Seizures

Diagnostic studies of seizures

1. Accurate, comprehensive description of seizures and health history 2. EEG 3. Magnetoencephalography in conjunction with EEG 4. Greater sensitivity for detecting small magnetic fields generated by neuronal activity 5. CBC, serum chemistries, liver and kidney function, UA to rule out metabolic disorders 6. CT or MRI in new-onset seizure to rule out structural lesion 7. Cerebral angiography, SPECT, MRS, MRA, and PET in selected situations 8. Diagnosing seizure type is necessary to determine appropriate treatment

Gerontologic Considerations

1. Many experience a 1st single seizure and a large percentage of them do not have another seizure. 2. Must be recurring for antiseizure drug therapy 3. More responsive to antiseizure drugs 4. More likely to experience side effects at lower doses 5. Phenytoin may be problematic for older adults with compromised liver function 6. Phenobarbital, Tegretol, Mysoline negatively affect cognitive function

EEG

1. May help determine type of seizure and pinpoint seizure focus 2. Many patients do not have abnormal findings

Emotional support and identification of coping mechanisms to adjust to personal limitations imposed by disease

1. Medical alert bracelets 2. Referrals to agencies and organizations

Nursing Assessment: Precipitating factors

1. Metabolic acidosis or alkalosis 2. Hyperkalemia 3. Hypoglycemia 4. Dehydration 5. Water intoxication

Convulsive status epilepticus

1. Most dangerous 2. Can cause ventilatory insufficiency, hypoxemia, cardiac dysrhythmias, hyperthermia, and systemic acidosis 3. Can be fatal

Interprofessional care

1. Most seizures do not require emergency medical care because they are self-limiting and rarely cause bodily injury 2. Seizure disorders are primarily treated with antiseizure drugs 3. Goal of therapy is preventing seizures with minimum toxic side effects from drugs 4. Cure is not possible 5. No solution for medically refractory epilepsy 6. If seizures fail to respond to the 1st two medications, there is only a 5%-10% chance of achieving success with further medication changes

Neurologic assessment involves testing for toxicity

1. Nystagmus 2. Hand and gait coordination 3. Cognitive functioning 4. General alertness Noncompliance is concern

Complex focal seizures

1. Patients have loss of consciousness or alteration in awareness 2. Eyes remain open but cannot interact 3. May display strange behaviors 4. Automatisms - repetitive, purposeless actions 5. Do not remember an activity started before or continued during seizure 6. These seizures usually last between 30 seconds and 2 minutes. 7. Patients may be tired or confused following the seizure, and may not return to normal activity for hours.

Simple focal seizures

1. Person remains conscious and alert 2. Experiences unusual feelings or sensations that can take many forms 3. Sudden and unexplainable feelings of joy, anger, sadness, or nausea 4. May hear, smell, taste, see, or feel things that are not real

Primary drugs for treatment of generalized tonic-clonic and focal seizures

1. Phenytoin (Dilantin) 2. Carbamazepine (Tegretol) 3. Phenobarbital (Luminal) 4. Divalproex (Depakote) 5. Primidone (Mysoline)

Seizure Phases

1. Prodromal 2. Aural 3. Ictal 4. Postictal

Status Epilepticus

1. State of continuous seizure activity or condition when seizures recur in rapid succession without return to consciousness between seizures 2. Any seizure lasting > 5 minutes 3. Neurologic emergency 4. Can occur with any type of seizure 5. The longer a seizure lasts, the less likely it is to stop without drug therapy.

