Cai Ling B is a Chinese Asian is admitted at Rosewood Windsor Care Facility at Unit S1, Room number 122A under the supervision of the Kooturu Sri, a primary physician. Cai Ling is a 68 year old male and is diagnosed with persistent vegetative. His secondary diagnosis include Epilepsy, paralytic syndrome, nontraumatic intercerebral hemorrhage, dysphagia, dysfunction of the urinary bladder, hypertension, chronic embolism, muscle weakness, cyst of kidney. While Cai was admitted to the hospital, he was fitted with PEG tube and tracheostomy and was transferred from the John Muir Medical Center. His recent POLST (Physician Orders for Life-Sustaining Treatment) states that she is in full code (opposite of do not resusticate).
Upon assessment, Cai was awake but not alert and oriented. He was not communicating verbally but at times was responding by making an eye contact after ask he was asked with few questions. His pupils constrict equally but he was unable to follow commands, therefore I was unable to assess his accommodation. His upper extremities have a active passive range (can move arms on his own) of motion and his hands have contractures. On auscultation, his upper lobes have lung sounds and the lower lobes have wheezing and crackle.
Upon examination of his pulmonary condition, it was found that he needs tracheal suctioning due to sputum but only had mild amounts sputum during the time of assessment. Cai currently has a PEG (percutaneous endoscopic gastrostomy) tube placed in the left quadrant near the epigastria and receives nutrition feedings (jevity 1.5 cal: it is a calorically dense liquid food which has a patented blend of fiber that provides Complete yet Balanced Nutrition) daily along with his medicines. He had no signs of edema on both upper and lower extremities. Bowel sounds were active to auscultation and condom catheter is present. Patient is incontinent and currently in briefs. Cai is highly dependent to the healthcare providers. The immunology report of Cai indicates that his is high on the WB count along with high level of neutrophil count. The increase in the WBC count indicates the presence of inflammation. The WBC count of Cai is 15.61 where as the
normal range is 3.3-8.7 K/uL. The neutrophil count is 845 where as the normal count is 55 to 70%. Lately Cai is also suffering from depression and was taking anti-depressant and this mental condition is low. He was not sexually active and is in vegetative state.
Cai is suffering from Tonic Clonic Seizures. It is a type if seizures or convulsion which was previously known as “grand mal”. It is known as tonic clonic seizures, because it is combination of characteristics of tonic and clonic seizures. Tonic means stiffening and clonic means rhythmical jerking (French et al., 2015). Tonic phase comes fast with muscle stiffening, loss of consciousness, sudden involuntary bite on tongue or inside the chicks. Tonic phase is proceeded by clonic phase and it is characterized by jerk in the arms and in the legs in a rhythmic manner. This is followed by bending and relaxing of the elbows, hips and knees. The face becomes blue and the affected individuals experiences troubled breathing and lack of control over the bladder. This is processed with lack of consciousness. The seizures mainly last for 1 to 3 minutes. As the prognosis of the disease worsens, the seizures tenure prolongs leading to 10 minutes long seizures. Thus, it can be seen that tonic clonic seizures affect different parts of the body (French et al., 2015). The main part of the body, which modulates the neurological impulses leading to seizures, is brain. Tonic seizures can start at both the sides of the brain. When the start in both sides of the brain they are known as generalized onset motor seizures or generalized tonic-clonic seizure. Tonic clonic seizures initiating at one side of the brain and then spreading to both the sides of the brain are known as focal to bilateral tonic-clonic seizure. The basal ganglia is an important part of the brain that plays a pivotal role in the development of seizures (French et al., 2015). According to Human Physiology by Stuart Ira Fox, basal ganglia are the masses of grey matter, which is made up to neuron cell bodies located deep inside the white matter of the cerebellum. The main function of the basal ganglion is to control and co-ordinates the voluntary muscles. The basal ganglion at the cerebral cortex, controls and co-ordinates this functions. The cortical axons mainly execute this function by the release of the dopamine receptors in the Substantia Nigra. However, Rektor (2018) stated that basal ganglion does not play a pivotal part in the development of seizures. Basal ganglia is present inconsistently present in the first part of the seizure. The time span of the oscillatory activities and the absence of the epileptiform data highlights that basal ganglia plays an inhibitory role in the development of seizures. The inhibitory impact is mainly modulated by the feedback activity in the cortex (Rektor, 2018).
