module - 3 Seizure

Psychosocial concerns

Depression Social Isolation Counseling Support groups

Divalproex side effects

GI distress, N & V, hirsutism, weight loss

Types of seizures

Generalized - *Bilaterally and synchronous* distributed discharges Focal - Originates in *one hemisphere* of the brain in a localized area. Causes: - *Head injury* - *Brain infections* - *Stroke* - *Tumor* - *Cortical dysplasias* : a congenital abnormality of brain development where the neurons in an area of the brain failed to migrate in the proper formation in utero(자궁내의) - Genetic factors Idiopathic - unknown The International League Against Epilepsy (ILAE) differentiates between 3 main Seizure types: *Generalized, Focal, and idiopathic or unknown*. Generalized: usually start in one place in the brain and then move to the whole brain (both hemispheres) Going to affect the whole body because it affects the whole brain Focal seizures: usually confined to one hemisphere or a small part of the brain Going to affect one part of the body depending on where it is in the brain *Frontal lobe*: could be affected *smell* *Motive cortex*: can affect *motor issues* and can cause *trembling* and that is usually present on only one side but can be on both because a focal seizure can become a generalized seizure *Temporal* area: *hearing* is affected *Occipital*: *vision* affected (blurry or cant see) Sensory cortex: sensations that you are having *As a nurse you need to be able to write down when a patient has a seizure: time, what is happening to the patient, how long it lasts so that way dr. can diagnose it better*

Anticonvulsant therapy

Goals - Prevent seizure reoccurrence - Obtain max seizure control with minimal side effects NO CURE

Tonic-Clonic (Grand mal) seizure

Most common generalized seizure Loss of consciousness Fall to the ground Body stiffening (tonic) 10-20 secs Extremities jerking (clonic) 30-40 secs May accompany the seizure: - Cyanosis(청색증) - Excessive salivation - Tongue/cheek biting - Incontinence Post-ictal phase - May sleep for several hours afterwards - May have no memory of the event Post-ictal phase: may be have muscle soreness, fatigue. May not feel normal for hours to days post seizure. Safety first!!

Treatment of seizures

Most seizures do not require emergency medical care Exceptions: - Status epilepticus - Bodily harm occurs - First-time seizure

Other Generalized Seizures

Myoclonic - Sudden excessive jerking of body or extremities - May throw the person to the ground - Very brief, may occur in clusters Atonic - *"drop attack"* - Loss of muscle tone - Sudden fall to the ground - Loss of consciousness while falling, but returns by the time the person hits the floor - Normal activity can be resumed immediately Tonic seizure: sudden onset of increased tone in extensor muscles. Clients often fall Clonic seizure: begin w/ loss of consciousness, sudden loss of muscle tone, then limb jerking that may or may not be symmetric

Ethosuximide side effects

N & V, headache, gastric distress

Drug therapy nursing considerations for seizures

Neurologic assessment: assess for toxicity - *Nystagmus* - *Hand and gait coordination* - Cognitive functioning - General alertness Provide/encourage good dental and oral care Medication compliance Medication adherence a problem due to side effects. Gingival hyperplasia: can be extensive and require surgery to remove . *In this case phenytoin will need to be replaced with another med. (especially in kids)*

Nursing Interventions for seizures

Preventing injury Reducing the fear of seizures Improving coping mechanisms Safety-preventing injury, padding siderails, seizure precautions, Fear-compliance with medication and periodic monitoring. -education regarding triggers such as; stress, alcoholic beverages, electrical shocks, caffeine, diet, *constipation, fever, hyperventilation, and hypoglycemia*.

Idiopathic seizures

Pseudo seizures - May be misdiagnosed - Video EEG - Past history of abuse *Psychogenic non-epileptic seizures (PNES)* - Related to some kind of trauma (emotional abuse, physical neglect) and have a physical manifestation of seizure - Not r/t neuron firing - Conversion disorder look it up Unclassified/Psychogenic - Pseudo seizures that are psychiatric in origin. - Resemble epileptic seizures; may be misdiagnosed - Requires video EEG to capture typical episode. *Considered gold standard in discriminating between epileptic and non epileptic episodes. - Pts w/ these usually have history of emotional abuse, physical neglect, specific traumatic episode. - "Psychogenic non-epileptic seizures (PNES) do not result from abnormal electrical discharge from the brain. They are a physical manifestation of a psychological disturbance." Benbadis, et al (2015). Medscape. - PNES considered a psychiatric disorder known as a conversion disorder...where psychological stress presents in physical ways.