Complications of seizures

1. Status epilepticus causes brain to use more energy than is supplied 2. Neurons become exhausted and cease to function 3. Permanent brain damage can result 4. Subclinical seizures 5. Convulsive status epilepticus 6. Severe injury and death from trauma during a seizure 7. Patients who lose consciousness are at greatest risk 8. Persons with epilepsy have a mortality rate 2-3 times the rate of the general population 9. SUDEP 10. Effect on lifestyle is most common complication of seizure disorder

Immediate medical care if

1. Status epilepticus occurs 2. Significant bodily harm occurs 3. The event is a first-time seizure 4. Get them to the floor 5. Padded rails, suction, leeping rails up

SUDEP

1. Sudden unexplained or unexpected death in epilepsy (SUDEP). 2. SUDEP is higher in males, persons taking multiple antiseizure drugs, and patients with long-standing epilepsy who have poorly managed seizure activity. 3. The direct cause of SUDEP is unknown, but thought to be related to respiratory dysfunction, cardiac dysrhythmias, or cerebral depression.

Gliosis

1. Thought to interfere with normal chemical and structural environment of neurons 2. This makes them more likely to fire abnormally

Typical Absence Seizures

1. Usually occurs only in children and rarely beyond adolescence 2. May cease as child matures or develop into another type 3. Can be precipitated by flashing lights and hyperventilation 4. Typical symptom is staring spell "daydreaming" 5. Lasts only a few seconds 6. Often goes unnoticed 7. May occur up to 100 times/day when untreated 8. EEG demonstrates pattern unique to this type of seizure

Promote safety measures

1. Wear helmet if risk for head injury 2. General health habits (diet, exercise) 3. Assist to identify events or situations precipitating seizures and avoid if possible 4. Instruct to avoid excessive alcohol, fatigue, and loss of sleep 5. Improved approaches to perinatal, labor, and delivery care have reduced fetal trauma and hypoxia and thereby have reduced brain damage leading to seizure disorders. 6. Help the patient to handle stress constructively.

Common side effects involve the CNS and include

Diplopia, drowsiness, ataxia, and mental slowing

Antiseizure drugs should not be

Discontinued abruptly as this can precipitate seizures

Ictal

From first symptoms to the end of seizure activity

Newer antiseizure meds may be safer for older adults: Fewer effects on cognitive function and less drug interactions

Gabapentin Lamotrigine Oxcarbazepine Levetiracetam

Broad spectrum drugs can be effective for multiple seizure types

Gabapentin (Neurontin) Topiramate (Topamax) Lamotrigine (Lamictal) Tiagabine (Gabitril) Levetiracetam (Keppra) Zonisamide (Zonegran)

Common side effect of phenytoin

Gingival hyperplasia and Hirsutism

Often found in area of brain from which seizure activity arises

Gliosis (scar tissue)

Postictal

Recovery period after the seizure

Vagal nerve stimulation: a form of neuromodulation, is used as an adjunct to drugs when an accessible focal point cannot be identified for surgical removal.

1. Adjunct to medications when surgery is not feasible 2. Exact mechanism not known 3. Thought to interrupt synchronization of epileptic brain-wave activity and stop excessive discharge of neurons 4. In vagal nerve stimulation, a surgically implanted electrode in the neck is programmed to deliver the electrical impulse to the vagus nerve, usually on the left side. 5. The patient can activate it with a magnet when he or she senses a seizure is imminent. 6. Vagal nerve stimulation can cause adverse effects such as coughing, hoarseness, dyspnea, and tingling in the neck. 7. Battery life is 5 to 10 years, and surgical replacement is required. 8. Benefits of this therapy can be seen within 24 months after implantation.

After care

1. After the seizure the patient may require repositioning (to open and maintain the airway), suctioning, and oxygen. 2. A seizure can be frightening for the patient and for others who witnessed it. 3. Assess their level of understanding and provide information about how and why the event occurred. 4. This is an excellent opportunity for you to dispel many common misconceptions about seizures. 5. After observation and treatment of the seizure, implement patient and caregiver teaching, and psychosocial intervention.

Nursing assessment: Absence

1. Altered Consciousness 2. Minor facial motor activity

Nursing assessment: Complex focal seizures

1. Altered consciousness with inappropriate behaviors 2. Automatisms 3. Amnesia of event

Surgery is an option for many with uncontrolled epilepsy remove the epileptic focus or prevent spread of epileptic activity in the brain.

