Status epilepticus

Introduction
Status epilepticus is occur when a continuous seizure activity lasting more than five minutes or when seizures occur close together and the person doesn't recover between seizures. There are also different types of status epilepticus.
Convulsive Status Epilepticus
This term is used to describe the more common form of emergency situation that can occur with prolonged or repeated tonic-clonic (also called convulsive or grand mal) seizures. Most tonic-clonic seizures end normally in 1 to 2 minutes, but they may have post-ictal (or after-effects) symptoms for much longer. Convulsions may involve jerking motions, grunting sounds, drooling, and rapid eye movements. This makes it hard to tell when a seizure begins and ends.

Nonconvulsive Status Epilepticus

This term is used to describe long or repeated absence or complex partial seizures.

People with this type may appear confused or look like they're daydreaming. They may be unable to speak and may be behaving in an irrational way. (Epilepsycom, 2015)

Presentation 
Signs & symptoms

·         Muscle spasms

·         Falling because of uncontrollable jerking movements of the arms and legs

·          Loss of consciousness or awareness

·         Unusual noises

·         Loss of bowel or bladder control

·         Clenched teeth

·         Irregular breathing

·         Unusual behavior

·         Difficulty speaking

·         A "daydreaming" look  or   Temporary confusion (Mayoclinicorg, 2015)

Causes

·         Genetic influence

·         Head trauma

·         Brain conditions, such as brain tumors or strokes, can cause epilepsy. Stroke is a leading cause of epilepsy in adults older than age 35.

·         Infectious diseases such as meningitis, AIDS and viral encephalitis

·         Prenatal injury such as an infection in the mother, poor nutrition or oxygen deficiencies. This brain damage can result in epilepsy or cerebral palsy.

·         Developmental disorders such as autism and neurofibromatosis.

Risk factors

·         Age. The onset of epilepsy is most common during early childhood and after age 60

·         Family history

·         Head injuries

·         Stroke and other vascular diseases

·         Dementia

·          Brain infections

·         Seizures in childhood

Diagnose

·    Electroencephalogram (EEG).

·         Computerized tomography (CT) scans. CT scans can reveal abnormalities in the brain that might be causing seizures, such as tumors, bleeding and cysts.

·         Magnetic resonance imaging (MRI). Able to detect lesions or abnormalities in the brain that could be causing seizures.

·         Functional MRI (fMRI). A functional MRI measures the changes in blood flow that occur when specific parts of the brain are working.

·         Positron emission tomography (PET). PET scans use a small amount of low-dose radioactive material that's injected into a vein to help visualize active areas of the brain and detect abnormalities.

·         Single-photon emission computerized tomography (SPECT) A SPECT test uses a small amount of low-dose radioactive material that's injected into a vein to create a detailed, 3-D map of the blood flow activity in the brain during seizures.

·         Neuropsychological tests. In these tests, doctors assess the thinking, memory and speech skills. The test results helps to determine which areas of brain are affected. (Hopkinsmedicineorg, 2015)

Management 

drug therapy

Anti-epileptic drugs (AED)

Generally, they work by changing the levels of the chemicals in your brain that conduct electrical impulses. This reduces the chance of a seizure.

Examples of commonly used AEDs include,

Sodium valproate

Carbamazepine

Lamotrigine

Levetiracetam

Oxcarbazepine

Ethosuximide

Topiramate

also using, Diazepam,  Lorazepam,  Phenytoin,  Fosphenytoin, Phenobarbital

Side effects

Side effects are common when starting treatment with AEDs. drowsiness

• a lack of energy
• agitation
• headaches 
• uncontrollable shaking or tremor
• hair loss or unwanted hair growth
• swollen gums
• rashes

Surgery

Epilepsy surgery to removes the area of the brain that's causing the seizures.

Therapies

       Vagus nerve stimulation. In vagus nerve stimulation, implant a device called a vagus nerve stimulator underneath the skin of chest, similar to a heart pacemaker. Wires from the stimulator are connected to the vagus nerve in the neck.

      Ketogenic diet. Some children with epilepsy have been able to reduce their seizures by following a strict diet that's high in fats and low in carbohydrates. In this diet, called a ketogenic diet, the body breaks down fats instead of carbohydrates for energy. After a few years, some children may be able to stop the ketogenic diet and remain seizure-free.

