When recurrent seizures occur at a frequency which does not allow consciousness to be regained in the interval between seizures, it is called status epilepticus. Severe and permanent brain damage may result from status epilepticus persisting for more than an hour. The longer the duration of status epilepticus, the more difficult it is to control and higher is the incidence of morbidity and mortality.
Lactic acidosis, hypoglycemia, autonomic dysfunction, hyperthermia and shock may follow as the condition proceeds. This is a medical emergency which may buy valium in uk prove fatal unless controlled properly-the mortality being 5-50%. Therapy should be started without any delay. There are many therapeutic regimes but no one is totally satisfactory. When the patient is first seen, 10mg diazepam can be given intravenously over a period of 2-10 min. The action lasts for 30-60 minutes and hence repetition of the dose may be necessary (total 60-80mg). At the same time, a loading dose (in those cases who have not taken the drug previously) of phenytoin (0.5-1g) intravenously is given. This should achieve an optimum therapeutic level in the serum. Oral maintenance dose could be started once the patient becomes conscious. The anti-convulsant action of intravenous phenytoin is manifest within 10-20 minutes. Alternatively, phenobarbitone injection (up to 0.8 to 1g per 24 hours) or thiopental anesthesia in a dose of 0.3-0.6g intravenously would control the status. Sometimes we need to know in specificity the types or kinds of drugs to use in specific or particular epileptic cases.
Choice of drugs in the various types of epilepsy
1. Generalized tonic-clonic seizures: Phenytoin sodium, Carbamazepine, Phenobarbitone, Sodium Valproate etc.
2. Partial elementary seizures (Simple partial seizures): Carbamazepine, Phenytoin sodium, Primidone, Phenobarbitone, Sodium Valproate etc.
3. Partial complex seizures: Carbamazepine, Sodium Valproate, Primidone, Phenytoin sodium and Phenobarbitone
4. Absence attacks with 3sec, spike and waves: Sodium valproate, Ethosuximide and Trimethadione
5. Myoclonic epilepsy: Sodium Valproate, Ethosuximide and Trimethadione.
6. Infantile spasms: ACTH/Corticosteriods, Nitrazepam and Clonazepam.
7. Neonatal seizures, Febrile seizures: Phenobarbitone and Sodium Valproate.
8. Status epilepticus: Diazepam, CLonazepam and Lorazepam.
General supportive measures include: maintenance of the airway and prevention of aspiration; prevention of injuries, proper oxygenation, maintenance of fluid and electrolyte balance and maintenance of nutrition. In the majority of cases, failure to control status epilepticus is due to delay in starting treatment; inadequate dosage of anti-convulsants; improper route of administration of drugs and inadequate supportive care.
Some types of epilepsy respond to surgical treatment which consists of removal of the epileptogenic focus. general indications for surgery include the following:
1. Failure to control the seizure by various combinations of anticonvulsant drugs.
2.Demonstration of an epileptogenic focus by EEG and other investigational methods.
3. The attacks must be present for a long enough time (a few years at least) for the surgeon to be reasonably sure that all potentially epileptogenic areas have become symptomatic and the possibility of spontaneous remission is remote.
The largest number of surgical ablation has been done for temporal lobe epilepsy. The general surgical procedures adopted include cortical excision, hemispherectomy, and stereotaxic surgery. Several other procedures are also under trail. In 40-50% of intractable cases, surgical management has been beneficial. The resultant neurological disability is acceptable in terms of the benefit achieved.
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