1. Anterior temporal lobe resection 2. However, the current goal of neurosurgery is a careful resection of a precisely localized area within a lobe of the brain. 3. About 70%-80% are seizure free after this procedure 4. 10%-20% have marked reduction in seizure activity -Not all types of epilepsy benefit from surgery. -An extensive preoperative evaluation is important, including continuous EEG monitoring and other specific tests to ensure precise localization of the focal point.

Nursing assessment: Simple focal seizures

1. Aura 2. Focal sensory, motor, cognitive, or emotional phenomena 3. Unilateral "marching" 4. Motor seizure

Overall goals for patient

1. Be free from injury during seizure 2. Have optimal mental and physical functioning while taking antiseizure medications 3. Have satisfactory psychosocial functioning

Focal seizures

1. Begin in specific region of cortex in one hemisphere of brain 2. Produce manifestations based on function of area of brain involved 3. For example, if the discharging focus is located in the medial aspect of the postcentral gyrus, the patient may experience paresthesia and tingling or numbness in the leg on the side opposite the focus. 4. Any tonic-clonic seizure preceded by aura or warning is a focal seizure that generalizes secondarily 5. Secondary generalized seizure may result in transient residual neurologic deficit postictally (Todd's paralysis)

Clonic seizures

1. Begin with loss of consciousness and sudden loss of muscle tone 2. Followed by rhythmic limb jerking that may or may not be symmetric 3. Relatively rare

Nursing assessment: Health Hx

1. Birth defects or injuries at birth 2. Anoxic episodes 3. CNS trauma or infections 4. Stroke 5. Metabolic disorders 6. Alcoholism 7. Exposure to metals or carbon monoxide 8. Hepatic or renal failure

Many of the antiseizure drugs have a long half-life

1. Can be given 1-2X/day 2. A simplified drug regimen can increase medication compliance 3. Medications should be routinely reviewed and adjusted as needed 4. Unnecessary combination therapy should be avoided whenever possible.

Tonic-clonic Seizures (generalized)

1. Characterized by loss of consciousness and falling 2. Body stiffens (tonic) with subsequent jerking of extremities (clonic) 3. Cyanosis, excessive salivation, and tongue or cheek biting may occur 4. Postictal phase for tonic-clonic characterized by muscle soreness, fatigue 5. Patient may sleep for hours 6. May not feel normal for hours to days 7. No memory of seizure

Myoclonic

1. Characterized by sudden, excessive jerk or twitch of body and extremities 2. Can be forceful enough to cause fall 3. Brief 4. May occur in clusters 5. The jerk represents a muscle contraction and may be forceful enough to hurl the person to the ground. 6. These seizures last no more than a few seconds

Nursing Assessment cont.

1. Compliance with antiseizure medications, barbiturate or alcohol withdrawal, cocaine/amphetamines 2. Family history 3. Headaches, aura, mood or behavioral changes before seizure 4. Anxiety, depression, loss of self-esteem, social isolation 5. Decreased sexual drive, erectile dysfunction 6. Bitten tongue, soft tissue damage, cyanosis 7. Abnormal respiratory rate 8. Apnea (ictal) 9. Absent or abnormal breath sounds 10. Airway occlusion 11. Hypertension, tachy/bradycardia 12. Bowel/urinary incontinence, excessive salivation 13. Weakness, paralysis, ataxia (postictal) 14. Abnormal CT, MRI, EEG

Three requirements for surgery

1. Confirmed diagnosis of epilepsy 2. Adequate trial of drug therapy without satisfactory results 3. Defined electroclinical syndrome

Effect on lifestyle

1. Depression 2. Social stigma still exists 3. Discrimination in employment and education 4. Driving sanctions 5. Perhaps the most common complication of seizure disorders is its effect on a patient's lifestyle. 6. Patients may develop ineffective coping methods because of psychosocial problems related to having a seizure disorder. 7. In particular, an increased incidence of depression occurs in persons who have seizures that are difficult to control. 8. Antiseizure drugs and the continued need to manage a chronic disease also can contribute to depression. 9. Although attitudes have improved in recent years, a diagnosis of epilepsy still carries a social stigma. 10. Patients with epilepsy may experience discrimination in employment and educational opportunities. 11. Transportation may be difficult because of legal sanctions against driving. 12. Screen patients frequently for depression, and encourage them to pursue available treatment options.