Potential future treatments is deep brain stimulation (Uptodatecom, 2015)

References

Hopkinsmedicineorg. 2015. Hopkinsmedicineorg. [Online]. [20 April 2015]. Available from: http://www.hopkinsmedicine.org/healthlibrary/conditions/nervous_system_disorders/status_epilepticus_134,42/

Mayoclinicorg. 2015. Mayoclinicorg. [Online]. [20 April 2015]. Available from: http://www.mayoclinic.org/diseases-conditions/epilepsy/symptoms-causes/dxc-20117207

Uptodatecom. 2015. Uptodatecom. [Online]. [20 April 2015]. Available from: http://www.uptodate.com/contents/convulsive-status-epilepticus-in-adults-classification-clinical-features-and-diagnosis

Epilepsycom. 2015. Epilepsy Foundation. [Online]. [21 April 2015]. Available from: http://www.epilepsy.com/learn/impact/seizure-emergencies/status-epilepticus

Status Asthmaticus

Introduction 
During an asthma attack, also called an asthma exacerbation, airways become swollen and inflamed. The muscles around the airways contract, causing breathing (bronchial) tubes to narrow.

·         People (including children) with therapy resistant severe asthma. These are people who are unable to reduce their asthma symptoms and have frequent worsening of asthma symptoms and asthma attacks, despite taking multiple asthma medicines.

·         People (including children) who are not therapy resistant but who have poorly managed difficult asthma.

Presentation

Signs and symptoms 

·         Severe shortness of breath, chest tightness or pain, and coughing or wheezing

·         Low peak expiratory flow (PEF) readings

·         Worsening symptoms despite use of a quick-relief (rescue) inhaler

·         Severe breathlessness or wheezing, especially at night or in the early morning

·         The inability to speak more than short phrases due to shortness of breath

·         Having to strain your chest muscles to breathe

·         Low peak flow readings when you use a peak flow meter

·         Bluish tint to your lips

·         Agitation, confusion, or an inability to concentrate (Mayoclinicorg, 2015)

Causes

Common asthma attack triggers include:

·         Pollen, pets, mold and dust mites

·         Upper respiratory infections

·         Tobacco smoke

·         Exercise

·         Inhaling cold, dry air

·         Gastro esophageal reflux disease (GERD)

 Food allergies rarely cause asthma yet they can cause a severe life-threatening reaction. The most common foods associated with allergic symptoms are,

·         Eggs

·         Cow's milk

·         Peanuts

·         Tree nuts (such as almonds, pecans, walnuts)

·         Soy

·         Wheat

·         Fish

·         Shrimp and other shellfish

·         Food preservatives

·         Dried fruits or vegetables

·         Potatoes (packaged and some prepared)

·         Wine and beer

·         Bottled lime or lemon juice

·         Shrimp (fresh, frozen, or prepared)

·         Pickled foods

Symptoms of food allergy can include hives, rash, nausea, headache, vomiting,sneezing and nasal congestion. Some people may experience wheezing or anaphylaxis  a swelling of the throat that can cut off the airway.

Management

Quick-relief inhalers (bronchodilators) quickly open swollen airways that are limiting breathing. In some cases, allergy medications are necessary.

Long-term asthma control medications

·         Inhaled corticosteroids. These anti-inflammatory drugs include fluticasone (Flovent HFA), budesonide (Pulmicort Flexhaler), flunisolide (Aerobid), ciclesonide (Alvesco), beclomethasone (Qvar) and mometasone (Asmanex).

·         Leukotriene modifiers. These oral medications including montelukast (Singulair), zafirlukast (Accolate) and zileuton (Zyflo) help relieve asthma symptoms for up to 24 hours.

·         Long-acting beta agonists. These inhaled medications, which include salmeterol (Serevent) and formoterol (Foradil, Perforomist), open the airways.

·         Combination inhalers. These medications such as fluticasone-salmeterol (Advair Diskus), budesonide-formoterol (Symbicort) and mometasone-formoterol (Dulera) contain a long-acting beta agonist along with a corticosteroid. Because these combination inhalers contain long-acting beta agonists, they may increase your risk of having a severe asthma attack.

·         Theophylline. Theophylline (Theo-24, Elixophyllin, others) is a daily pill that helps keep the airways open (bronchodilator) by relaxing the muscles around the airways. 
(Uptodatecom, 2015)

Quick-relief (rescue) medications

·         Short-acting beta agonists. These inhaled, quick-relief bronchodilators act within minutes to rapidly ease symptoms during an asthma attack. They include albuterol (ProAir HFA, Ventolin HFA, others), levalbuterol (Xopenex) and pirbuterol (Maxair). Short-acting beta agonists can be taken using a portable, hand-held inhaler or a nebulizer.

·         Ipratropium (Atrovent). Like other bronchodilators, ipratropium acts quickly to immediately relax your airways, making it easier to breathe.

·         Oral and intravenous corticosteroids. These medications which include prednisone and methylprednisolone relieve airway inflammation caused by severe asthma. They can cause serious side effects when used long term.

·         Intubation, mechanical ventilation and oxygen (Asthmaorguk, 2015)

Allergy medications may help if your asthma is triggered or worsened by allergies. These include:

·         Allergy shots (immunotherapy). Over time, allergy shots gradually reduce your immune system reaction to specific allergens.

