status epilepticus
Introduction
Introduction to status epilepticus The status of epileptic seizures (statusepilepticus) or epilepsy state is that the consciousness is not fully recovered between the epileptic seizures and frequently recurred, or the seizure persists for more than 30 minutes without stopping. Long-term (>30min) seizures, if not treated in time, may cause irreversible brain damage due to hyperthermia, circulatory failure or neurotoxic excitotoxicity, and the disability rate and mortality rate are high, so epilepsy is a common emergency in internal medicine. Epilepsy can occur in any type of epilepsy, usually referred to as a generalized tonic-clonic attack. Epilepsy occurs mostly in patients with epilepsy. The most common cause is inappropriately discontinued AEDs, or acute encephalopathy, stroke, encephalitis, trauma, tumor and drug poisoning. Non-standard AEDs treatment, infection, mental factors, excessive Fatigue, maternity and alcohol consumption can also be induced. The cause of individual patients is unknown. Continuous epileptic seizures or epileptic seizures are consecutive seizures, but consciousness is clear between the two episodes. basic knowledge The proportion of the disease: the incidence of this disease in patients with epilepsy is about 3%-8% Susceptible people: no specific people Mode of infection: non-infectious Complications: arrhythmia cerebral palsy
Cause
Epilepsy status
(1) Causes of the disease
Drug factor (25%)
More common in newly-occurring patients began to standardize drug treatment after sudden withdrawal, reduction, not timely or not prescribed medication, multiple times missed medication, stop the drug, use "prescription" and arbitrarily change the dose or type of drug, resulting in The effective blood concentration was not achieved, and 21% of children with epilepsy and 34% of adults had epilepsy.
Brain organic lesions (25%)
Brain trauma, brain tumor, cerebral hemorrhage, cerebral infarction, encephalitis, metabolic encephalopathy, degenerative disease, perinatal injury and drug poisoning patients without epileptic history with epilepsy as the first symptom accounted for 50% to 60%, with epilepsy history The status of epilepsy accounts for 30% to 40%.
Acute metabolic disease (15%)
Patients with acute metabolic disease without epileptic seizures accounted for 12% to 41% of the initial symptoms of epileptic seizures, and those with a history of epilepsy accounted for 5% of recurrent symptoms.
Genetic factors (5%)
Idiopathic epilepsy is mostly related to genetic factors.
Other factors (10%)
In patients with epilepsy, fever, systemic infection, surgery, high mental stress and excessive fatigue can induce a sustained state even if the effective blood concentration is maintained. In addition, alcohol, alcohol withdrawal, pregnancy and childbirth, sedatives, isoniazid, tricyclic or tetracyclic antidepressants can also be induced.
(two) pathogenesis
At present, it is believed that the occurrence of status epilepticus is related to the excitability of the epileptic foci and the peripheral dysregulation in the brain. The area around the epileptogenic area can inhibit the epileptic seizure, and it will stop after a certain period of time. When the surrounding area is weakened, the epileptic activity is in the cortex. Long-term operation in the synaptic ring can lead to partial persistent seizures; epileptic activity is projected from the cortex through the descending fibers to the thalamic and midbrain reticular formation, which can cause loss of consciousness, which is transmitted to the entire cerebral cortex by the diffuse thalamic system. Comprehensive tonic-clonic seizure (GTCS).
Prevention
Prevention of status epilepticus
prevention:
Prevention of epilepsy is very important. Prevention of epilepsy is not only related to the medical field, but also to the whole society. Prevention of epilepsy should focus on three levels: one is to focus on the cause, to prevent the occurrence of epilepsy; the second is to control the seizure; the third is to reduce the adverse effects of epilepsy on the physical, psychological and social aspects of patients.
1. Prevention of epilepsy: Genetic factors make certain children convulsive and produce seizures under the trigger of various environmental factors. In this regard, special emphasis should be placed on the importance of genetic counseling. Family surveys should be conducted in detail to understand whether there are seizures and seizures in the parents, siblings and close relatives of the patients, and some serious hereditary diseases that can cause mental retardation and epilepsy. Prenatal diagnosis or screening during neonatal screening should be performed to determine termination of pregnancy or early treatment.
For secondary epilepsy, it should be prevented from its specific specific cause, prenatal care for maternal health, reduction of infection, nutritional deficiencies and various systemic diseases, so that the fetus is less affected. Prevention of childbirth accidents, neonatal birth injury is one of the important reasons for the onset of epilepsy, avoiding birth injury is important to prevent epilepsy. If the pregnant woman can be regularly checked, the new method is delivered, and the dystocia is dealt with in time, the birth injury can be avoided or reduced. Pay attention to the febrile seizures in infants and young children, try to avoid seizures, and immediately control the medication. Active prevention, timely treatment and reduction of sequelae in children with central nervous system diseases.