Drug therapy

1. Drugs act by stabilizing nerve cell membranes and preventing spread of the epileptic discharge 2. About 1/3 of patients require a combination regimen for adequate control 3. Therapeutic drug ranges are guides 4. Newer drugs do not require drug levels 5. Drug therapy should begin with a single drug based on the patient's age and weight and type, frequency, and cause of seizure. 6. Dosage should be increased until seizures are controlled or toxic side effects occur. 7. If seizure control is not achieved with a single drug, dosage or timing of administration may be changed or a second drug may be added. About one third of patients require a combination regimen for adequate control. Patients should discuss emerging treatments with their HCPs to provide the best control with the least amount of medication. 8. The therapeutic range for each drug indicates the serum level above which most patients experience toxic side effects and below which most continue to have seizures. 9. However, therapeutic drug ranges are only guides for therapy. 10. If the patient's seizures are well controlled with a subtherapeutic level, the drug dosage need not be increased. 11. Likewise, if a drug level is above the therapeutic range and the patient has good seizure control without toxic side effects, the drug dosage does not need to be decreased. 12. Serum drug levels are monitored if seizures continue to occur, seizure frequency increases, or drug adherence is questioned. Because they have a very large therapeutic range, many newer drugs do not require drug-level monitoring.

Primary drugs used to treat absence and myoclonic seizures

1. Ethosuzimide (Zarontin) 2. Divalproex (Depakote) 3. Clonazapam (Klonopin) Some of these drugs are broad spectrum and appear to be effective for multiple seizure types.

Expected outcomes

1. Experience breathing pattern adequate to meet oxygen needs 2. Experience no seizure-related injury 3. Express acceptance of seizure disorder by admitting presence of epilepsy and adhering to recommended treatment

Atypical absence seizures

1. Eye blinking 2. Jerking movements of the lips 3. Lasts more than 10 seconds 4. Usually continue into adulthood 5. The patient may be somewhat responsive during seizure activity. 6. This type of seizure commonly lasts more than 10 seconds (as much as 30 seconds), with a gradual beginning and end. 7. If the patient has cognitive impairment, seizure activity may be difficult to distinguish from usual behavior. 8. An EEG demonstrates atypical spike-and-wave patterns

Two major classes of seizures

1. Generalized 2. Focal

Ketogenic diet has been effective in controlling seizures in some

1. High-fat, low carbohydrate diet 2. Ketones pass into the brain and replace glucose as an energy source 3. When a person is on this diet, ketones are produced and pass into the brain and replace glucose as an energy source. 4. Meals must be carefully planned because the amount of protein and carbohydrate in the diet must be restricted. 5. Patients on this diet who use anticoagulants need close monitoring for bleeding. 6. Although HCPs are more likely to recommend the diet for children than adults, the diet can work equally well in both age groups. 7. However, long-term effects of the diet are not clear.

Teach patients

1. Importance of following the specific drug regimen 2. What to do if a dose is missed: take it as soon as they remember

Status epilepticus drugs

1. Initially, rapid-acting IV lorazepam (Ativan) or diazapam (Valium) 2. Followed by long-acting drugs

Prevention of recurring seizures is major goal in treatment

1. Instruct on importance of adherence to medication, not to adjust dose without physician 2. Keep regular appointments 3. Teach family members emergency management 4. Remind family, caregivers, and significant others that it is not necessary to call an ambulance or send a person to the hospital after a single seizure unless the seizure is prolonged, another seizure immediately follows, extensive injury has occurred, or if it is unknown if there was a first-time seizure. 5. If a dose is missed, usually the dose should be made up if the omission is remembered within 24 hours.