Diagnosis of seizures

*Developmental History (very important)* Past history of injury Assessment - *Neurological* MRI Electroencephalography (EEG) CT Scan *LP - test for infection(meningitis)* A negative EEG does not mean the patient does not have a seizure disorder *Diagnosis is aimed at determining the type of seizure, frequency, severity, and factors that precipitate them*. *Developmental History-pregnancy and childhood* *Labs*: Is there a simple underlying cause? *Infection, hypoglycemia, acidosis*, etc. *EEG*: measures electrical impulses in brain; determines level of brain activity during activities, surgery, sleep; only useful if the patient has a seizure during the test (*helps determine type of seizure*) A negative EEG does not mean that the patient does not have a seizure disorder. (some people with clinical seizures may have normal EEGs and those that have never had seizures may have abnormal EEGs.) EEG's may need to be repeated often or continuous EEG monitoring may be needed to detect abnormalities. *Video studies with EEGs can determine the type of seizure as well as the duration and magnitude(size)*. EEGs used to confirm: - Seizures - Head injury - *Encephalitis* - Brain tumor - *Encephalopathy* - Memory issues - Sleep disorders - Stroke: dead tissue due to blockage of blood flow - dementia Instructions prior to EEG: wash hair; no product in hair; avoid caffeine at least 8 hours prior to test; Takes 30-60 minutes to complete; CT or MRI: structural issues, hypoxia, stroke LP: Rule out(배제하다) infection: meningitis Toxicology screen: drugs?

Epilepsy diagnosis

*Diagnosed after having 2 unprovoked seizures* Etiology: - Abnormal neurons: stimulus that provokes cell membrane of neuron to depolarize tends to induce seizure - Scar tissue - Astrocyte functionality(상관 관계) - Idiopathic Generalized Epilepsy: genetic predisposition(경향) - Cryptogenic: unknown underlying cause Scarring is believed to interfere with the normal chemical and structural environment of the brain neurons, making them more likely to fire abnormally. A single seizure is NOT a reliable factor indicator that an individual has epilepsy. Astrocytes: Activation of astrocytes by hyperactive neurons is one of the crucial factors that predispose neurons nearby to the generation of an epileptic discharge. (Astrocytes are types of glial cells which provide support, nourishment, and protection to neurons. Astrocytes play a role in synaptic transmission; act as phagocytes for neuronal debris; restore neurochemical milieu and provide support for repair; can contribute to scar tissue formation. Lewis, p. 1336) Genes: Abnormalities in specific genes that control the flow of ions in and out of cells and regulate neuron signaling or are involved with protein and carbohydrate metabolism. In one research article epilepsy was classified as idiopathic (with a presumed genetic basis), symptomatic (resulting from a structural abnormality), or cryptogenic (resulting from an unknown underlying cause). Focal Epilepsy: Abnormal genes may influence the disorder in subtle ways. For example, a person with epilepsy may have an abnormally active version of a gene that increases resistance to drugs. This may help explain why antiseizure drugs do not work for some people. One explanation for the establishment of focal epilepsy is decreased local GABA-mediated inhibition. Many facets of epilepsy can be elicited experimentally by blocking GABA receptors with the toxin picrotoxin previously described. The decrease in GABA inhibition permits cells to fire synchronously, thus producing massive local excitation and initiation of a seizure. Clinically, seizures can often be terminated by inducing a barbiturate coma. High dose barbiturates presumably potentiate GABA's inhibitory effects, preventing local hyperexcitation by hyperpolarizing the cell membranes. Retrieved from http://nba.uth.tmc.edu/neuroscience/m/s1/chapter13.html

