Topic: Status Epilepticus

Name: Mahum Memon

Roll no: 2K19/PHA/64 (Morning)

Class: 3rd Prof (1st Semester)

Subject: Pharmacology

Institute: Faculty of Pharmacy, University of Sindh

Submitted by:2k19/PHA/64 (Mahum Memon)

Submitted to: Professor Muhammad Akram Khatri

 Context

S.No: Topic Page

1. Introduction 1

2. Signs and Symptom 1

3. Etiology 1

4. Pathophysiology 2

5. Electroencephalogram 2-3

6. EEG changes and Interpretations 3-4

7. Diagnostic Tests 4

8. Drugs used to treat Status Epilepticus 5-6

 STATUS EPILEPTICUS 1

INTRODUCTION:
Def: Status Epilepticus is a medical emergency in which there is occurrence of continuous
seizers for more than 5 minutes or back to back seizures without awakening.
Status Epilepticus can be of two types:
1) Generalized convulsive status Epilepticus:
Generalized seizures include absence, atonic, tonic, clonic, tonic-clonic, myoclonic and
febrile seizures.
2) Non convulsive status epilepticus
Previously it was thought that the time period for patients of status epilepticus was more
than 30 minutes but new research have shown that seizure lasting more than 30 minutes
can cause permanent neurological damage so we cannot wait for that much longer period
of time so we should treat it early.
For now according to international league against epilepsy
For gernalized tonic clonic seizures > 5 minutes.
The mortality rate is about 20% to 30%.
Signs and Symptoms of Status Epilepticus:
Involuntary muscle movement
Patient can be seen confused
Patient can hear noise which is not usual
Bladder control is lost
Breathing will be irregular
Patient could not speak properly

Etiology of Status Epilepticus:

Anticonvulsant withdrawl
Metabolic disturbances like hypoglycaemia, hyperglycaemia
Drug toxicity
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CNS infection like encephalitis, meningitis, CNS tumors
Head trauma

Pathophysiology of Status Epilepticus:

Actually it is not known that why seizure starts or stops although it is likely that seizure
initiates when there is imbalance between excitatory and inhibitory neuron. The threshold
for seizure in mature and immature brain is different actually it is lower in immature brain
but the mechanism is still unclear.
Excitatory synapse matured earlier than inhibitory synapse and this cause increase
susceptibility of excitatory neurotransmitter receptor so imbalance between excitatory
synapse and inhibitory synapse increases.

Electroenchephalogram (EEG)
EEG is the graphical recording of electrical activities of brain and encephalography is the
study of electrical activity of brain.
EEG is useful for diagnosis of neurological disorders.
The pattern of EEG is altered in epilepsy which occurs due to excessive discharge of impulses
from cerebral cortex.
Method of Recording EEG
Electroencephalograph: it is the instrument which records EEG.
Electrodes: Scalp electrodes, those are from the instrument and the are placed over the
unopened skull or brain after opening the skull or by piercing into the brain.
These electrodes are of two types i.e unipolar and bipolar, while using bipolar electrodes
both of the terminals are placed in different parts of brain while using unipolar the active
electrode is placed on cortex and indifferent electrode is kept in some part of body that is
away from cortex.
Waves of EEG:
The electrical activity that is recorded by EEG may have synchronized and desynchronized
waves.
The synchronized are regular and invariant waves.
The desynchronized waves are irregular and variant.
In normal person the EEG has 3 frequency bands.
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1) Alpha rhythm
2) Beta rhythm
3) Delta rhythm
In children there is also theta rhythm shown by EEG.

1) Alpha waves are regular and invariant i.e. synchronized.

These waves can be seen when a person is in resting condition with closed eyes and these
waves can be diminished when eyes becomes and they have less frequency than beta
waves.
2) Beta waves are desynchronized waves.
These waves have high frequency and low amplitude and beta rhythm is recorded with
metal activity in awake state.
These are not affected with opening of eyes.
3) Delta waves have high amplitude and low frequency.
These waves during sleep.
These are not affected by closing or opening of eyes.
If they are present when person is awake it means there is a pathological condition. It can
be tumor epilepsy or mental deficiency or depression.
4) Theta waves are generally found in children having low frequency and amplitude.
Changes Status Epilepticus:
Seizure types include generalized tonic-clonic (GTC), absence, and myoclonic.
Accordingly, EEG typically shows generalized spikes or sharp waves, 3-Hz or faster
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spike-wave complexes (SWCs; clinically associated with absence seizures), and
polyspikes (clinically associated with myoclonic seizures).

Interpretations in EEG:

When there is occurrence of seizure there is change in frequency and amplitude of waves
and formation of sharp peaks or spikes which indicate the seizure when the seizure stops
the waves will become normal, when there is a series of spikes they will be called
polyspikes.
Diagnostic Test for status epilepticus:
1) EEG:
EEG is necessary for diagnosis of status epilepticus because it is helpful to
differentiate between different types of seizures.
2) Brain imaging:
A brain Computed Tomography (CT) or Magnetic Resonance Imaging (MRI) scanning
is necessary for determination of the cause of seizures and or to identify the
conditions like stroke brain tumor or brain inflammation.
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3) Lumbar puncture:
If there is possibility of infection, lumber puncture is used.
It is a procedure in which fluid is drawn that surrounds the brain and spinal cord for
testing.

Treatment for Status Epilepticus

First line medication for Status epilepticus:
Benzodiazepines:
Mechanism of Action: Benzodiazepines enhance the inhibition of Gamma amino butyric acid
by binding benzodiazepine – GABA and barbeturine – receptor complex.

IV Benzodiazepines:
Firstly IV medications are given to patients
IV Diazepam 0.15 to 0.2mg/kg (max 10mg/dose) IV may repeat once in 5 minutes if needed.
IV Lorazepam 0.05 to 0.1mg/kg administered slowly over 2 to 5 minutes. If needed repeat
the dose in 10 to 15 minutes.
(Lorazepam is preferred over diazepam due to longer duration of action)
There are also some other benzodiazepines which can be used.
If IV line is not secure due to seizure patient can be given intramuscular benzodiazepines
Second line medication for status epilepticus:
IV valproic acid 10-15mg/kg/day IV divided q12
Mechanism of action: It shows its pharmacological activity by acting on GABA level in the
CNS, it can block voltage gated ion channel and by inhibiting histone deacetylase.
Phenytoin IV Infusion 10 to 15mg/kg at a rate not exceeding 50mg per minute.
Mechanism of action: phenytoin reduces the inward movement of sodium by binding
voltage gated ion channel.
(in normal saline)
IV/IM fosphenytoin 15-20mg (advantageous over phenytoin)
IV levetiracetam 20-30mg/kg
Mechanism of action: the mechanism of action of levetiracetam is novel which is
modulation of synaptic neurotransmitter release through binding to the protein SV2A in the
brain
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If Person still have seizures then phenobarbital is given.
Phenobarbital 20mg/kg given over 20 minutes.
Mechanism of action: They enhance the inhibitory action of gamma amino butyric acid
GABA.
If patient still suffering from status epilepticus it means patient might have late rerefrectory
status epilepticus
So the General Anesthesia will be given to stop seizures.