According to Conradsen et al. (2013) tonic seizures causes muscle weakness along with involuntary tightening of the muscles followed by jerk and twist. This might be the reason why Cai is experiencing muscle weakness followed by contractures in the hands. However, his upper extremities were found to posses’ active-passive range. This means that though he can move his arm on his own, his fingers tips are experiencing contractures. In order to study the dynamics between the tonic-clonic seizures and the muscles, Conradsen et al. (2013) conducted a study with surface electromyography (EMG) over deltoid muscles. The analysis of the results highlighted that the A longer clonic phase was associated with shorter onset of the tonic phase along with higher seizure of occurrence. At the onset phase of the seizure, there is the effect over the muscle cells occurs at low frequency. However, during the transition to tonic to clonic phase there occurs vibration in the muscles. Conradsen et al. (2013) concluded that the inhibitory mechanisms that contribute to generalized tonic clonic seizures (GTCS) termination counteract the seizure initiation and this account for the gradual onset of the muscle stiffness. Both the active inhibition and mechanisms associated with the metabolic depletion act synergistically to the stop the seizures leading to muscle stiffness and contraction of the figures as experienced by the Cai.
The integumentary system of the body comprises of the skin and its appendages which acts to protect the body from several different kind of damages like loss of water from the body ad threats coming from the external atmosphere. The main organs, which are included in the integumentary system, include the epidermis, dermis, hypodermis, hair, nails, sebaceous glands, sudoriferous glands and ceruminous glands (Waitman, 2015). The analysis of the Cai revealed that he has no signs of edema on both upper and lower extremities. Thus the effect of the tonic clonal seizures in case of Cai has not affected the integumentary system of the body. According to Izumida et al. (2017), the most common form of edema occurring during the tonic-clonal seizure is pulmonary edema. Pulmonary edema is condition in which the lung is filled with water of mucus and the is commonly known as lung congestion. When pulmonary edema occurs, body struggles to fetch adequate oxygen. Kennedy et al. (2015) stated that pulmonary edema resulting out of the tonic-clonic seizure is not directly associated with an immediate development of congestive heart failure. If pulmonary edema is left untreated, it leads to the development of congestive heart failure leading to sudden unexpected death in epilepsy.
According to Nei (2009) seizures affect the heart rate and rhythm. In the majority of the cases, seizure-related to the cardiac changes are transient and do not surface to generate clinically significant abnormalities for the patient. Nei (2009) stated that in adults generalized tonic-clonic seizures cause a sudden increase in the heart rate. Patients suffering from the temporal lobe seizures are associated with dominant increase in the heart rate. The pattern of change in the heart rate associated with seizures is characterized by steep acceleration during the onset of seizure. This is followed by a marked variations during the seizures and postictally. Seizures associated with the asytole and bradycardia are less common. Ictal bradycardia occurs only under the settings of the respiratory changes suggesting the importance of the cardio-respiratory changes. The electrical stimulation of human insular cortex highlights that the right hemisphere have greater sympathetic influence. The left hemisphere have greater parasympathetic control. The seizures are also associated with abnormalities in the heart rate and heart rhythm. The abnormalities in the heart rate are associated with the generation of the atrial fibrillation, supraventricular tachycardia atrial premature depolarization and bundle branch block along with ventricular premature depolarization (Nei, 2009). The most recent PLOST state of Cai reports resuscitation. This signifies that Cai heart rate might be abnormal leading to insufficient flow of the oxygen to the brain. The cardiopulmonary resuscitation can be defined as an emergency procedure that is a combination of chest compressions with the help of artificial ventilation in order to preserve the intact function of the brain and helps to ensure spontaneous circulation of the blood.
Under cardio anomalies, it can also be highlighted that Cai has the previous reported history of non-traumatic intercerebral hemorrhage. According to Nei (2009), intercerebral hemorrhage (ICH) arises due to bleeding within the brain tissue. It is the life threatening events leading to cardiac accident. Intercerebral hemorrhage mainly results in the oxygen deprivation within the body, which leads to the generation of hypertension and arteriovenous malformations along with head trauma. All these lead to the development of cardiac stroke or cardiac accident.
