Extreme Situation Recorded under Status Epilepticus - Case Study Example

Introduction The patient named Master Bradley Jackson was a five year old boy admitted to the hospital for a detailed investigation for seizures. The child was diagnosed of several tonic-clonic type of seizures majorly on the left side of the body. The patient recorded failure of consciousness and occasional situations of incontinence in his medical history during the last four months owing to seizures. The recordings on the Glasgow Coma Scale (GCS) did not revealed any sign of recovery from his previous state. The patient was also recorded with a series of seizure episodes that lasted for 1.5 minutes each even after being treated with benzodiazepine midazolam. However, his situation got stable after the stabilising procedure followed in the intensive care unit. After the patient got stabilised, he was shifted to the paediatric intensive care unit (ICU) and finally to the neurological department where he is being treated presently. In this regard, the case is selected for its criticality. Additionally, the case aids nurses in having a better understanding about critical assessments as well as diagnostics conducted in relation to epilepsy. 1. Clinical Assessment and Diagnostics In Relation To the Signs and Symptoms Tonic-clonic is a type of seizure that covers up the entire brain and affects several operations performed by the brain. The CT scan of the patient had detected hardly any abnormalities. This can be possible as the recurrent occurrences of seizures can be indicative to the presence of certain ‘microscopic or macroscopic’ brain lesion. Conversely, this lesion cannot be identifiable by any pathological or biochemical abnormalities (Garcia & Strub, 2011). Thus, further tests should be performed in order to locate any minor injuries in the brain and also diagnose for the microscopic presence of the injury in the nerve cells. The benzodiazepine midazolam is one of the best medications and most effective procedure for the treatment of seizures in children. The midazolam group of benzodiazepine is observed to be best suited for providing first aid to the child at the time of severe convulsion. However, there should be a parallel diagnosis of any side effects that may occur during the treatment (Panchal et al., 2013). The clinical history of several patients suggests that epileptic episodes are not properly recorded and hence does not provide evidences about the exact situations. The seizures are unprovoked situations of patients that may have several syndromes from change in the behaviour to the severe instances of consciousness (Garcia & Strub, 2011). By observing the different biochemistry tests, it has been identified that the reports were mostly within the reference range except for the sodium level, which was on the lower margin. This indicates that the child was suffering from the series of convulsions due to the lower level of the sodium content. However, Sodium Valproate has been provided by the hospital in order to ensure that the series of convulsion can be stopped with immediate effect (Johannessen & Landmark, 2010). The haematology reports suggest that the reports are mostly within the range hence, no abnormalities were evident. However, the reports need to be continuously monitored to prevent any kind of discrepancies in the long run. As no abnormalities were detected, the child needs to be monitored frequently in order to prevent severe effects caused by the undetected brain lesion if any. Contrary to the CT scan report, Glasgow Comma Scale had a score of 15, which suggested that there are injuries in the brain. Thus the chances of having microscopic brain injuries cannot be nullified completely (Middleton, 2011; Matis & Birbilis, 2008). The episode of seizure can be an outcome of a series of causes. Considering the child’s high fever, it can also be recognised that the seizure episode can be a reason of high fever or some kind of infections like encephalitis or meningitis. This considers further testing of blood that would enhance the level of diagnosis. In addition, the seizure episode can also be an outcome of the Lennox-Gastaut syndrome (LGS), which is a rare form of the childhood-onset of epilepsy. This epileptic syndrome arises between the 2nd and 6th years of a child and evidences severe as well as multiple seizure episodes at frequent intervals. The case of the child needs to be further diagnosed to ensure the actual cause of the epileptic attacks (ICSI, 2013; Tyagi et al., 2010). 2. The Conditions Pathophysiology in relation to the Presenting Signs and Symptoms The interpretation can duly be observed to be abnormal owing to the different instances of disturbance of physical conditions as well as biochemical functions of the patient. These abnormalities are evident towards the physical manifestation of the diseases that has been leading to physiological disturbances. Hence, the pathophysiological evidences need to be recorded as well as monitored, so that the proper diagnosis could be conducted. The abnormalities need to be analysed to prevent any further degradation of the patient (Ibrahim, 2008). The abnormalities that have been recorded under the pathophysiological tests could be identified as a body temperature of 37.1oC with an abnormal heart rate of 98 and SpO2 98%. In addition to the above the severity of the patient’s condition could be identified from his respiratory rate 22 and blood pressure being 110/58. The pathophysiological conditions presented in the case of the 5 year old child can be identified to be quiet threatening. With