2. Control episodes: mainly to avoid the predisposing factors of epilepsy and comprehensive treatment to control the onset of epilepsy. Statistics show that after the first seizure, the recurrence rate is 27% to 82%. It seems that most patients will relapse after a single episode. Therefore, it is particularly important to prevent the recurrence of epileptic symptoms.
3. Reducing the sequelae of epilepsy : Epilepsy is a chronic disease that can be prolonged for years, even decades, and can have serious adverse effects on the patient's physical, mental, marital, and socioeconomic status. In particular, deep-rooted social prejudice and public discriminatory attitudes, patients' misfortunes and frustrations in family relations, school education and employment, and restrictions on cultural and sports activities can not only cause stigma and pessimism, but also seriously affect patients' physical and mental health. A family, a teacher, a doctor, a nurse, and even the society itself that develops and plagues patients. Therefore, many scholars have emphasized that the prevention of sequelae of epilepsy is as important as the prevention of the disease itself. The sequela of epilepsy is both the patient's body and the whole society. This requires the community to understand and support people with epilepsy. Minimize the social sequelae of epilepsy.
Complication
Epilepsy persistent complication Complications arrhythmia cerebral palsy
Epilepsy status is a clinical emergency. Failure to treat it in time can lead to serious irreversible brain damage or even death. It should be treated immediately. The longer the epileptic state, the more severe the brain damage. The seizure lasts for more than 10 hours and often causes severe brain damage, which lasts for a short time. The persistent state of frequent episodes can lead to the following complications:
1. Seizures of muscles can cause lactic acidosis, blood pH value and other metabolic disorders, the patient's respiratory arrest leads to severe hypoxia, a large amount of oxygen consumption during vigorous exercise of the whole body muscle, causing brain, heart and vital organs of the body Sexual damage, cerebral hypoxia can cause brain edema and even cerebral palsy.
2. Pulmonary vascular pressure is significantly increased, severe pulmonary edema can cause sudden death, blood catecholamine levels can be increased, which can be secondary to arrhythmia. It is also an important cause of death. In vivo lactic acid accumulation can cause myosinuria, and serum muscle enzymes can be significantly increased to cause lower kidney. Unit kidney disease.
Symptom
Symptoms of status epilepticus Common symptoms Chronic neonatal epilepsy persistent state responsive hypoglycemia proteinuria metabolic acidosis frontal lobe epilepsy... Stagnant hypokalemia frontal lobe epilepsy island episode
The status of epileptic seizures is mainly divided into two types: generalized seizure state and partial seizure state. Among them, the overall tonic-clonic seizure state and the simple partial seizure state are the most common.
1. Comprehensive seizure persistence
(1) Comprehensive tonic-clonic seizures: It is a common clinically dangerous epileptic state, and the tonic-clonic seizures occur repeatedly, disturbance of consciousness (coma) with hyperthermia, metabolic acidosis, hypoglycemia, shock, electrolyte imbalance (hypokalemia and hypocalcemia, etc.) and myoglobinuria, etc., can cause brain, heart, liver, lung and other multiple organ failure, autonomic nerve and vital signs change, encephalitis, stroke can occur secondary Sexual GTCS persists, with partial seizures first, and then generalized to GTCS.
(2) persistent state of tonic seizures: more common in children with Lennox-Gastaut syndrome, showing varying degrees of disturbance of consciousness (less coma), with tonic seizures or atypical discomfort, loss of tension, etc., EEG appears to be more persistent Slow spine - slow wave or sharp - slow wave discharge.
(3) The state of clonic seizures: the performance of clonic seizures lasts longer, with confusion or even coma.
(4) Sustained state of myoclonic seizures: Myoclonus is mostly focal or multifocal, showing rhythmic recurrent myoclonic attacks, muscles are beating-like twitching, continuous hours or days, multiple unconscious disorders, special hair Patients with episodes of myoclonic seizures (benign) rarely have epilepsy, advanced endemic encephalopathy such as subacute sclerosing panencephalitis, familial progressive myoclonic epilepsy, etc.; EEG shows generalized discharge, 1 Simple myoclonus status: seen in children with seizures and tonic-clonic seizures, EEG can distinguish between myoclonic state and myoclonic state; 2 symptomatic myoclonic state: more common, often combined with degenerative Encephalopathy such as Ramsay-Hunt myoclonic cerebellar coordination disorder, progressive myoclonic epilepsy such as Lafora disease, hepatic encephalopathy, renal encephalopathy, pulmonary encephalopathy and toxic encephalopathy, and hypnotic poisoning.