According to Van de Vel et al. (2013) co-monitoring of the respiratory functions along with seizures with the help of pulse oxumetry has revealed ictal respiratory changes (IRCs) along with tonic-clonic convulsions associated with partial seizures of the temporal lobe origin. The pre-Botzinger complex in the rostral ventrolateral medulla is the principal locus for the respiratory rhythm generation along with expiratory control neurons near the nucleus. The inputs to these neurons descend from the insula, hypothalamus and the reticular formation. In tonic clonal seizures, direct stimulation occurs in the limbic target causing apnea. The case report of Cai highlights that on auscultation, his upper lobes is producing rhonchi lung sounds while the lower lobes have wheezing along with crackles. The lungs are also filled with sputum, which is creating the blockage for the proper respiration and thus tracheal suctioning was important. The condition of Cai is reaching towards the sudden unexpected death in epilepsy (SUDEP). According to Van de Vel et al. (2013) tonic clonic seizures causes apnoea and bradycardia causing to sudden unexpected death in epilepsy (SUDEP). Other pulmonary complications occurring during tonic clonal seizures include pulmonary insufficiency. During the onset of the generalized seizure activity, the sympathetic activity of the lungs increases significantly and it is manifested by an increase in the systemic and pulmonary vascular pressure. Neurogenic pulmonary edema as experienced by Cai is also common pulmonary complications in tonic clonal seizures and it is associated with SUDEP. The pulmonary edema occurs due to increase in the preload and pulmonary capillary permeability (Epilepsy Fpundation, 2018).
The interaction of the seizures with the neurosensory system is very complex. Abnormal neuronal electricity activity corresponding to a seizure can involve central centers for the proper regulation of the autonomic activity. Seizure can be present with autonomic symptoms during the initial stages and this proper study of the autonomic manifestations f the seizures are important. In relation to the neurosensory system of Cai, it can be said the Cai was awake but was not alert and oriented. He is non-verbal but at times was responding by looking at the healthcare professionals upon his questions. His pupils constrict equally. However, he was unable to follow the commands given by the health care professionals. This shows that his glass glow coma scale is poor. In the eye opening response, he is opening his eyes in response to speech (score 3). In the domain of verbal response, he is showing no response (score 1) but at times was responding to questions. In the domain of the best motor response be can moves his hands and thus considering that he is obeys commands (Score 6) or it can be moving hands in response of the localized pain (5). In the domain of pupils’ contraction it can be elaborated further that altered papillary behavior is commonly present during the epileptic seizures. The case study highlights that the patient is in the vegetative state and thus his Glass Glow Coma Scale is extremely low at the time of admission. Symptomatic pupilary hippus is the main feature of the tonic-clonal seizure as reported under the modern literature. Mainly bilateral papillary hippus is the main semiologic feature and this is a autonomic phenomenon selective for the pupils. It does not involve any other autonomic-mediated responses (Centeno et al., 2011). In relation to the case study, it can be highlighted further that Cai is incontinent at present. This means that he has no voluntary control over his impulses and thus signifying a complete loss of the voluntary functions of the neurological system. This is also the reason behind his paralytic syndrome. Cai is also taking anti-depressant pills lately and this might be an indicators of his mental health. Prolong illness might have lead to the development of depression.
Tonic-clonal seizures are not directly associated with any of the ill-effects of the gastro-intestinal system. This is as per the reports highlighted in the case study which states that bowel sounds were active to auscultation. According to HarSHe et al. (2016), abdominal epilepsy, a variant of temporal lobe epilepsy is associated with the gastro-intestinal complications and is commonly seen among the children. However, the conditions abdominal seizures also prevalent among the adults and is associated with chronic and recurrent gastro-intestinal symptoms along with more than one neuropsychiatric manifestations (HarSHe et al., 2016). However, from the case study, it is clear that Cai is suffering from certain complications in the epigastrium and thus was receiving his nutritional feedings with jevity 1.5 cal: it is a calorically dense liquid food which has a patented blend of fiber that provides Complete yet Balanced Nutrition. Cai is also suffering from dysphagia and this signifies that that he is facing difficulty in swallowing and this might be the reason why he on PEG tube and is on Jevity diet. Morrison and Hodgdon (2013) argued that the development of the tonic clonal seizures lead to the development involuntary movements in the different parts of the body. This might be the reason why he is unable to swallow the food and thus suffering from dysphagia and is fitted with PEG tube. Morrison and Hodgdon (2013) stated that obstruction of the small bowel causes symptoms shortly after the onset. This is followed by abdominal cramps centered around the umbilicus or in the epigastrium. This construction mainly leads to vomiting and at times lead to complete obstruction epigastrium. Complete obstruction of the epigastrium lads to minimal peristalsis movements leading lack of proper nutritional access in the body (Morrison & Hodgdon, 2013).
