Seizure_Disorders

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					       Seizure
      Disorders
Brian Elliott, Dawn Garcia, Jenna Jordan, Dawn
      Miller, Margo Reis, Michelle Simons
 Seizure/Epilepsy distinction
• Seizures are a sudden uncontrolled electrical
  charge of neurons in the brain that interrupts
  normal function.
• Symptom of an underlying illness
• Any seizure resulting from a systemic or
  metabolic disturbance that is resolved when the
  underlying problem is corrected is not epilepsy.

• Epilepsy is a condition in which a person has
  spontaneously recurring seizures caused by a
  chronic underlying condition.
•
                Generalized Seizures
•   GENERALIZED SEIZURES: Involves both sides of the brain.
•   Bilateral synchronous discharges in the brain from the onset of a seizure.
•   Entire brain is affected.
•   Usually no warning or “aura”.
•              Subtypes
•              Tonic-Clonic (AKA Grand Mal)
•              Clinical Manifestations:
•   Loss of consciousness.
•   Stiffening of the body for 10-20 sec. (Tonic)
•   Jerking movements of the extremities. (Clonic)
•   May appear cyanotic, have excess salivation, bite their tongue or cheek, and may experience incontinence.
•   During postictal phase, usually sore, tired, and confused; may sleep for several hours.
•
•             Typical Absence (AKA Petit Mal)
•   Usually occurs in children; rarely goes beyond adolescence.
•   May develop into another type of seizure.
•             Clinical Manifestations:
•   Brief staring spell lasting a few seconds.
•   Brief loss of consciousness.
•   May occur up to 100 times a day if untreated.
•             Atypical Absence
•             Clinical Manifestations:
•   Staring spells.
•   Brief warnings.
•   Peculiar behavior during the seizure.
•   Confusion after the seizure.
                                      Partial Seizures
•   PARTIAL SEIZURES: Begins in a specific region of the cortex.
•   Caused by focal irritations.
•   Unilateral manifestation arising from a localized area of the brain.
•   Exception:
•   Partial seizures may spread to involve the whole brain leading to a               generalized tonic-clonic seizure.
•   A tonic-clonic seizure that is preceded by an aura or warning is a partial seizure that generalizes secondarily.
•   Many tonic-clonic seizures sometimes appear to be primarily generalized, but the partial component can be
    missed.
•   Postictally, secondary generalized seizures can result in a temporary neurological deficit called Todd”s paralysis.
•             Subtypes
•             Simple Partial
•             Clinical Manifestations:
•   No loss of consciousness.
•   Usually last < 1 minute.
•   May involve an alteration in motor, sensory, or autonomic system.
•             Complex Partial
•             Clinical Manifestations:
•   Usually in the temporal lobe.
•   Lasts > 1 minute.
•   ALOC: mental cloudiness.
•   Psychomotor sx: Lip-smacking, continuing an activity before seizure began, or fumbling with objects.
•   Psychosensory sx: vertigo, déjà vu, visual or auditory sensations, altered thought processes


•   THERE ARE OTHER TYPES OF SEIZURES DISCUSSED IN YOUR BOOK ON PAGES 1534-1535.
Algorithm for classification
        of seizures
        Figure 59-1 page 1534
                         Phases
• Prodromal Phase:
• Sign or activity which precedes a seizure.

• Aural Phase:
• Sensory warning.

• Ictal Phase:
• Full seizure.

• Postictal Phase:
• Period of recovery after the seizure.
                                           Causes
•   First 6 months of life – severe birth injury, congenital defects involving the central nervous system,
    infections, and inborn errors of metabolism.

•   2 – 20 years of age – birth injury, infection, trauma, and genetic factors.

•   20 – 30 years of age – structural lesions, such as trauma, brain tumors, or vascular disease.

•   After 50 years of age – cerebrovascular lesions and metastatic brain tumors.


•   ¾ of all seizure disorder cases are considered idiopathic

•   The cause of recurring seizures has been attributed to a group of abnormal neurons that seem to
    undergo spontaneous firing. The firing spreads by physiologic pathways to involve adjacent or
    distant areas of the brain. If the activity spreads to involve the whole brain, then a seizure occurs.
    The factor that causes the abnormal firing is unclear.
             How is it diagnosed?

• New evidence points to astrocytes, or cerebral support
  cells, may play and important role in recurring seizures.
  Astrocytes release glutamate that triggers synchronous
  firing of neurons.

• Often the area of the brain from which the epileptic activity
  arises is found to have scar tissue (gliosis). The scarring is
  thought to interfere with the normal chemical and
  structural environment of the brain neurons, making them
  more likely to fire abnormally.
                           Diagnostic studies
Diagnostic Studies (table 59-7)

•   Accurate and comprehensive description of the seizures
•   Patient’s health history.
     –   Recent illness, trauma,
     –   Medication (new and old and whether patient is compliant), and
     –   Recent social activity such and change in consumption of drugs or alcohol.

