance abuse, if any. And ask about the details of the epileptic attack, its duration, and symptoms. A non-convulsive type of status epilepticus can be very hard to identify as the individual does not lose consciousness throughout the attack. The underlying cause of status epilepticus is diagnosed with the following tests:

• Blood tests to observe the glucose levels, electrolytes, calcium, magnesium, blood gas levels, kidney and liver function tests, and other basic blood parameters.

• In known epileptic individuals, the levels of antiepileptic drugs present in one’s blood are checked.

• Blood cultures and urine tests to look for possible infections and inflammation affecting brain function.

• An electroencephalography (EEG) study is conducted to evaluate the pattern of electrical activity for each part of the brain. Abnormal activity is indicative of functional impairment in the respective area. The doctor may order continuous EEG monitoring to check whether the seizure activity is responding to the dose of the drug administered.

• Imaging studies such as computed tomography (CT) scans or magnetic resonance imaging (MRI) of the brain to identify structural abnormalities and possible damage inside the brain.

Conclusion:

Status epilepticus is a very rare type of seizure. It is more common in small children and the elderly. This may be regarded as the worst form of an epileptic attack of all seizures. Since unmanaged epilepsy disorders tend to develop into status epilepticus, one must keep their seizures well under control with proper medication and follow-up. Otherwise, chances are it may develop into a longstanding epileptic disorder that recurs from time to time. It is also recommended to avoid alcohol and drug abuse to prevent episodes of status epilepticus. Sharing awareness about the condition helps one’s family and loved ones do the needful at the time of the attack.