According to Gulleroglu et al. (2013), the urinary incontinence complicates the end phase of the clinic stage of the tonic-clonic seizure. During this time, the sphincter muscles relax in a patient with a full bladder. The urinary incontinence generally complicates the partial seizures resulting from a combination of an increased in the intra-vesicular pressure and complete of partial loss of the cortical inhibition of the mictutrition reflex. In case of the urinary system, Cai was with condom catheter. The installation of the condom catheter is done in order to measure the output of the urine. Moreover, it is also installed in the patients who are unable to move and go to the washroom. Thus the installation of the condom catheter to Cai indicates that his urinary functions are operating at a stable rate and the installation is done for the hygienic purposes and to count the urine output. However, installation of the condom catheter might leads to the generation of the urinary tract infection if not replaced or cleaned regularly and this increase in the level of infection within the body leads to seizures in the urinary tract. The previous case history of Cai stated that he has bladder dysfunction and this might lead to the installation of the condom catheter due to incontinence in urine retentsion. He is also experiencing the cyst in kidneys and this might further propagate in renal complications.
According to Velíšková & DeSantis (2013), interactions between the hormones, epilepsy and the medications, which are used for the treatment of epilepsy are complex and requires proper tri-directional interactions. These tri-directional interactions affect both men and women under various ways. Abnormalities, which are underlying the endocrine status, occur commonly among the people who are suffering from the tonic clonal seizures and are commonly described under the concept of the sex steroid hormone axis. The common symptoms, which are associated with the tonic clonal seizures, include sexual dysfunction, decrease in the level of fertility. However, in case of the Cai. No direct reference to the malfunction in the endocrine system is provided. Velíšková & DeSantis (2013) are of the opinion that the malfunction of the neuronal systems hampers the proper transport of the hormones to the different parts of the body leading to the several hormonal complications.
The tonic clonal seizures or the grand mill seizures at times hampered the reproductive system. This hamper in the reproductive system is reflected like loss of the erectile function, which is classified as the erectile dysfunction, and loss of the sperm and libido. Velíšková and DeSantis (2013) stated that seizures disorders are mainly common in males in comparison to females as highlighted in the case study, Cai is male. Velíšková and DeSantis (20130 also stated that reciprocal relationship exists between the sex hormones and seizures and sex hormones can be considered as adjunctive therapy among the patients suffering from tonic clonal seizures. In case if Cai, the case study highilights that he is not sexually active and this might be an indications that his reproductive system has been affected as a result of tonic clonal seizures.
The immune system is also hampered under the tonic clonal seizures. According to Vezzani, Lang and Aronica (2016), both innate and the adaptive immune responses are hampered under the tonic clonal seizures leading to rise in the inflammatory responses which might lead to swelling of hands and feets. The main inflammatory response develops in brain. In tonic clonal seizures, the function of the brain is disrupted and thus leading to the generation of unwanted inflammatory response. However, his current physiological state indicates that he is very weak and thus can be immune-compromised. He has elevated level of white blood cells. The level of the white blood cell count is 15.61 k/micro liter (normal range: 3.3 to 8.7 K/ micro liter). High level of white blood cells or the lymphocytes within the body indicates high level of infections within the body. According to Owen, Punt and Stranford (2013) in response of the infection within the body, the first line of defense is the innate immunity. When the innate immunity fails, then the second line of defense, which arrives is the adaptive immune response. Under the adaptive immune response, the body first produces neutrophils and macrophages, which are polymorpho-nucelar cells. The poly-morpho nuclear cells are multi-nucleated cells. This multi-nuclear cells helps to phagocytose the harmful bacteria or other pathogens through the secretion of the phagocytotic enzymes. Marcophage and the neutrophils mainly engulfs the bacteria or the pathogen leading to its death or relase phagocytic enzyme which cleaves the bacterial cells leading to bactericidal activity (Owen, Punt & Stranford, 2013). This is due to this reason that Cai has high count of neutrophils (84.1 and the normal count is 55 to 70%).
References
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Conradsen, I., Moldovan, M., Jennum, P., Wolf, P., Farina, D., & Beniczky, S. (2013). Dynamics of muscle activation during tonic–clonic seizures. Epilepsy research, 104(1-2), 84-93.
Epilepsy Fpundation. (2018). Generalized Seizures or SE. Access date: 5th of December 2018. Retrieved from: https://www.epilepsy.com/learn/professionals/co-existing-disorders/pulmonary-disorders/generalized-seizures-or-se
Fox, S. I. (2003). MP: Human Physiology. McGraw-Hill.
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