SpO2 98% at the room temperature suggests that the child was suffering from asthma. Contrary to this, the heart rate was below 140 and additionally, the respiratory rate was below 22 and hence, the child could be interpreted to be suffering from a moderate asthma. The fever being within range a continuous monitoring needs. Moreover, it also needs to be diagnosed that if the fever is caused due to any kind of diseases or infection, then proper treatment procedures should be followed for stabilising body temperature (Dudley Respiratory Group, 2011). By computing the different physical abnormalities, it was evident that the episodes of seizures were the outcome of some undiagnosed disease. The reports of the electroencephalography (EEG) need to be monitored for the next 24 hours. However, the chances that the reports can be both positive and negative cannot be nullified. It has also been noted that at several instances the patients who are suffering from epilepsy has a normal EEG report (Beletsky & Mirsattari, 2012). Moreover, on a positive note, the patient became seizure free within 16 hours of his treatment after being shifted to the paediatric intensive care unit. Since, certain reports of the patient that include EEG reports are still pending due to which interpretation of the pathophysiology could not be possible. The biochemistry and the haematology reports were observed to be normal and most of the reports were within the range. However, the major concern is that the GCS score was high i.e. 15 when the CT scan conducted revealed no sign of brain injury. This needs further testing, so that proper reporting could be done and the microscopic or macroscopic injuries if any could be located. In addition, the condition of the patient needs to be continuously monitored in order to prevent any fatal instances that may lead to further degradation of the patient (Garcia & Strub, 2011). 3. Pharmacological Management of the Pathophysiology Condition The tonic-clonic type of seizures indicates severe situations of emergencies that need urgent medical attention and immediate anti-convulsion treatments. The best first aid suggested for the treatment of this severe class of seizure is benzodiazepine midazolam. The patient was duly treated with the medicine but he did not recover from his epileptical status. The “status epilepticus” or SE signifies the state in which the child was brought in can even lead to neurological emergencies. Owing to the varying nature of the after effects and the symptoms of this epilepticus phases, the opinions for the clinical diagnosis of the disease even varies. Mostly in the cases of the children, it has been observed that in situations of convulsive status epilepticus (CSE) are required to be treated with ‘downward extrapolation’ of the dosage and provided with anticonvulsant drugs. However, while treating patients having CSE as in the referred case, due notice should be kept about the fact that both under and over treatment can be equally fatal for the child. Additionally, the different metabolism must be duly recorded before treating with the anticonvulsive drugs (Appleton et al., 2010; Costello & Cole, 2014). The patient is also observed to be having a moderate respiratory problem when shifted to the neurological ward after being stabilised. This could possibly be a side-effect of the anti-convulsion medicine provided to the patient at the time of emergency. This effect needs to be attended immediately to prevent severity if it is diagnosed to be a side-effect of treatment made through benzodiazepine midazolam (Appleton et al., 2010). The respiratory problem diagnosed must be immediately adhered by increasing the airflow and by providing a respiratory support. Inhalation through the intravenous medication needs to be provided immediately if the syndrome is acute. Moreover, a continuous observation must be done in order to ensure that there are no respiratory blockages. This could also lead to the recurrence of the seizure episodes (Lugogo & MacIntyre, 2008). Through continuous monitoring of the patient’s neurological imbalances, the possible recurrence of the epilepticus syndromes could be prevented. The hypersensitivity recorded needs to be normalised in order to prevent the side-effects of the antiepileptic drugs (AED). In addition, the use of the AED had no effect on the patient’s condition and accordingly, the epilepticus treatment being provided needs to be re-evaluated. The continuous monitoring of the heart rate and respiratory functions needs to diagnose any cerebral vascular predispose constantly, which is secondary to the brain injury (Queensland Health, 2010; Wahab, 2010). The proper diet of the patient needs to be planned in order to enhance the quality life of the patient. The patient should be provided with Ketogenic Diet (KD), which constitutes of a high fat, low protein and carbohydrate diet. The diet plays an important role for the treatment of the refractory epilepsies (Hanzhou et al., 2014). KD is best suited as the epileptic causes of the patient are not traceable and the AED are also not working for recovering his situations of episodes of seizures. KD helps in fulfilling the nutrient requirements of the patient and helps in maintaining a balance between protein, minerals and vitamins for the patient. The medium chain of the triglyceride diet ensures that the palatability is improved in the health condition of the patients. Moreover, the use of proper diet would ensure that the pharmacological management could be conducted properly. Correspondingly, it would also ensure that the immune system of the patients develops, so that it can accept the drugs that are being provided to the patient (Rogovik & Goldman, 2010). 