Ketogenic diets and biofeedback

*Ketogenic diet* has been effective in controlling seizures in some. - *High-fat, low carbohydrate diet* - Ketones pass into the brain and replace glucose as an energy source. Biofeedback to control seizures teaches patient to maintain a certain brain wave frequency. The diet is strict and is often begun in a hospital setting. It has been proven successful with some children who do not respond well to medication. However, it may be used in conjunction with anti-seizure medication in some individuals. The diet is high in fat, supplies adequate protein and is low in carbohydrates. This combination changes the way energy is used in the body. Fat is converted in the liver into fatty acids and ketone bodies. Another effect of the diet is that it lowers glucose levels and improves insulin resistance. An elevated level of ketone bodies in the blood, a state known as ketosis, leads to a reduction in the occurrence of epileptic seizures. Retrieved from Charlie foundation. Biofeedback/Neurofeedback: With Neurofeedback, specific symptoms of Epilepsy can be targeted, however, every individual is different and to what extent the brain can recover or compensate abnormalities. Since abnormal brain activity, also know as instabilities, are seen as the main cause of Epilepsy, the most important goal during Neurofeedback training is stabilizing the brain. In other words, 'to train the brain to control it's abnormal activity'. Neurofeedback is a treatment option applicable to all types of seizures and helpful in the case of brain damage and brain abnormalities. Other training options can be physical calming, resulting in improved balance and coordination, or enhancing emotional control, which for example can reduce anxiety. As the research shows, Neurofeedback can be very effective in reducing or eliminating epileptic seizures. Some people might describe Neurofeedback as a 'cure' for epilepsy, however we don't use this term as we don't regard brain deregulation as a 'disease'. Retrieved from http://www.braintrainuk.com/other-conditions-that-neurofeedback-supports/neurofeedback-for-epilespy/

Focal seizures

*More common than generalized seizures* Simple focal (no impairment of consciousness) *Complex Focal (impairment of consciousness)* Focal evolving to secondary generalized seizures Simple focal (jacksonian seizures) will not lose consciousness, may experience confusion, tingling, odd mental(hallucination) and emotional events, may have déjà vu moment or extreme response to taste or smell. Left with a little muscle weakness lasts about 90 seconds Complex focal do have an impairment of consciousness, usually occur in *temporal lobe*, motionless, vacant stare, emotions can be exaggerated, repetitive movements, usually last up to 2 minutes. Can progress to generalized. Can leave patient with a headache afterward

Phases of seizures

*Prodromal* - Signs or activity that precede a seizure *Aural* - Sensory warning *Ictal* - Full seizure *Post-ictal* - Recovery period after the seizure Not all phases may be recognized by person. The person may have warning symptoms before the attack, such as: - *Fear or anxiety* - *Nausea* - *Vertigo* (feeling as if you are spinning or moving) - *Visual symptoms* (such as flashing bright lights, spots, or wavy lines before the eyes) Aura: precede temporal lobe seizures in 80% of cases - Abdominal (a rising epigastric sensation) - Psychic aura (fear, déjà vu) - Parietal lobe seizures: Electrical sensation, tingling - Occipital lobe: Visual changes...colored lines, spots, shapes, loss of vision.

Epilepsy

*Spontaneous* *Recurring* "A central nervous system disorder in which nerve cell activity in the brain becomes disrupted, causing seizures or periods of unusual behavior, sensations and sometimes loss of consciousness." Chronic seizure condition Around 3 million people have this Increasing in older adults but most forms occur in childhood and are diagnosed in childhood If it is a woman in her childbearing years effectiveness birth control is less effective due to anticonvulsants *Long-term use of seizure meds is related to bone* *loss* *During pregnancy the risk of congenital deformity is higher by 2-3 times* *Issues with med absorption can lead to liver failure so always check liver function tests* Epilepsy is a seizure disorder of varied causes and symptoms and its *treatment depends on various factors including the age of onset and type of seizure*. Sometimes the seizure is absent or mild enough to not warrant treatment. May resolve over time. Spontaneous recurring seizures caused by a chronic underlying condition. Around 3 million people have active epilepsy 200,000 cases diagnosed yearly Incidence is increasing in older adults in US *Most forms of epilepsy occur in childhood*. Epilepsy in Women Over 1 million women have epilepsy. *Increase in epilepsy during menses*. Effectiveness of BCP(Birth Control Pill) is reduced by anticonvulsant drugs. Therefore planning for childbearing is important. During pregnancy, change in epilepsy. The risk of congenital deformity is higher (2-3X). Long term use of antiseizure medications is associated with *bone loss and osteoporosis*. Geriatric population Older adults have a high incidence of new onset epilepsy. Problems with medication interaction, decreased absorption, and metabolism can lead to critical levels or changes in renal and liver failure. Approximately 50% of epilepsy cases are caused by unknown factors. In the remaining cases, they are typically genetic, environmental, or trauma related. Conditions that result in epilepsy: Birth defects-over 500 genes can be linked to this. Deprivation of oxygen to the brain-during birth Severe head injuries-can cause seizures in adults and children and can be seen years later. Brain infections-meningitis, AIDs, viral encephalitis Brain tissue alteration: Alzheimer's disease or if suffered a stroke (*stroke is leading cause of epilepsy in adults older than age 35*)

