What is an epistatus?

Many have heard about the diagnosis of "epilepsy", but not everyone knows what an "epistatus" is.

Epistatus (status epilepticus) is a complication of epileptic syndrome. It is a state where one epileptic fit has not yet ended, and the next one is already coming. Those. the patient does not come to himself, there is a group of seizures one by one, consciousness is not restored. The second variant of this ailment is if one seizure lasts 30 minutes or more. Epistatus can develop as a result of various causes, including being the first manifestation of epilepsy. If it is accompanied by cramps, it poses a threat to the life of the patient and requires immediate medical attention.

Causes of the epistatus

To the development of the epistatus can lead to the use of alcohol or drugs.

The following can lead to the epistatus:

• abrupt withdrawal of anticonvulsants;
• replacement of original drugs with generics. Generics are medicines-copies containing the same active substance as the original, but produced by another firm under other requirements;
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• abuse of medicines that can alter the effects of anticonvulsants (hypnotics, sedatives, etc.);
• use of alcohol and drugs;
• brain tumors;
• a sharp decrease in blood sugar;
• acute disorders of cerebral circulation;
• meningitis or encephalitis;
• craniocerebral trauma (especially with the presence of hematomas);
• cicatrical-adhesive processes in the brain;
• metabolic disorders (eg, hyponatremia, uremia);
• poisoning;
• acute adrenal insufficiency;
• severe infectious diseases with severe intoxication and high fever.

Thus, it becomes clear that the epistatus is not always a consequence of epilepsy. It can also occur with completely different diseases.

From the epistatus it is necessary to distinguish a series of epileptic seizures. Seriality is said when seizures follow one another, but between them the patient's condition improves, consciousness, breathing is restored, and cardiac activity is normalized. A series of epicenters, in the end, can move into an epistatus.

When the epistatus develops, there are disorders of all life support systems of the organism. During convulsions, there is a stopping of breathing (apnea), and oxygen does not flow to organs and tissues, the carbon dioxide content in the blood rises. After convulsions, breathing is compensatory (hyperpnoea) to restore the body's needs. Reducing the oxygen content and increasing the carbon dioxide content, the alternation of phases of apnea and hyperpnoea increase the convulsive readiness of the brain. The excitation threshold after one seizure is already reduced, and additional factors from the outside only contribute to the occurrence of repeated electrical activity. The circle closes. Impulses circulate through the neurons of the cerebral cortex continuously, new and new seizures arise.

In the unconscious state, a decrease or loss of the pharyngeal reflex is possible. Because of this, the contents of the stomach and saliva can enter the respiratory tract, which increases the frustration of breathing. In addition, each epitope is accompanied by an increase in heart rate, an increase in blood pressure. Repeated seizures lead to the disintegration of muscle fibers, their particles enter the blood and are entered into the kidneys, "clogging" the tubules and disrupting the formation of urine. Such an "overload" the body can not tolerate for a long time. If you do not give the patient urgent medical help, then even a lethal outcome is possible.

Clinical picture

Theoretically there are so many clinical forms of the epistatus, how many types of seizures. In practice, the selection of two types is preferable: convulsive and non-convulsive.

Convulsive epistatus- a consequence of incessant generalized epicentries. Especially dangerous is the status of generalized tonic-clonic epicasis. It, unfortunately, occurs most often.

Clinically convulsive status epilepticus manifests itself as follows. After one seizure with convulsions, the patient does not manage to recover, consciousness is not completely restored. More often it is violated by the type of sopor (when voluntary activity is absent, but the protective reaction of the body to light, sound, pain is preserved). And then a new generalized seizure develops. Again complete loss of consciousness, tonic, then clonic convulsions. Tonic convulsions are accompanied by crying, very strong compression of the jaws, biting the tongue. The trunk bends in an arc. Clonic convulsions are alternate contraction of flexor and extensor muscles, because of which hands and feet "twitch", the head beats against the floor, foam is released from the mouth. Repeated cramps can lead to even fractures of the limbs, so strong are muscle contractions. When the cramps stop, the patient does not come to, but falls into a coma. After a while, the cramps are repeated again. The frequency of convulsive seizures may range from 3 to 20 per hour.

The first 30 minutes of the epistatus, the protective capabilities of the neurons of the brain are at the limit of their capabilities, The next 30 minutes of the brain cells can still resist the process of destruction, but with great difficulty. If the status lasts more than 60 minutes, then the brain damage becomes irreversible. Arterial pressure jumps, cardiac arrhythmias, circulatory arrest, respiratory arrest, sudden increase in intracranial pressure, cerebral edema, decay of the muscular tissue with the formation of renal failure, a violation of blood coagulability - all these processes that develop in the process of status, pose a threat to the life of the patient.

There are several conditional division of status periods: early (the first 30 minutes), steady state (30-60 minutes), refractory (after 60-90 minutes). Such a classification by time is needed to determine the volume of treatment activities, the type of medications used.

