Q J Med 2000; 93: 837-838
© 2000 Association of Physicians
Historical note |
Status epilepticus treated with a muscle relaxant: the first success
From the Whiston Hospital, Prescot, Merseyside 1 Glasgow Royal Infirmary, Glasgow, UK
Summary
In 1958, an 11-year-old girl with status epilepticus was given the current treatments which failed to control the convulsions. In order to stop the fits, protect the airway, prevent hypoxia and hyperpyrexia, intermittent positive pressure ventilation (IPPV) and complete muscle paralysis with d-tubocurarine was used for a total of 6 h. The girl made a complete recovery, the first patient to do so using this plan of action.
‘Diseases desperate grown, By desperate appliances are reliev'd, Or not at all.’ King Claudius, Hamlet, Act IV, Scene III.
Introduction
Status epilepticus is defined as two or more seizures without full recovery or recurrent epileptic seizures for more than 30 min.2 It is a life-threatening condition which requires urgent action, and treatment should follow current policies (guidelines).2–5 Anaesthesia with IPPV is required in those cases where drug treatment fails. When this occurred in 1958, it required courageous and rapid action to embark on the potentially hazardous treatment of paralysis and mechanical ventilation even though this had been used to control the convulsions of tetanus. This milestone of intensive care is briefly recalled.
The patient
An 11-year-old girl known to have idiopathic epilepsy was admitted to Alder Hey Children's Hospital Liverpool with generalized convulsions which had started 1 h previously. Treatment with paraldehyde, phenobarbitone and hyoscine proved ineffective in stopping the convulsions. The mucous membranes were cyanosed, and retained secretions could be seen in the pharynx through the clenched teeth. Additional physical signs were tachycardia and pyrexia. The urgency of the situation called for ‘desperate appliances’ to protect the airway, restore adequate gas exchange and stop the convulsions. These were achieved by induction of anaesthesia with thiopentone, paralysis with d-tubocurarine, and intubation of the trachea. The secretions were then cleared from the pharynx and trachea by suction, and IPPV was started. Anaesthesia was maintained using a mixture of oxygen and nitrous oxide, and phenobarbitone was continued throughout. This treatment was carried out by H.I.A. Nisbet, who was then registrar in anaesthesia. The convulsions ceased, and the heart rate and temperature fell. Manual IPPV was used at first, followed by mechanical IPPV from the Fazakerley ventilator6 designed by the Liverpool anaesthetist J.R. Esplen. Complete paralysis required a small second dose of d-tubocurarine. After a total of 6 h IPPV, the patient was weaned off the ventilator and extubated. The girl spoke briefly, and then lapsed into natural sleep. Recovery was complete, an extremely unlikely outcome without intensive care. The clinical experience and facilities should be recorded; the latter bore no relation to those of present-day intensive care. Fortunately, Nisbet routinely used d-tubocurarine for general anaesthesia, a pioneering advance made by Griffiths and Johnson7 and introduced into routine practice in 1946.8 This experience made possible the secure intubation, paralysis and application of controlled IPPV which proved effective in stopping the convulsions.
Discussion
In this case published by Nisbet in 1959,1 prompt application was the key to success. The idea was suggested in 1941 by Bennett:9 ‘certainly, experimentation with curare is worthy of trial in any convulsive disorder that endangers life.’ But for status epilepticus, it was 17 years from idea to application. Success in tetanus came first. In 1935, curare alone controlled the convulsions of tetanus but failed to save life.10 During 1952–54, the combination of curare with IPPV to treat tetanus succeeded in Denmark,11 Italy12 and the UK.13 To return to status epilepticus; only one case report on the use of curare was found. In 1941, Bennett9 gave intravenous curare continuously to a child with encephalitis when sedatives and ether anaesthesia failed to stop the continuous convulsions. During treatment with curare the fits ceased, but the child died from the primary brain pathology.
In status epilepticus, it is important to suppress the excess cerebral activity as quickly as possible, as this can lead to neuronal damage.14 D-tubocurarine and other paralysing agents do not act on the brain and hence the importance of using centrally-acting agents concurrently as in the above case. Formerly, thiopentone was first choice for inducing general anaesthesia, but currently the agents midazolam or propofol are preferred followed by continuous infusion.4
Status epilepticus has a high mortality of around 20%,4 and in one series of elderly patients was as high as 35%,15 the main determinants being the age of the patient (the elderly have a worse prognosis), the nature of any underlying disease and the duration of the status episode.16 Only about a third of cases occur in known epileptics.17 For this group, it follows that ‘prevention is better than cure.’ Intensive care services should be used as part of the prophylaxis, as clearly stated over 30 years ago by Bjørn Ibsen, a member of the Danish team that conquered tetanus: ‘Intensive care units are of great value not only to patients who are admitted for treatment, but even more so to the many patients who due to the experience gained are saved from complications later. When the patient is saved by intensive therapy it has very often been said; why was he allowed to be so ill? It would have been easier to prevent this than cure it’.18
Acknowledgments
We would like to thank the librarians of the Liverpool Medical Institution and Whiston Hospital, Liverpool for their continued help.
Notes
Address correspondence to Dr I.J. Gordon, Archbishops House, Church Road, Liverpool L25 5JF. e-mail: ijgord{at}cwcom.net 
References
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