Status epilepticus

A state of continuous seizure activity (*>5 mins*) *Two or more sequential seizures without recovery of consciousness between seizures* Both convulsive and non-convulsive *Most common type is tonic-clonic* Life- threatening medical emergency *Subclinical seizures - sedated patient seizes without external signs* Lack of perfusion, neuron exhaustion can cause them to not work, can cause hypothermia, can cause brain to not keep up with metabolic availability When this happens you give a PRN med to help stop the seizure - *Ativen* make sure safety first and can help to breath. Convulsions- involuntary muscle contractions During repeated seizures, the brain uses more energy than can be supplied Neurons become exhausted and stop functioning *Tonic-clonic status epilepticus is most dangerous type* Can cause ventilator insufficiency, dysrhythmias, and hyperthermia Cerebral edema: Seizures increase cerebral metabolic rate; if oxygen delivery does not keep up with metabolic demand, brain ischemia, edema, neuronal dysfunction, and death can occur. Hyperemia (blood engorgement) from increased cerebral metabolic rate encourages vasogenic edema (This edema results from disruption of the blood brain barrier, allowing protein-rich fluid to accumulate in the extracellular space [1].)

Seizure definition

Abnormal motor, sensory, autonomic or psychic activity (or combo of) that results from a sudden excessive discharge from cerebral neurons. All or part of brain involvement Can last seconds to minutes Cause may or may not be known Causes may be related to other disorders Affects all ages Seizures are overexcited neurons and depending on where the seizure is and how it is affecting the brain determines how it presents The brain contains billions of neurons (nerve cells) that create and receive electrical impulses. Messages from the body are transmitted along the neuronal pathway. Electrical impulses allow neurons to communicate with one another. During a seizure, there is abnormal and excessive electrical activity in the brain. Cells may continue firing after a task is finished/completed. Any part of the body controlled by these nerve cells may continue to respond...leading to....Changes in awareness, behavior, and/or abnormal movements. Usually lasts only a few seconds to minutes. Retrieved from http://www.uptodate.com/contents/seizures-in-adults-beyond-the-basics?view=print The term "seizure" is often used interchangeably with "convulsion." Convulsions occur when a person's body shakes rapidly and uncontrollably. During convulsions, the person's muscles contract and relax repeatedly. There are many different types of seizures. Some have mild symptoms without shaking. Retrieved from https://www.nlm.nih.gov/medlineplus/ency/article/003200.htm

Simple focal seizure

Also referred to as Simple Partial seizure Simple motor or sensory phenomena - Motor: face twitching, fidgeting(안절부절못하게 하다), blinking - Sensory: numbness or tingling; visual, auditory, gustatory Usually do not involve a loss of consciousness Rarely last longer than 1 minute *Can progress to generalized seizure* *Can have an aura* Simple - Involves single part of brain; no loss of consciousness and rarely last longer than 1 minute. May be motor, sensory or a combination *Complex - last longer than a minute and have a postictal(발작후) phase. Involve an alteration in consciousness* Signs and symptoms usually relate to area of brain affected. Sensory: hearing sounds, smelling odors; Gustatory (taste) Vertiginous (dizziness) Many times focal seizures precede a generalized seizure. Client may experience an aura or warning. Tonic-clonic seizures many times are secondary generalized seizures, extending from a focal seizure that spread across

Selection of anti-seizure meds

Based on: - Type of seizure - Age and gender of the patient - Other medical conditions that are present - Potential adverse side effects of the individual medicines Therapeutic range for each drug indicates - Serum level above which, most patients experience side effects - And below which, most patients continue to have seizures *check the liver function every 6 month* Research has shown that when people first start on seizure medicine, only 47% became seizure free with the first medicine. When a second drug was tried, another 14% of people became seizure free. When more than two drugs were tried the response to medicines decreased markedly. Long term use of anti seizure meds is associated with: Bone loss; osteoporosis/osteopenia *Increased risk of fractures: One reason maybe die to antiepileptic meds metabolism of Vitamin D*. Renal and liver damage