•   EEG is a useful adjuvant to the history if it shows abnormalities.
•   EEG should be done within 24 hours of a suspected seizure

•   Correct classification of the seizure type - The choice of treatment depends on the classification of the
            type of seizure.
•   Physical Examination
•   Birth and developmental history, Significant illness and injuries, Family history, Febrile seizures,
            Comprehensive neurologic assessment.
•   Seizure History
•   Precipitating factors, Antecedent events, Seizure description (including onset, duration, frequency,
            postictal state)

Diagnostic Studies (table 56-9)
•   CBC, electrolytes, LFP’s, fasting glucose, BUN, creatinine
•   Lumbar puncture for CSF analysis
•   Electroencephalography (EEG)
•   CT, MRI, MRA, MRS, PET scan
                 Genetic Factors
• The role of heredity in the etiology of seizure disorders has
  been difficult to determine because of the problem of
  separating hereditary from environmental or acquired
  influences:
• Seizure activity is often a symptom of many other medical
  conditions such as: hypoxia, infection, DM, HTN, alcohol or
  drug overdose or withdraw, cancer, and head trauma to
  name just a few.

• Some families carry a predisposition to seizure disorders in
  the form of an inherently low threshold to seizure-
  producing stimuli, such as trauma, disease, and high fever.
                       Incidence
• Approximately 2.7 million people suffer from active epilepsy
  each year.
• The incidence rates are high during the first years of life,
• Decline through childhood and adolescence,
• Plateau in middle age,
• Rise sharply again among the elderly.
• Those over the age of 60 are the greatest population with the
  highest prevalence of new-onset epilepsy.
Status Epilepticus
                  Status Epilepticus
•   Life Threatening Emergency

• Continuous seizure activity or seizures that occur in rapid
  succession without a return of consciousness between.

• Brain uses enormous amount of energy.

• Neurons may cease to functionbrain damage.

• Tonic-clonic is the most dangerous  hypoxia, cardiac
  dysrhythmias, hyperthermia, systemic acidosis, and death.
                    Assessment & Emergency
Tonic- Clonic seizures
                          Management
•    In an emergent situation it is critical for the nurse to assess for the signs of an oncoming seizure, or
    symptoms that the patient is in the midst of a seizure episode in order to apply appropriate life saving
    interventions. Some of these symptoms include:
      –   Presence of an aura
      –   Loss of consciousness
      –   Signs of bowel/bladder incontinence
      –   Tachycardia, diaphoresis
      –   Pallor, flushing or cyanosis
      –   Confusion and headache
      –   Signs associated with tonic, hypertonic, clonic and postictal phases of a seizure
      –   Presence of repeated clonic tonic seizures for several minutes in a row

      An outline of assessment findings and interventions can be found on page 1537 table 59-8

•   Health information that is important to obtain during an assessment would include

      –    the last episode of a seizure and any co morbidities related to it.
      –    compliance with their drug regimen

    A detailed non emergent assessment of a patient with seizure disorders or epilepsy can be
    found on page 1539 Table 59-11.
Assessment Findings & Interventions
                                 Interventions
•   Emergent interventions for our patient center around the ABC’s and prevention of injury
    which include:

     – Maintaining the patients airway - Position the patients head and body to one side to lessen
       the risk of aspiration. Assist with suctioning, oxygen therapy, and assisted ventilation as
       needed after the seizure episode ends.

     – Maintaining patient safety - If sitting or standing, clear the area around the patient and ease
       them down to the floor supporting their neck and head in your lap, and loosen any
       constrictive clothing.

     – Never restrain or force objects into the mouth of a person during a seizure. This can lead to
       further injury of the patient and possibly to the care giver.

     – Stay with the patient through the entire seizure episode and carefully observe the exact
       onset, and events that preceded it. Assessment of the course and nature of the seizure is
       critical in order to help diagnose the type of seizure, and identify subsequent treatment to
       follow.

•   Continued assessment of vitals and LOC after the episode has completed is important as well
    as providing explanation of events, reassurance, and a period of rest for the patient.

