Clinical Profile, Immediate Outcome and Risk Factors Determining Adverse Outcome Of Status Epilepticus in Children: Managed in an Urban Tertiary Level Referral Centre

Kumar, N (2006) Clinical Profile, Immediate Outcome and Risk Factors Determining Adverse Outcome Of Status Epilepticus in Children: Managed in an Urban Tertiary Level Referral Centre. Masters thesis, Madras Medical College, Chennai.


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INTRODUCTION: Status Epilepticus (SE) is one of the most critical medical emergencies that may result in significant morbidity and mortality if not addressed in a timely and effective manner1. The approach in generalized convulsive SE is modified by changing concepts regard the definition of SE and studies justifying more aggressive treatment, with earlier intervention started prior to arrival to hospital. Currently SE has 1/5 the morbidity and 1/3 the mortality of pre -19702. But still mortality is around 11-53% 3, 4, 5. Improvements reflect studies, retrospective data, changing definition of SE (from >60 minutes to > 5 minutes). But most important factor is improved care. Although most seizures in children stop prior to arrival at a hospital, an estimated 60,000 US children are treated each year for SE. 1/3 of the episodes will be initial event in a patient with new onset epilepsy and an additional third occur in children with established epilepsy. Up to 70% of children with epilepsy beginning before age 1 will experience as episode of SE in their life time. Incidence is about 50000- 2.5 Lakhs times/year in US. 21% were <1year and 64% were <5 years. <50% of SE has h/o epilepsy. 15% of the epileptics will have SE at one time. 10% of the epileptics will present with SE at I time itself. IMPORTANT CAUSES: Acute causes:CNS infections, febrile convulsions, trauma, metabolic derangements, toxins, drugs overdose, vascular, hypoxia etc. Static causes: Idiopathic epilepsy (here SE may be the first manifestation or may be precipitated by drug default /poor compliance, irregular drugs sudden withdrawal of AED, change of drugs, inadequate AED level in serum, fever, stress, sleep deprivation), structural brain lesions either developmental or acquired. Progressive causes: Degenerative cerebral disorders. AIM OF THE SYUDY: Aim of this study is to determine clinical profile, and immediate outcome of SE in children, managed in our hospital. Secondary aim is to identify risk factors influenzing adverse outcome. DISCUSSION: 1. Hypoglycemia at arrival was noted in 13 children and hyperglycemia in 11 cases. Hypoglycemia may be the cause of SE or consequence. None of the children responded to 25% dextrose alone so the cause of hypoglycemia in this study was due to the consequence of prolonged SE. Low HCO3 was seen in 19 cases and all were found to have metabolic acidosis by ABG. 3 hypo natremias, 14 cases of hypokalemias, 1 case of hyper kalemia, 11 cases of hypocalcemia No case of hyper calcemia or hyper natremia was seen.. 2. LP and CSF analysis was done in 70 cases either antimortum or post mortum in case of death. Out of them, 54 children had normal CSF, 16 cases had abnormal CSF (elevated protein, decreased sugar, pleocytosis). 2 children had organisms in CSF. 3. CT brain was done for 56 cases and found to be normal in 35 cases and abnormal in 21 cases. USG cranium was done in 39 cases and found to be normal in 31 cases. MRI was done in 4 cases to confirm the CT findings. CT brain was usually done in all cases of SE with focal onset of seizures (28 cases) and it was abnormal in 25 cases (89.2%) 4. We were not able to do bedside EEG or EEG during seizures. Inter ictal EEG was done for 54 children. All cases of febrile SE were undergone for EEG (19 cases) and found to have normal EEG. 40 cases had normal EEG and 14 had abnormal EEG. 5. FINAL DIAGNOSIS: Most common causes of SE were remote symptomatic ( structural lesions) – 34%, idiopathic epilepsy- 17%, Acute CNS infections- 15%, Febrile SE-15%, septic shock-7%. Others were toxin, drug over dose, acute encephalopathy. SUMMARY: In our study also duration > 1 hour, increasing distance from the place of seizure onset, acute CNS infection, need for IPPV were significant independent risk factors that predict poor out come. Commonest seizure type is GTCS and NCSE accounts for 20 % of SE. In our study also commonest seizure type is GTCS and NCSE account for 26% of SE. This may be because prolonged CSE in many cases (13.3%) resulted in NCSE due to neuro electro mechanical dissociation. Proper pre hospital therapy is associated with good out come observed in this study. No or improper pre hospital therapy is a significant risk factor for poor outcome in univariate analysis. Kwong et al 83 concluded that Pre hospital Rx with BZD reduces adverse outcome. Allredge BK et al 92 also concluded that, Pre hospital therapy was associated with shorter duration of SE (P=0.007), reduced likelihood of recurrent seizures in ER (P=0.045), no significant difference between PR and IV and simplify the subsequent management of these patients. In this study, 57 cases (44.9%) presented as SE in heir first episode of fits which is comparable with other literatures 2 and out of them, H/o poor drug compliance was present in 14 cases and that could be the cause of SE in them where as 59.4% of the individuals had pervious epilepsy while 40.6% had not in Garzon et al 84 study and 43% has no prior SE in Mah JK et al 90 study, 28/60(46.6%) were no h/o prior fits in Dunn DW et al 91 study, 16 patients (53.3%) had SE I episode with out prior H/o fits in Kalra veena et al 97 study. CONCLUSION: 1. Mortality in SE in this study is 15.7% . Higher mortality in this study is mainly due to the underlying cause than SE itself. Most of the cases of SE were young children of <6 years of age and mortality is also high in young children of <3 years who had 85% mortality. But there is no clear cut definition of SE is formulated in this age group till now. 2. There is no significant sex difference. 3. Commonest seizure type is GTCS. But NCSE also accounts for 26% of the cases. 4. All were required supplementary oxygen at arrival and most of them were apneic, hypoxic and shocky.

Item Type: Thesis (Masters)
Uncontrolled Keywords: Clinical Profile ; Immediate Outcome ; Risk Factors ; Determining Adverse ; Status Epilepticus ; Children ; Urban Tertiary ; Level Referral Centre
Subjects: MEDICAL > Paediatrics
Depositing User: Ravindran C
Date Deposited: 19 Apr 2018 10:58
Last Modified: 19 Apr 2018 10:58

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