4. Prioritised Plan of Care The child has been brought in with a SE syndrome and the episodes of seizures could not be avoided even after the use of AEDs. The seizure episodes were lasting for a duration of 1.5 minutes hence, needed to be treated with the acute level of AED namely Midazolam. Since, the initial trauma of the seizure could be stabilised by the use of the stabilisers, the main motive of the caregivers is to diagnose the side-effects of the use of AEDs. Additionally, the cause of the seizure episode also needs to be identified to prevent from any severe situations and more effective diseases. The hospital has conducted the schedule care that has actually prevented the patient’s seizure episodes from occurrences. The patient’s CT scan report depicted no sign of abnormalities and there are no valid chances of any kind of damages. However, in contradiction to the above, the GCS scale has a high record of 15 that indicates that there are high chances of having microscopic or macroscopic injury in the brain liens (Garcia & Strub, 2011). In this regard, the patient should be further tested to specify the eminent cause of the seizure episode. Continuous monitoring of the patient is to be done as the tonic-clonic seizures has severe effects like shallow breathing and rolling of eyes (Appleton et al., 2010). The reports of the patient collected in the neurological ward suggested possible chances of the side effect from AED. The moderate respiratory problem recorded with the severe abnormalities of the blood pressure (BP), heart rate as well as the respiratory rate needs to be duly controlled and treated properly (Queensland Health, 2010; Wahab, 2010). In addition, the CT scan reports needs to be cross checked by conducting a magnetic resonance imaging (MRI) scan, so that microscopic injury if any can be identified. Since, the patient is not recorded of any neuron disorders at the initial phase of the testing, further tests are needed to be conducted to ensure that other causes of disorders are diagnosed and treated appropriately. Detailed testing needs to be conducted to diagnose chances of meningitis and prevent the recurrence of episodes of seizures (ICSI, 2013; Tyagi et al., 2010). Additionally, proper respiratory support needs to be provided to prevent from suffocation and also to control the blood pressure level efficiently. The blood pressure level needs to be monitored for preventing the patient from a situation of hypertension, which would be responsible for further recurrence of seizure. Moreover, the EEG report needs to be diagnosed considering the fact that the chances of abnormalities cannot be nullified even if the reports are negative. The detailed reporting of the seizure episodes needs to be performed through proper documentation, so that the patient needs are monitored still the vital or critical signs are stabilised (Seattle Children’s Hospital, 2012). A prioritised plan of care for the patient is provided hereunder. Conclusion The case referred is of an extreme situation recorded under status epilepticus. The child was observed to be suffering from continuous recurrence of the episodes of seizures and t AEDs were highly ineffective. Later on, the .health conditions of the child was stabilised with the use of stabilisers in the ICU. The use of midazolam from the benzodiazepine group suggests that the epileptic attack was quiet severe. This could be identified to be fatal, as this type of seizure episodes are identified to adversely damage the brain. The GCS score of the child was 15 that suggested that there are brain injuries. Contradicting the above scores, the child did not have any signs of abnormalities as per the record of the CT scan. Hence, a detailed test should be conducted to find the actual reason leading to the situation of episodes of seizures. Tests should be farther conducted in order to locate any kind of internal microscopic injuries. Moreover, the abnormalities found in the pathological reports are to be monitored with immediate effect in order to prevent any severity. The biochemistry imbalances need to be continuously monitored to prevent the recurrence of any metabolic imbalances leading to the episodes of seizures. In addition, a detailed analysis needs to be performed to stabilise the vital signs of the patient. Moreover, the patient should also be provided with a respiratory support as well as a BP support to prevent any further adverse situations. The patient should be also diagnosed in detail to prevent from the threat of any adverse metabolic conditions. Once the vital signs are stabilised and detailed reports are attained, further diagnosis must be conducted. A detailed examination of the patient’s history and physical evidences needed to be further examined to investigate into the actual cause of the seizure episode. The detailed analysis must be conducted through the use of controlled trail and proper support systems. The patient should be monitored till the revival of the patient from critical symptoms within their normal range. References Appleton R., Macleod S., & Martland T. (2010). Drug management for acute tonic-clonic convulsions including convulsive status epilepticus in children (Review). The Cochrane Collaboration, 1-26. Beletsky, V., & Mirsattari, S. M. (2012). Epilepsy, mental health disorder, or both? Retrieved from http://www.hindawi.com/journals/ert/2012/163731/. Costello, D. J., & Cole, A. J. (2014). 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