Status epilepticus

Hyperpyrexia associated with sustained muscle contractions: an alternative diagnosis to central fever

Muscle activity is the principal source of body heat production, and elevated core body temperatures may occur in healthy exercising persons. Hyperpyrexia from sustained tonic muscle contractions can also occur in a number of pathological conditions. The present case of hyperpyrexia associated with dystonic posturing and sustained muscle contraction in a child with encephalopathy illustrates the importance of recognizing muscular activity in the generation of fever of unknown origin following central nervous system injury. The pathophysiology, clinical features, and management of this uncommon cause of fever are discussed.

Status epilepticus in children. The acute management

Status epilepticus is a common pediatric emergency that may result in significant morbidity and mortality. This article provides a clinical update on generalized tonic-clonic status epilepticus in children and a practical approach to their initial stabilization and pharmacologic management. Only an organized approach to the initial stabilization and management of the child in status epilepticus will help prevent unnecessary complications and death.

Status epilepticus in children: etiology, clinical features, and outcome

Between August 1984 and September 1986, data were gathered prospectively on 114 episodes of convulsive status epilepticus, defined as seizure duration longer than 30 minutes, affecting 97 children. Status epilepticus was symptomatic in 72% (chronic 59%, acute 13%) and idiopathic or febrile in 28%. We identified precipitating factors in 63% of episodes. The most common factors were inadequate blood levels of anticonvulsants (32 of 60 episodes in children with prior seizures) and febrile illnesses, excluding meningitis or encephalitis (38 of 114 episodes). There was an elevated peripheral white blood cell count in 60%, acidosis with a pH of less than 7.0 in 12.5%, and cerebrospinal fluid pleocytosis not due to meningitis or encephalitis in 8 of 64 episodes. Eight children died, three with severe pre-existing brain damage, two with meningitis, and two with a poorly defined encephalopathy. Eighteen children developed a new neurologic deficit. Outcome was associated with the etiology and duration of status epilepticus, with age at the time of status a minor factor. A permanent deficit occurred in only five children with idiopathic or febrile status epilepticus.

Metabolism of paraldehyde to acetaldehyde in liver microsomes. Evidence for the involvement of cytochrome P-450

A concentration-dependent acetaldehyde (AcH) generation was observed when paraldehyde was incubated with the mouse liver microsomal fraction. The process, which exhibited a requirement for oxygen and NADPH and was inhibited by carbon monoxide, was found to have a Km of 17.9 mM with respect to paraldehyde and a Vmax of 40.1 nmoles/mg protein/min with respect to AcH formation. NADH was much less effective as an electron donor than NADPH, though a more than additive increase in AcH generation was observed when both of these nucleotides were added to the incubation. The rate of microsomal AcH generation from paraldehyde was increased 2.5-fold by pretreatment of the mice with phenobarbital but only 0.6-fold by pretreatment with 3-methylcholanthrene. Pretreatment with 2-diethylaminoethyl-2,2-diphenylvalerate hydrochloride (SKF-525A) resulted in 54% inhibition of the reaction rate. Addition of metopirone to the incubation inhibited AcH generation in a concentration-related fashion, the inhibition being greatest, proportionately, in microsomes from phenobarbital-pretreated animals. The above results conclusively indicate the involvement of cytochrome P-540 mixed function oxidase in the formation of AcH from paraldehyde by mouse liver microsomes. It is also postulated that this process may be accomplished in the reaction analogous to O-dealkylation.

Treatment of status epilepticus with thiopentone sodium anaesthesia in a child

A 4-month-old infant was admitted to the Pediatric Intensive Care Unit with Pneumococcal meningitis. A few hours after admission he developed intractable convulsions that could not be stopped with phenytoin, phenobarbitone and a continuous drip of diazepam. Thiopentone sodium anaesthesia was induced for 24 h terminating the status epilepticus. The clinical course, correlary EEG findings, treatment protocol and blood levels of the drugs given are described in detail.