Carbamazepine side effects

Dizziness, drowsiness, diplopia, N&V, mild leukopenia

Clonazepam side effects

Drowsiness, behavior changes, headache, hirsutism

Lamotrigine side effects

Drowsiness, tremor, nausea, ataxia, dizziness, weight gain

More complications

Effect on lifestyle is the most common complication of seizure disorder. Social stigma(오명) still exists Discrimination/limitations in employment Driving limitations Pregnancy Outdoor activities *Safety: medical ID bracelets and cards* *6 months or 27 weeks seizure free before can drive* and have to submit a physicians evaluation of safety Discrimination in employment needs to be referred to US Equal Employment Opportunity Commission (EEOC). Although most people with epilepsy live a normal life span and rarely suffer injuries from seizures, there are some patients, especially those with tonic clonic seizures, who may need to take special precautions such as wearing a helmet to protect the head during falls or avoid swimming or taking a bath without someone present to intervene (prevent drowning) if a seizure occurs. Other precautions during activities such as driving, childcare, and sport participation should be seriously considered as seizure activity may compromise an individual's ability to function safely during certain activities. Retrieved from emedicinehealth.com: http://www.emedicinehealth.com/slideshow_pictures_epilepsy/article_em.htm There should always be a lifeguard or buddy present when you go swimming. https://www.nlm.nih.gov/medlineplus/ency/patientinstructions/000128.htm Driving limitations: Every state regulates driver's license eligibility of persons with certain medical conditions. The most common requirement for people with epilepsy is that they be seizure free for a specific period of time (6 months or 27 weeks) and submit a physician's evaluation of their ability to drive safely. Another common requirement is the periodic submission of medical reports, in some states for a specified period of time and in others for as long as the person remains licensed. Retrieved from http://www.epilepsy.com/driving-laws/2008806 Women with a history of epilepsy who are being treated for this problem should consult their OB/GYN physician before getting pregnant about how to best reduce the risk of fetal malformations, miscarriage, perinatal death, and increased seizure frequency. Many women who follow the instructions of their physicians by altering their medications and/or dosage can become pregnant and deliver a healthy child. *Many antiseizure meds are teratogenic*.

Nursing management during seizure

Ensure patient safety Provide privacy Ease patient to the floor Remove glasses and loosen restrictive clothing Do not force anything into the patients mouth Do not restrain patient Document time and duration of the seizure Observe for consciousness If possible place on his/her side *Monitor VS and oxygen saturation* Suction as needed *Establish IV access* Anticipate administration of *phenytoin, benzodiazepines, or phenobarbital* Pg. 961 med surg book Airway!! Breathing!! Circulation!! Patient safety priority #1. Another important responsibility of the nurse is to observe and record sequence of seizure. Document the following: - *Activity prior to seizure*. - *Occurrence of an aura* - *First movement in a seizure* - *Type of movements* - *Area of body involved* - *Size of pupils, eyes open or closed*. - *Incontinence* - *LOC* - *What happens after the seizure*. Are there other ways to administer meds if IV access is unavailable? *Rectal, IM, buccal, or nasal routes* may be necessary in situations where an IV cannot be started. Do not put anything between their teeth. If you cannot put anything in the mouth, how can one suction the client that is seizing? Describe how one would suction the client.

Drugs for absence and myoclonic seizures

Ethosuximide (Zarontin) Divalproex Clonazepam (Klonopin) Lamotrigine 1963 in med surg book look at table for drugs Ethosuximide *Zarontin* : *drug of choice for absence seizures*; Reduces low threshold Calcium channel currents; inhibits GABA aminotranferase; SE: gastric distress, headaches, hiccups, euphoria, skin rashes Divalproex-Depakote *Clonazepam* (Klonopin): a *benzodiazepine*; potent *antiepileptic med*; increase frequency of chloride channel opening; long acting drug with efficacy for absence seizures; effective with myoclonic seizures; SE: (sedation; Ataxia, behavior disorders(. *Lamotrigine (la-MOE-tri-jeen) Lamictal: effective in myoclonic, generalized seizures in childhood and absence seizures*. Suppress sustained rapid firing of neurons and inactivates sodium channels. Used as an add on drug; SE: dizziness, headache, nausea, diplopia, rash.

Population affected by seizures

First 6 months of life - severe birth injury, infections, *inborn errors of metabolism*, CNS congenital defects 2-20 year olds - birth injury, infection, trauma, genetic factors 20-30 year olds - *structural lesions (trauma, brain tumors, vascular diseases)* Over 50 years old - strokes, metastatic(전이된) brain tumors 30% of all epilepsy causes have no attributable causes (idiopathic generalized epilepsy)

ALGORITHM FOR CLASSIFICATION OF SEIZURES

If a patient is diagnosed with a seizure disorder, it is very important to classify the seizure type correctly. The choice of treatment depends on the type of seizure. look at the picture on the PPT Grand mal (tonic-clonic)/generalized seizure Preictal: no aura is noted in the case study; 50% of all patients have an aura. Ictal: epipleptic cry (simultaneous contractions of the diaphragm and chest muscles causes cry); loss of consciousness (LOC). Observe movement of head and eyes, muscle rigidity, progression of seizure, and the duration and LOC, incontinence of stool and urine. Protect from injury; turn to side and loosen clothes. Postictal: does not remember seizure, confused, hard to arouse from sleep. Assess airway, breathing, vital signs, neurologic checks; keep on side and clean up the patient; reorient the patient as the patient awakens.

