Status Epilepticus 

During my many years in the medical field, I have experienced many kinds of seizures, mainly triggered by brain tumours such as Glioblastoma. But even when I was a teenager, one of my best friends experienced seizures. Just not the kind we would think of when we picture an Epileptic Seizure. She was one of the people with Absent Seizures, which means, in the middle of a conversation, she would just start staring and break up talking. Sometimes only a few seconds, sometimes up to a minute. She would then awake as if she was daydreaming.
So I learned early that a seizure isn't just the cramping body on the floor, but that there are several kinds of epilepsy.

As I mentioned before, I have seen Tonic-Clonic Seizures quite often, but what I haven't experienced until that night was a Status Epilepticus. And here is how that went:

It was 9 pm, and I was just getting my handover from the afternoon shift and was about to start my night shift, when we heard someone calling for help. Naturally, we would go and see what had happened. We found a family, the father caring a small child in his arms, the mother crying and another child in her arms. Both two little sweet girls. Susi (name changed) was 6 years old and lay in his father's arms, apathically, not reacting to any of us. We guided the father and Susi into one of our treatment rooms, called the nearest doctor and started examining her. The father explained (in broken German) that the girl was getting ready for bed and, while she brushed her teeth, hit her head on the mirror and then fell into this state. (I need to mention that we weren't a clinic for kids, we usually sent kids to the next clinic which was a 30-minute drive, but of course, we would not this here.) Luckily, we had an Emergency Doctor in the house, as we just got another patient by the ambulance. He examined her, we took the blood pressure, pulse and the oxygen saturation, except for a slightly raised pulse, all seemed well. The girl was still lying there, eyes open, staring like a doll, no muscle tension whatsoever, no reaction to pain stimuli, nothing. We were startled, worried she could stop breathing and just did not know what had happened to her. The next step was to get a CT done to see if she had a bleeding in her brain somewhere. But due to the lack of experience we had with kids and because we did not have a Neurologist at hand, we decided to send the girl with the ambulance straight to the next University Hospital. The Emergency Doctor was still considering intubating her so that he does not need to do it while they drive, in case she stopped breathing on her way to the hospital. He decided against it, as she was stable so far, and we all hoped for the best. Everything happened quite fast and within 15 minutes Susi was on her way to the clinic. 

I remember standing outside next to the vehicle and shaking. Seeing little kids like that always made me weak, especially since I was a mum myself. Naturally, this story did not leave my mind so fast. 

The next day when I came to work, my colleague told me that the doctor who drove the girl to the University Hospital, called that they figured out that Susi suffered from a Status Epilepticus, but she is well now and the family can take her home soon. I was relieved to hear that, and learned another lesson, now I know what a Status Epilepticus looks like ...

Looking back, we also realized that we got the situation wrong. We thought she hit her head at the mirror and then fell into this state, which made us think of a bleeding. But she must have had the seizure first and, due to a lack of muscle tension, fell into the mirror. This is where one realizes how important it is to a have a discussion after such incidents with the team involved, to make sure we all learn out of such situations and are on the same page.

We even thought about abuse, and that the father hit the kid hard, which brought her into this. Considering what we know now, and looking back at how much he cared for her, this seems highly unlikely, though you never know what happens behind closed doors ...

Status epilepticus is a medical emergency characterized by a seizure lasting longer than 5 minutes or multiple seizures occurring without a return to normal consciousness between episodes. Immediate medical intervention is crucial, as this condition can lead to permanent brain damage or death. 

Types of Status Epilepticus:

1. Convulsive Status Epilepticus: This type involves convulsions and may lead to long-term injury. Symptoms include jerking motions, grunting sounds, drooling, and rapid eye movements.

2. Nonconvulsive Status Epilepticus: Individuals may appear confused or as if they're daydreaming, may be unable to speak, and might exhibit irrational behavior.

Common Causes:

• In Children: Infections accompanied by fever are the primary cause. Children with severe, refractory seizure disorders are also at risk. 

• In Adults: Common causes include stroke, autoimmune disorders, imbalances in blood substances (such as low blood sugar), excessive alcohol consumption or withdrawal, and withdrawal from seizure medications.
  
  

Symptoms:

• Muscle spasms
• Falling
• Confusion
• Unusual noises
• Loss of bowel or bladder control
• Clenched teeth
• Irregular breathing
• Unusual behavior
• Difficulty speaking
• A "daydreaming" appearance

Diagnosis:

Healthcare providers conduct a thorough physical examination and review the patient's medical history, including medication use and potential substance abuse. Diagnostic tests may include an electroencephalogram (EEG) to measure brain electrical activity, lumbar puncture to check for infections, and CT or MRI scans to identify brain abnormalities.

Treatment:

The primary goal is to terminate the seizure promptly and address any underlying causes. Treatment may involve:

• Administration of oxygen
• Blood tests
• Intravenous (IV) line placement
• Glucose administration if low blood sugar is a factor
• Use of antiseizure medications such as diazepam, lorazepam, levetiracetam, lacosamide, phenytoin, fosphenytoin, phenobarbital, or valproate, delivered via IV or intramuscular injection
  
  

In severe cases, mechanical ventilation may be necessary until the patient can breathe independently. 

Complications:

The severity of complications varies based on the underlying cause and can range from no lasting issues to death. Prompt and effective treatment is essential to minimize the risk of long-term consequences. 

For more detailed information, please refer to the Johns Hopkins Medicine resource on status epilepticus.