·         Omalizumab (Xolair). This medication, given as an injection every two to four weeks, is specifically for people who have allergies and severe asthma. It acts by altering the immune system.

·         Allergy medications. These include oral and nasal spray antihistamines and decongestants as well as corticosteroid and cromolyn nasal sprays.

References 

Uptodatecom. 2015. Uptodatecom. [Online]. [7 May 2015]. Available from: http://www.uptodate.com/contents/treatment-of-severe-asthma-in-adolescents-and-adults

Mayoclinicorg. 2015. Mayoclinicorg. [Online]. [7 May 2015]. Available from: http://www.mayoclinic.org/diseases-conditions/asthma-attack/basics/symptoms/con-20034148

Asthmaorguk. 2015. Asthma UK. [Online]. [7 May 2015]. Available from: http://www.asthma.org.uk/advice-severe-asthma

Acute LVF ( Acute left ventricular failure)

Introduction

Heart failure occurs when heart cannot pump enough blood to body demand. This can be chronic or acute.The heart failure could begin on the left or right side of the heart, or both sides may fail at the same time. If heart muscle is too weak, the ventricles can stretch out and fail to work efficiently. These are a few different types of heart failure.

Left-sided heart failure: This is the most common type of heart failure. Patient presents short of breath due to backed-up fluid in the lungs. 

There are two types of left-sided heart failure. Systolic heart failure, This pumping problem prevents the left ventricle from proper pumping and is most often associated with acute heart failure. & Diastolic heart failure,This is caused by a blood-filling problem in the left ventricle.

Presentation

Signs & symptoms 

• Edema
• Shortness of breath
• Weakness & fatigue
• Irregular or fast heartbeat
• Coughing and wheezing
• Spitting up pink phlegm
• Decreased ability to concentrate
• Chest pain (Mayoclinicorg, 2015)

Causes

Disease or a birth defect, Acute MI, Mitral regurgitation, arrhythmia, aortic dissections,valve destruction (endocarditis), myocarditis, Poor diet and lack of exercise, high blood pressure, diabetes, faulty heart valves,coronary artery disease, inherited heart defects, and a damaged or inflamed heart,  infections,allergic reactios,viruses that damage the heart, cardiopulmonary bypass surgery. (Healthlinecom, 2015)

Diagnosis

Chest X-ray

Blood tests

Stress test

Electrocardiogram

Echocardiogram

Angiogram

CT scan & MRI

Management 

·         Angiotensin-converting enzyme (ACE) inhibitors. ACE inhibitors are a type of vasodilator, a drug that widens blood vessels to lower blood pressure, improve blood flow and decrease the workload on the heart. Examples include enalapril (Vasotec), lisinopril (Zestril) and captopril (Capoten).

·         Angiotensin II receptor blockers.  Losartan (Cozaar) and valsartan (Diovan), have many of the same benefits as ACE inhibitors. They may be an alternative for people who can't tolerate ACE inhibitors.

·         Beta blockers. This class of drugs not only slows heart rate and reduces blood pressure but also limits or reverses some of the damage to heart if patient have systolic heart failure. Examples include carvedilol (Coreg), metoprolol (Lopressor) and bisoprolol (Zebeta).

·         Diuretics.  such as furosemide (Lasix)

·         Aldosterone antagonists. These drugs include spironolactone (Aldactone) and eplerenone (Inspra). These are potassium-sparing diuretics, which also have additional properties that may help people with severe systolic heart failure live longer.

·         Inotropes. These are intravenous medications used in people with severe heart failure in the hospital to improve heart pumping function and maintain blood pressure.

·         Digoxin (Lanoxin)

·         Calcium channel blockers may improve exercise tolerance via their vasodilatory properties, and nondihydropyridine calcium channel blockers are also used for ventricular rate control in patients with atrial fibrillation.

·          Amlodipine has antianginal properties and is also indicated in hypertension.
 (Medscapecom, 2015)

Surgery options 

·         Coronary bypass surgery. 

·         Heart valve repair or replacement

·         Implantable cardioverter-defibrillators (ICDs)

·         Cardiac resynchronization therapy (CRT), or biventricular pacing

·         Heart pumps & heart transplant 

References

Medscapecom. 2015. Medscapecom. [Online]. [22 April 2015]. Available from: http://emedicine.medscape.com/article/163062-treatment

Healthlinecom. 2015. Healthline. [Online]. [22 April 2015]. Available from: http://www.healthline.com/health/acute-heart-failure

Mayoclinicorg. 2015. Mayoclinicorg. [Online]. [7 May 2015]. Available from: http://www.mayoclinic.org/diseases-conditions/heart-failure/basics/symptoms/con-20029801