Actions of anti-seizure drugs

Increase seizure threshold Regulating neuronal firing by either inhibiting excitatory processes or enhancing inhibitory processes Prevent seizure from spreading to adjacent neurons Action: Stabilizes nerve cell membranes and prevents spread of epileptic discharge. Many meds act on Na, Calcium channels and controls, inactivates channels firing at high frequencies by blocking the influx of flow of Na or Calcium Many medicines act on brain cells to affect the way substances move in and out of the cells. Others try to change the way substances called 'neurotransmitters' excite (e.g. stimulate) or inhibit (e.g. stop or slow down) the way information is sent from one cell and area of the brain to another.

Drug Therapy for status epileptics

Initiate Rapid acting IV antiseizure drugs Short Acting: - *Lorazepam (Ativan)* - *Diazepam (Valium)* Long Acting: - *Phenytoin* - *Phenobarbital* *Sedation is big with short acting drugs* Lorazepam and diazepam: Benzodiazepines; primary meds for status epilepticus; muscle relaxant activity; potentiates GABA function

Nursing Management after the seizure

Maintain patent airway Place patient on his/her side to prevent aspiration Suction as needed *Orient* the patient upon awakening Allow the patient to sleep after the seizure Pharmacology: - *Supplemental oxygen* - *IV fluids (maintain hydration)* - *Anticonvulsants to control seizures* *Nurses role is to provide safety, document, and to prevent complications*. Patient is at risk for *hypoxia, vomiting*, and *pulmonary aspiration*.

Complications of seizures

Injury or Death - *Patients who lose consciousness are at greatest risk*. Cerebral *edema, ischemia*, and *brain dysfunction* Metabolic complications - *Acidosis* - *Hypoxemia* - *Hypoglycemia* - *Electrolyte imbalances* Can die or have severe injury A seizure can cause a metabolic complicaton Injury/death may occur due to trauma during the seizure Persons with epilepsy have a mortality rate 2-3 times the rate of the general population. Forty percent of these deaths are epilepsy-related and are caused by accidents occurring during seizures, suicide, treatment-related death, death due to underlying disease, and *sudden unexplained death in epilepsy (SUDEP)*. SUDEP is higher in males, those on multiple anti-seizure medications, and patients with long-standing epilepsy. The direct cause of SUDEP is unknown, but it is thought to be related to *respiratory dysfunction, cardiac dysrhythmias, or cerebral depression*. Cerebral edema: Seizures increase cerebral metabolic rate; if oxygen delivery does not keep up with metabolic demand, brain ischemia, edema, neuronal dysfunction, and death can occur. *Hyperemia* (blood engorgement) from increased cerebral metabolic rate encourages vasogenic edema (This edema results from disruption of the blood brain barrier, allowing protein-rich fluid to accumulate in the extracellular space).