A more in depth care plan for patients with seizure disorders or epilepsy can be found on page
   1540 and 1541 Care Plan 59-2.
        Diet Considerations

Post-Seizure                     Maintenance

    • Regular meals and          •    Balanced nutrition
      snacks in between if       •   Good food choices
      feeling shaky, faint, or   •   Abstain from alcohol
      hungry
                                 •   Caffeine in moderation
                                 •   Be knowledgeable about
                                     any foods that may be
                                     contraindicated with
                                     specific medications
Effect on Bowel and Bladder

    During a tonic-clonic seizure it is a
    good possibility that the patient may
    experience     urinary     or    fecal
    incontinence during the ictal phase
                                              Medications
Certain drugs are used for specific seizure disorders:

Generalized Tonic-Clonic and Partial Seizures:           Classification:
•   carbamazepine (Tegretol)
•                                                        anticonvulsant, mood stabilizer
•   divalproex (Depakote)                                anticonvulsant, vascular headache suppressants

•    felbamate (Felbatol)
•    gabapentin (Neurontin)                              analgesic adjuncts, anticonvulsant, mood stabilizers
•    lamotrigine (Lamictal)                              anticonvulsant
•    levetiracetam (Keppra)                              anticonvulsant (pyrrolidines)
•    oxcarbazepine (Trileptal)                           anticonvulsant (carbamazepine analogues)
•    Phenobarbital                                       anticonvulsant, sedative/hypnotics (barbiturates)
•    Phenytoin (Dilantin)                                antiarrhythmics, anticonvulsants (hydantoins)
•    Primidone (Mysoline)
•    Tiagabine (Gabitril)                                anticonvulsant
•    Topiramate (Topamax)                                anticonvulsant, mood stabilizers
•    Valproic acid (Depakene)                            anticonvulsant, vascular headache suppressants
•    Vigabatrin (Sabril)
•    Zonisamide (Zonegran)                               anticonvulsant (sulfonamides)
•
•    Absence, Akinetic, and Myhoclonic Seizures:
•    clonazepam (Klonopin)                               anticonvulsants (benzodiazepines)
•    divalproex (Depakote)                               anticonvulsant, vascular headache suppressants
•    ethosuximide (Zarontin)
•    phenobarbital                                       anticonvulsant, sedative/hypnotics (barbiturates)
•    valproic acid (Depakene)                            anticonvulsant, vascular headache suppressants
                         Drug Therapy
• Seizure disorders are treated primarily with anti-seizure drugs.
• Therapy is aimed toward preventing seizure occurrence.
• Anti-seizure drugs act by stabilizing nerve cell membranes and preventing
  spread of the epileptic discharge.
• The principle for drug therapy is to begin with a single drug based on
  patient age, weight, type, frequency, and cause of the seizures and to
  increase the dosage until the seizures are controlled or until toxic side
  effects occur.

• See page 1538 for more info
          Toxic Effects of major drugs used:
•   Tegretol
    Ataxia, aplastic anemia, thrombocytopenia,

•   Depakote
    Hepatotoxicity, pancreatitits, hyperammonemia

•   Trileptal
    Stevens-Johnson syndrome, multiorgan reactions

•   Gabitril
    Agranulocytosis, aplastic anemia, stevens-johnson syndrome

•   Topamax
    Increased seizures, suicide attempt

•   Depakene
    Hepatotoxicity, pancreatitis, hyperammonemia

•   Zonegran
    Allergic reaction, stevens-johnson syndrome
 Surgical Interventions and other
             therapies
SURGERY:
A significant number of patients whose epilepsy cannot be controlled with drug therapy are candidates
     for surgical intervention

Before surgery can be performed, three requirements must be met:
     1.   The diagnosis of epilepsy must be confirmed,
     2.   There must have been an adequate trial with drug therapy without satisfactory results,
     3.   The electroclinical syndrome (type of seizure disorder) must be defined


     – The benefits of surgery include cessation or reduction in frequency of the seizures
     – Some examples of surgeries are: limbic resection, multilobar resections, anterior temporal
       lobe resections, and amygdalohippocampectomy

     See table 59-9 page 1538 for other surgery examples

     OTHER THERAPIES:
     – Vagal nerve stimulation
     – Biofeedback
       Nursing Considerations
• Care plan page 1540
                             Teaching

• Patient and family teaching is critical for the prevention and
  maintenance of reoccurring seizures.

• Guidelines for teaching are shown on page 1541 table 59-12
  These include:

    – The importance of medication compliance and attending follow up
      appointments to prevent re occurrence of seizures.
    – Use of non drug techniques
    – Importance of medic alert bracelet and ID cards.
    – Avoidance of excessive alcohol and fatigue
    – Importance of diet.
    – Family education includes, how to protect your family member during a
      tonic-clonic seizure
     When to call 911: a prolonged seizure, another seizure immediately
      follows, or extensive injury
                 Psych-social Considerations
•   One of the most important nursing considerations and aspects of education for these patients includes the
    psychosocial effects and fears of living with seizure disorders and it’s possible limitations.

Limitations include:
•    Recurring seizures
•    Incontinence
•    Loss of self control
•    Driving restrictions
•    Discrimination in employment
•    Social embarrassment.

•   As nurses we can provide support through education and helping the patient to identify coping mechanisms.
•   We can refer the patient to in house social services .
•   Provide information about their local Epilepsy foundation for social support
•   Refer them to state services and agencies that can help with financial problems,
    job placement, and driving restrictions in their state.
The End

				
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