Anxiety status epilepticusrepresents a lesser threat to life. Disturbance of consciousness varies from sopor to coma, it is possible simply confusion of consciousness. Characteristic disorders of behavior from minor (moderate excitation) to strongly expressed in the form of psychoses, schizophreniform-like conditions. Patients can stay in this state for a long time. Cases are described when there is more than 24 hours of non-convulsive status. In this state, patients from the outside look just a little inhibited, but they seem quite adequate. They perform ordinary activities in the home, use public transport, prepare to eat. Simply, their behavior and actions are different from the usual (for example, the head of the department suddenly goes to wander, picking in the garbage). It turns out that the patients seem to lead a "second life". Very often they are mistaken for mentally unhealthy people. An inconclusive epistatus is very difficult to diagnose. Sometimes a correct diagnosis can be made only after an electroencephalography.

Treatment

Epileptic status requires immediate medical attention. Without medication, mortality from the generalized tonic-clonic epistatus can reach 50%.

Arrangements for the patient's withdrawal from the status begin immediately at the patient's location, continue in the ambulance, and then in the emergency room and emergency room.

At the outset, it is necessary to ensure the patency of the upper respiratory tract: eliminate the tongue lagging, remove dental prosthesis or other foreign objects (if any in the oral cavity), remove saliva, insert airway. Next, you need to achieve intravenous access (catheterization of the peripheral vein is desirable), which is very difficult in the period of numerous seizures. Intramuscular injections of drugs in the case of an epistatus are not effective. After gaining access to the vein immediately introduced Sibazon (Seduxen, Relanium, Diazepam) 10-20 mg in a mixture with 20 ml of 40% glucose. The drug should be administered very slowly, so as not to provoke a reflex stop of breathing and a sharp drop in blood pressure (the rate of administration should not exceed 2-5 mg per minute). If the convulsions stop after a single injection, the patient is taken to the emergency room, where he will be examined by a neurologist. If convulsions are not stopped by a single administration of Sibazone, then the injection is repeated (or using lorazepam 4 mg intravenously). Sibazon has a shorter duration of action than Lorazepam. Lorazepam acts for about 12 hours, does not cause respiratory depression and pressure decrease, so give preference to it.

In the emergency room, emergency interventions do not stop, the provision of emergency care is carried out simultaneously with the examination and diagnostic procedures. Blood is taken for biochemical analysis (sugar, potassium, magnesium, sodium, calcium, hepatic samples, creatinine, residual nitrogen, urea, total protein, etc.), coagulograms, determination of alcohol content. Diagnostic minimum includes a general blood test, general urine analysis, electroencephalography, ECG. Computed tomography (or at least echoencephalography), examination of a neurosurgeon and an ophthalmologist is desirable if possible. The whole complex of additional research methods is aimed at establishing the cause of the epistatus. After all, if the epistatus is symptomatic (that is, caused by another disease, rather than epilepsy itself), then it is required treatment of the underlying disease, and sometimes surgical intervention (for example, with intracerebral hematoma, aneurysm, etc.).

If the previous actions did not stop the seizures, then pass to the intravenous drip of Sibazon(100 mg of the drug are dissolved in 500 ml of 5% glucose solution, injected at a rate of 40 ml per hour), which allows maintaining a constant concentration of the drug in the blood. All these activities are carried out at an early stage of the epistatus.

In the period of steady-state status in the hospital (in the intensive care unit), along with Sibazon, Phenytoin 15 mg / kg at a rate of 50 mg per minute or Phenobarbital 10 mg / kg at a rate of 100 mg per minute. If after an hour the cramps do not stop, then the status goes to the refractory stage.

If there is no effect from Phenobarbital or Phenytoin, the patient needs general anesthesia. To do this, use sodium thiopental: inject 100-250 mg for 20-30 seconds intravenously on saline, then every 2-3 minutes for 50 mg until discontinuation convulsions, and then drip a maintenance dose of 3-5 mg / kg, as long as the electroencephalography shows epileptic activity in the brain. After the last convulsive attack, anesthesia continues for another 12-24 hours. It is also possible to use Propofol (there are data on its greater effectiveness) instead of Tiopental: immediately 2 mg / kg, then 5-10 mg / kg per hour, and after cramping 1 mg / kg per hour.

If the administration of either sodium thiopental or propofol also does not work, then anesthesia using nitrous oxide and oxygen is used.

Along with the use of funds for the elimination of convulsive syndrome, drugs are used to maintain the vital functions of the body: cardiac remedies (Korglikon, Euphyllinum), corticosteroids (Prednisolone, Dexamethasone), drugs for lowering blood pressure (Clophelin, Clonidine), respiratory stimulants (Cordiamin), means for the prevention of cerebral edema (Mannitol, Mannitol, Diacarb, Lasix), drugs for correction of acid-base balance of blood (sodium bicarbonate), drugs for correction of coagulation properties of blood (Heparin, Curantil), inhibitors of proteolytic enzymes (Contrikal, Gordoks), antipyretic, vitamins (especially B6). If necessary, intubation of the trachea and mechanical ventilation (artificial lung ventilation).

When the status epilepticus is stopped, the patient continues to be treated for complications that may have occurred during his lifetime (aspiration pneumonia, venous thrombosis, thrombophlebitis, bone fractures, renal, hepatic insufficiency, etc.), as well as the underlying disease that caused the development of the epistatus.

Epileptic status - this is in most cases life threatening the patient's condition, requiring immediate medical care, and sometimes resuscitation. The faster the help is provided, the less the consequences will be for the patient.