Primidone side effects

Lethargy, irritability, diplopia, ataxia, impotence

Drugs for generalized *tonic-clonic and focal seizures*

Phenytoin (Dilantin) - can cause *gingival hyperplasia* Carbamazepine (Tegretol) Phenobarbital Divalproex Primidone (Mysoline) Dilantin in peds a side effect is *gingival hyperplasia (swollen red gums)* and it is a major side effect. You want to make sure they are at a therapeutic level so you want to re-assess levels (10-20 in children and adutls) side effects are: *attaxia, gingival hyperplasia, sometimes hypotension. Anything greater than 30 is considered a toxic level*. Tegretol is a tricyclic antidepressant (N, visual disturbances) *Phenobarbital has a sedation* with it and it blocks calcium as it moves across Table 66-4 pg. 1963 in book Phenytoin (Dilantin) is one of the oldest antiepileptic drug. It alters Na, Ca and K+ conduction; inhibits high frequency repetitive firing. SE: *ataxia, nystagmus, gingival hyperplasia*; nausea, hypotension (with IV phenytoin); can cause congenital birth defects Metabolized in the liver; Half life = 22 hours Needs a therapeutic level: The total phenytoin reference range varies by age, as follows: Children and adults: 10-20 mcg/mL Neonates: 8-15 mcg/mL Phenytoin toxicity: *Toxic phenytoin levels are defined as greater than 30 mcg/mL*. *Lethal levels are defined as greater than 100 mcg/mL. There is not an antidote*. In case of overdose: If found early may use activated charcoal Supportive care is the mainstay of therapy with phenytoin intoxication Toxicity is usually seen as skin reaction, peripheral neuropathy, ataxia and drowsiness. In children, gingival hyperplasia. Loading doses to achieve rapid therapeutic levels should be checked 1 hour after an intravenous loading dose and 24 hours after an oral loading dose. IV Loading doses: 15-20 mg/kg. Rate not to exceed 25 -50 mg/min. Avoid extravasation....is caustic to tissues. Patients who are on long-term phenytoin therapy generally do not need to be monitored at intervals less than 3-12 months after a steady state has been reached unless clinically indicated, for example in patients who may have intentionally or unintentionally taken a toxic dose.[4] *Intravenous administration of phenytoin ceased seizure activity in 60%-80% of patients in status epilepticus within 20 minutes*. Retrieved from http://emedicine.medscape.com/article/2090306-overview#a2 Carbamazepine inhibits high frequency firing; also used as a tricyclic antidepressant; SE: nausea and visual disturbances, granulocyte suppression, aplastic anemia Phenobarbital: oldest antiepileptic drug; has sedative effects; prolongs opening of chloride channels; block Calcium currents; inhibits high frequency firing only at high concentrations; SE: sedation, behavioral changes; cognitive impairment Primidone (mysoline): causes sedation, GI issues/pain; Mechanism of action is like phenytoin. Divalproex: can be used for bipolar disorder or seizures; migraines. Can cause severe birth defects. Reduces # of seizures by controlling abnormal activity of neuro impulses; Treats complex focal seizures; simple and absence seizures Lamictal (lamotrigine) and (levetiracetam)-kepra are used frequently. Many of the medications can cause hepatotoxicity.

Phenobarbital side effects

Sedation, irritability, diplopia, ataxia

Seizure response dogs

Seizure response dogs receive special training to assist those in distress - Can find help if owner is in trouble - Can pull away objects that pose danger - Can carry information about their handler for emergency response teams - Provide emotional support

Complex focal seizures

Some alteration or loss of consciousness Behavioral, emotional, affective, and cognitive *Location is usually in the temporal lobe* Usually last longer than 1 minute Confusion in the post-ictal period *Confusion/altered neuro may be the only s/s* *Automatisms (repetitive movements)* - *Lip smacking* - *Fidgeting* - *Blinking* After seizure, person forgets what he/she was doing before Occurs in frontal or temporal lobe & often involve other areas of the brain that affect alertness and awareness. Other automatisms: picking at the air, repeating words/phrases, laughing After seizure the person may not remember what they were doing during the seizure.. They may attempt to pick right back up to what they were doing before. It depends on how long the seizure activity lasts and the focus of the seizure within brain. See http://emedicine.medscape.com/article/1183962-clinical

Atypical absence seizure

Staring spell with S&S - Brief warnings - Peculiar(특이한) behavior during the seizure - *Confusion after the seizure* *Longer lasting (15 - 60 seconds)* *Associated with loss of postural tone* Since this is just another type of absence seizure, the same unique EEG pattern applies here also (spike & wave)

Surgical treatment for seizures

Surgical intervention to remove the epileptic focus or prevent spread of epileptic activity in brain Benefits of surgery - Cessation of seizures - Reduction in frequency of seizures Anterior temporal lobe resection is the most common surgical intervention. - About 70% of patients are essentially seizure free after this procedure. Not all types of epilepsy benefit from surgery. Three requirements for surgery - *Diagnosis of epilepsy confirmed* - *Adequate trial with drug therapy without satisfactory results* - *Electro-clinical syndrome (type of seizure) must be defined*

Generalized Seizures

TONIC-CLONIC ABSENCE (TYPICAL, ATYPICAL, ABSENCE W/ SPECIAL FEATURES) MYOCLONIC TONIC ATONIC (DROP ATTACKS) CLONIC Both hemispheres of the brain, causes both sides of the body to react Tonic clonic: grand mal seizure (first stage: tonic phase where the muscles suddenly contract if the throat is affected you will here a high pitched musical sound after this phase the pt may be *incontinent* of Band B, may chew their tongue, wake up with *severe fatigue and sleep* for a long while after seizure) (clonic is where you start jerking) Absence (petty mal): Affect a lot of kids in school (or adults) what happens is you will see them just stare off for a few seconds and then they come back, tested often by having them blow on a tissue to show this. Can happen up to 100 times a day. Atypical is a little movement and head drop or some other trunk movement. Typical is just staring off Atonic: look at YouTube video of it. Safety is a big issue with that so some *kids wear helmets* Myoclonic: Clonic: is the jerking seizure. Occurs a lot in babies. Can be misconstrued(...을 오해하다) as jitteriness(덜덜 떨다)