Tonic Seizures

1. Involve sudden onset of maintained increased tone in the extensor muscles contributing to sudden stiff movements. 2. Often occur in sleep 3. Affect both sides of body 4. Usually last less than 20 seconds 5. Consciousness is usually preserved

Atonic seizure

1. Involves tonic episode or paroxysmal loss of muscle tone 2. Begins suddenly and person falls 3. Typically last less than 15 seconds 4. Person usually remains conscious 5. Can resume normal activity immediately 6. Great risk for head injury

Complex focal seizures sx

1. Loss of consciousness or an alteration in their awareness, producing a dreamlike experience. 2. Their eyes are open and they make movements that may seem purposeful, but they cannot interact with observers. 3. Some people display strange behavior such as lip smacking or other repetitive, purposeless actions (automatisms).

Nursing assessment: Tonic clonic

1. Loss of consciousness, 2. Muscle tightening then jerking, 3. Dilated pupils, 4. Hyperventilation then apnea, 5. Postictal somnolence

During a seizure

1. Maintain patent airway 2. Protect patient's head 3. Turn patient to the side 4. Loosen constrictive clothing 5. Ease patient to floor 6. Do not restrain patient 7. Do not place objects in patient's mouth

Observe, treat, and document seizure

1. Maintain patent airway, support head, turn to side, loosen constrictive clothing, ease to floor 2. Do not restrain patient or place any objects in their mouth 3. May require positioning, suctioning, or oxygen after seizure

Care cont.

1. When a seizure occurs, the nurse should carefully observe and record details of the event because the diagnosis and subsequent treatment often rest solely on the seizure description. 2. Note all aspects of the seizure. What events preceded the seizure? When did the seizure occur? How long did each phase (aural [if any], ictal, postictal) last? What occurred during each phase? 3. Both subjective data (usually the only type of data in the aural phase) and objective data are important. 4. Note the exact onset of the seizure (which body part was affected first and how); the course and nature of the seizure activity (loss of consciousness, tongue biting, automatisms, stiffening, jerking, total lack of muscle tone); the body parts involved and their sequence of involvement; and the presence of autonomic signs, such as dilated pupils, excessive salivation, altered breathing, cyanosis, flushing, diaphoresis, or incontinence. 5. Assessment of the postictal period should include a detailed description of the level of consciousness, vital signs, pupil size and position of the eyes, memory loss, muscle soreness, speech disorders (aphasia, dysarthria), weakness or paralysis, sleep period, and the duration of each sign or symptom.

Tonic phase lasts

10-20 sec

Clonic phase lasts for another

30-40 sec

Pregabalin (Lyrica)

Additional treatment for focal seizures that are not successfully controlled with a single medication

Subclinical seizures

Form of status epilepticus in which a sedated patient seizes but without external signs because of sedative use.

Use of carbamazepine, phenytoin, phenobarbital, primidone, topiramate, and oxcarbazepine can increase the risk of

Osteopenia and osteoporosis in older adults.

Seizures resulting from metabolic disturbances are not considered epilepsy if

Seizures cease when underlying condition is corrected

Prodromal

Sensations or behavior changes that precede a seizure

Aural

Sensory warning that is similar each time a seizure occurs

Locating seizure focus is critical for

Successful surgical intervention

Drugs for seizure disorder must be

Taken regularly and continuously, often for a lifetime

Complex absence seizures

The blank stare is accompanied by some type of movement (e.g., blinking, chewing, hand gestures)

Seizures

Transient, uncontrolled electrical discharge of neurons in brain, interrupting normal function

Because Ativan and Valium are short-acting drugs, you need to follow

their administration with a long-acting drug such as phenytoin or phenobarbital.