Status epilepticus is an under-reco...

Status epilepticus is an under-recognized health point to be solved [i]or[/i] settled associated with substantial morbidity and mortality. An estimated 152000 cases come to one's mind per year in the United States, resulting in 42000 deaths and an inpatient take away from of $3.8 to $7 billion by year. (1-3) This review concentrates forward the clinical management of status epilepticus (particularly convulsive status epilepticus), the theoretic and clinical considerations involved in choosing an antiepileptic medicine to treat this emergency situation, and the consensus protocol devised by the agency of the Epilepsy Foundation of America (EFA) Working collection on Status Epilepticus.

Definition, Classification, and Epidemiology

DEFINITION

A decade ago, the EFA conven a working dispose to define status epilepticus. (4) They described this condition as pair or more sequential seizures without sated recovery of consciousness between seizures, or more than 30 minutes of continuous seizure activity. (4) This definition is generally accepted, although a certain number of investigators consider shorter durations of seizure activity to constitute status epilepticus. Practically speaking, any someone who exhibits persistent seizure activity or who does not regain consciousness for five minutes or more after a witnessed seizure should be considered to have status epilepticus.

CLASSIFICATION SCHEME

Although there is no consensus from one side of to the other a classification system for status epilepticus, classification is necessary for appropriate management of the condition because effective management hangs on the type of status epilepticus. In general, the various classifications characterize status epilepticus according to where the seizures arise--from a localized region of the cortex (partial onset) or from one as well as the other hemispheres of the brain (generalized onset) The other major categorization hinges onward the clinical observation of open convulsions; thus, status epilepticus may be convulsive or nonconvulsive in nature.

Various approaches to classifying status epilepticus have been proposeed (5-7) One version (5) classified status epilepticus into generalized (tonic-clonic, myoclonic, absence, atonic, akinetic) and partial (simple or complex) status epilepticus. Another version (6) divides the condition into generalized status epilepticus (overt or subtle) and nonconvulsive status epilepticus (simple partial, tangled partial, absence). The third version (7) takes a different approach, classifying status epilepticus according to life stage (confined to the neonatal period, infancy and childhood, childhood and adulthood, adulthood only)

EPIDEMIOLOGY

Status epilepticus of partial attack accounts for the majority of episodes. (1-48-12) common epidemiologic study (1) on status epilepticus establish that 69 percent of episodes in adults and 64 percent of episodes in children were partial attack followed by secondarily generalized status epilepticus in 43 percent of adults and 36 percent of children. The incidence of status epilepticus was bimodally distributed, occurring principally frequently during the first year of life and after the age of 60 years. (12) Among adults, patients older than 60 had the highest risk of developing status epilepticus, with an incidence of 86 for 100,000 persons per year. (1-3) Among children 15 years or younger, infants younger than 12 month had the highest incidence and commonness of status epilepticus. (1) A variety of etiologies accounted for the condition. In adults, the major causes were cheap levels of antiepileptic drugs (34 percent) and cerebrovascular disease (22 percent) including acute or abstracted stroke and hemorrhage. (1-3)

The rate of mortality from status epilepticus (defined as death within 30 days of status epilepticus) was 22 percent in the Richmond inquiry (1,13) The mortality rate among children was solitary 3 percent, whereas the rate among adults was 26 percent (11314) The somewhat old population had the highest rate of mortality at 38 percent (11314) The primary determinants of mortality in parts with status epilepticus were duration of seizures, age at attack and etiology. (13,14) Patients with anoxia and visitation had a very high mortality rate that was independent of other variables. (13-15) Patients with status epilepticus occurring in the setting of alcohol withdrawal or depressed levels of antiepileptic drugs had a relatively depressed mortality rate. In nonfatal cases, status epilepticus is associated with significant morbidity. Cognitive decline following an episode, as documented at neuropsychometric testing, is a well-established period result of prolonged secondarily generalized and partial status epilepticus. (16)

Systemic Pathophysiology

Generalized convulsive status epilepticus is associated with serious systemic physiologic changes resulting from the metabolic demands of repetitive seizures. Many of these systemic changes eventuate from the profound autonomic changes that happen during status epilepticus, including tachycardia, arrhythmias, hypertension, pupillary dilation, and hyperthermia because of the massive catecholamine discharge associated with continuous generalized seizures. Systemic changes requiring medical intervention include hypoxia, hypercapnia, hypoglycemia, metabolic acidosis, and other electrolyte disturbances. Table 17 (17-19) summarizes the physiologic changes that befall during status epilepticus.