*Vagal nerve stimulation*

Thought to interrupt synchronization of epileptic brain-wave activity and stop excessive discharge of neurons After insertion, patient can activate it with a magnet when he/she senses an imminent seizure Adverse effects: *coughing, hoarseness, dyspnea, neck tingling* *Need surgical battery replacement q 5 years* Looks just like a pacemaker. Take the magnet out of the and swipe it across and it interrupts the excitability and it helps stop the seizure. Just do it once Gotta have a lot of seizures before they will get this for you Adjunct to medications when surgery is not feasible Exact mechanism not known Electrode implanted in the neck Signals can reduce or eliminate partial seizure activity and are usually placed in individuals that respond poorly to seizure medication.

Causes of seizures

Underlying cause-electrical disturbance. Metabolic conditions Structural: - Brain tumors - Cerebrovascular disease - Brain Injury CNS Infection Fever (childhood) Genetic Unknown causes V- Vascular (stroke, bleed) I- Infection (meningitis) T- Trauma (TBI - Traumatic brain injury) A- Autoimmune disorder (Lupus) M- Metabolic disorders (acidosis, electrolyte disturbances, hyperglycemia) (*metabolic disorders is a major cause of seizures*) I- Idiopathic (cause unknown) N- Neoplasms (some type of tumor that is occupying space in the brain) S- Psychiatric disorder (addiction) D- Drugs (alcohol, ETOH, many drugs) Metabolic condition: Acidosis Electrolyte disturbances Hypoglycemia Hypoxemia Drug withdrawal Dehydration Water Intoxication The list goes on: Malignant Hypertension Brain infection, including meningitis Brain injury that occurs to the baby during labor or childbirth Brain problems that occur before birth (congenital brain defects) Electric shock Heat illness (heat intolerance Phenylketonuria (PKU), which can cause seizures in infants Poisoning : an inborn error of metabolism that results in decreased metabolism of the amino acid phenylalanine. Untreated, PKU can lead to intellectual disability, seizures, behavioral problems, and mental disorders. Street drugs, such as angel dust (PCP), cocaine, amphetamines Toxemia of pregnancy Venomous bites and stings (snake bite) Drug withdrawal such as barbiturates and benzodiazepines (valium); alcohol Seizure activity and recreational drug use: High doses of amphetamines can cause severe tonic clonic seizures Cocaine can cause seizures within minutes to hours. Can be lethal...assoc w/ cardiac arrhythmias, heart attacks. Marijuana can decrease seizures with medicinal use or increase the likelihood in withdrawal or abrupt cessation. Fever in children: Febrile seizures/convulsion (body spasms, shaking). Usually lasts a few minutes, may occur due to increase or sudden rise in temperature. Occur in kids 3mos to 5 yrs; w/ peak around 8-20 months. 2-5% of all children experience febrile seizures. 25% of those have a first degree relative w/ hx of febrile seizures. Usually harmless....does not cause brain damage or lead to epilepsy. Small risk that the kids of who febrile seizures will have seizures later in life but is a very small risk Genetic: difficult to determine...could be wide range of issues. Could be related to environmental; acquired influences; low threshold to seizure producing stimuli/fever.

*Typical absence seizures*

Usually only in children (*4yrs - 14 yrs*) May completely stop or may evolve into a different type Characterized by: - Brief staring spell lasts a few secs - May go unnoticed - May be VERY brief, if any, loss of consciousness - When not treated, may occur up to 100 times/day - EEG pattern unique to this type of seizure (spike & wave) *Petit mal* (Show video linked in characterized) May begin about age 4 thru 14 yrs Absence seizures occur most often in people under age 20, usually in children ages 6 to 12. retrieved from https://www.nlm.nih.gov/medlineplus/ency/article/000696.htm

Phenytoin side effects

Visual problems, hirsutism, gingival hyperplasia, nystagmus, dysrhythmias Phenytoin-concerned if patient is on warfarin. Should not take at the same time. Phenytoin decreases absorption and increases the metabolism of oral contraceptives.