(5) Sustained seizure persistence state: the level of expression consciousness is reduced, even only showing reactivity, learning performance is decreased, EEG persistent spine-slow wave discharge, frequency is slow (<3Hz), mostly induced by improper treatment or withdrawal, etc. Clinical attention should be paid to identification.
2. Partial seizure continuance
(1) Simple partial seizures (Kojevnikov epilepsy): A part of the body such as face or mouth twitching, individual fingers or unilateral limbs continue to twitch for hours or days, unconscious disorder, can be left after the seizure The onset of Todd palsy can also be extended to a secondary generalized episode. The evolution of the disease depends on the nature of the lesion. Some cryptogenic patients may not be cured after treatment; some non-progressive organic lesions may be accompanied by ipsilateral myoclonus. However, the EEG background is normal; Rasmussen syndrome (partial continuous epilepsy) has early onset of myoclonus and other forms of seizures, with progressive diffuse nervous system damage, and the partial persistence of partial sensory seizures is less common.
(2) Peripheral leaf epilepsy state: also known as psychomotor epilepsy state, often showing disturbance of consciousness (fuzzy) and mental symptoms, such as decreased activity, slow response, sluggishness, loss of attention, poor orientation, silence or only Tone, as well as nervousness, anxiety, fear, impatience, impulsive behavior, hallucinations, delusions and dives, lasts for several days to several months, no memory afterwards; common in temporal lobe epilepsy, attention must be paid to the spirit caused by other causes Abnormal identification.
(3) unilateral convulsions with unilateral palsy: more often in young children, showing side convulsions, patients are usually conscious, accompanied by transient or permanent ipsilateral limb paralysis after the attack, infantile hemiplegic hemiplegia syndrome (HHS) also exhibits a half-sided convulsion, often with ipsilateral hemiplegia, and a persistent state can also occur.
(4) Sustained status of autonomic symptoms: a small number of patients show autonomic symptoms. Consciousness disorders can range from mild sleepiness to stupor, coma and urinary incontinence. If not treated in time, systemic seizures often occur, which can last from several hours to several days or even half a year. The patient could not recall the episode, and the near-term or distant memory was impaired after the attack. EEG showed focal epileptic discharge of temporal lobe and frontal lobe.
3. Sustained status of epilepsy in neonatal period: various performances, atypical, mostly mild twitching, singular and tonic movements of the limbs, often from one limb to another limb or half body twitching, apnea during onset, unconsciousness, EEG visible Characteristic abnormalities, 1 ~ 4Hz slow wave inclusion spikes or 2 ~ 6Hz rhythmic spine slow wave synthesis, tonic attacks are waves, clonic attacks have spikes, sharp waves are issued.
Examine
Examination of status epilepticus
1. Blood routine examination: Except for infection or blood system diseases leading to symptomatic persistence.
2. Blood biochemical examination: It can rule out hypoglycemia, diabetic ketoacidosis, hyponatremia, and chronic liver disease, renal insufficiency and CO poisoning.
4. Conventional EEG, video EEG and dynamic EEG monitoring: can display sharp waves, spikes, sharp-slow waves, spine-slow waves and other epileptic waves, which contribute to the diagnosis of seizures and epilepsy.
5. Electrocardiogram examination: can exclude large area of myocardial infarction, various types of arrhythmia lead to extensive cerebral ischemia, seizures after hypoxia and disturbance of consciousness.
6. Chest X-ray examination: can rule out severe pulmonary infection leading to hypoxemia or respiratory failure.
7. Head CT and MRI examinations are possible if necessary.
Diagnosis
Diagnosis and identification of status epilepticus
According to the history of epilepsy, clinical features, routine or video EEG examination, GTCS persistent episodes of consciousness loss can be diagnosed; partial seizure persistence can be seen in local persistent seizures, hours or days, unconscious disorder; marginal lobe Sustained status of epilepsy, autonomic symptoms have conscious disturbances, can be associated with mental disorders, and no memory afterwards.
Partial epilepsy status needs to be differentiated from transient ischemic attack (TIA). TIA may have paroxysmal numbness, weakness, etc., without consciousness disorder, lasting for several minutes to tens of minutes, easy to be confused with simple partial seizure duration TIA is more common in middle-aged and elderly people, often with hypertension, cerebral arteriosclerosis and other risk factors for stroke; status of epilepsy should be differentiated from snoring, migraine, hypoglycemia and organic encephalopathy. History and EEG are important identifications. in accordance with.
