Seizure Disorder Not the Cause, but the Symptom

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Seizure Disorder

• Not the Cause, but the Symptom

http//www.epilepsy.com/
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Is it the same as Epilepsy?

• Epilepsy is recurrent unprevoked seizures due to
  underling dysfunction of the brain
• Does our patient have Epilepsy?
• Can not be determined
• She did have a hemorhagic stroke
• She is still on Phyntonin
• How would you determine if she had epilepsy?

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Does our Patient have Eclampsia?

• Near birth time ??
• History of HTN??
• HELLP?

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Basal Ganglion Hematoma
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Types of Seizures

• Generalized-both hemispheres
• Partial-localized to specific area of one
  hemisphere
• Simple-No loss of consciousness
• Complete -Loss of consciousness
• Status epilepticus
• Non-epileptic seizures

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Types/Phases of Seizures

• Absence
• Myoclonic-rapid jerks
• Atonic - Flaccid
• Tonic- 10 to 20 sec. rigid legs extended elbows
  abducted
• Clonic- 1 to 2 min. Tremors
• Tonic-Clonic - alternating

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Nerve Transduction

• Action potential
• Open Ca Gates
• Na flows out all or nothing
• ATP required to repolarize via Na/K pumps
• Neurotransmitters released into synapse
• Receptors
• Threshold effects

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Pathophysiology

• 3 different mechanisms
• (1) hyperexcitable cortex has abnormal response
  of to initially normal thalamic input,
• (2) primary subcortical trigger, and
• (3) abnormal cortical innervation from
  subcortical structures.

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PathophysiologyAdapted from Cavazos et al 2007

• A seizure results from erratic electrical
  discharge of susceptible hyper-excitable neurons
  within an area of the brain (Focus).
• That, for unknown reasons, remain in a state of
  partial depolarization.
• Eventually neighboring GABA- inhibtory neuron are
  overcome and the firing spread.

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Pathophysiology

• Animal models implicate brainstem structures
• (1) a lateral geniculate body
• (2) ascending pathways through the mamillary
  bodies and anterior thalamus and
• (3) the substantia nigra,

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Phases of Seizure

• Preictal (Prodromal)-Prior to
• Ictal-During
• Postictal-After

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Preictal

• Aura-similar of onset of migraine
• Visual
• Bright lights, zig zag lines, tunnel vision,
  spots
• Auditory
• Hallucinations, modification of sounds
• Olfactory
• Burning rubber, electrical smell
• Tactile
• Numbness, weakness, separation from body
• Psychological

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Ictal

• Dependent on seizure type
• Absence (Petit mal) blank stares-muscle in
  complex
• Eye blinks, rubbing fingers, tasting movements of
  mouth
• Last 10-20 seconds
• Patient may not know they had one
• Can be differentiated from day dreaming

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Ictal-Clonic/Tonic

• Teeth clenching/grinding , Tongue biting
• Eyelid fluttering
• Eyes rolling up
• Falling down
• Foot stomping
• Hand waving
• Inability to move
• Incontinence

• Convulsion
• Difficulty talking
• Drooling
• Shaking
• Staring
• Stiffening
• Swallowing
• Sweating
• Rigitity

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PostictalCan range from none to

• Memory loss
• Writing difficulty
• Confusion
• Depression and sadness
• Fear
• Frustration
• Embarrassment

• Bruising
• Difficulty talking
• Injuries
• Sleeping
• Exhaustion
• Headache
• Nausea
• Pain
• Thirst
• Weakness
• Urge to urinate/defecate

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Treatment

• Diet-Ketogenic diet investigated in 1921 and
  studied extensively in 1930 (Barborka, 1930)
• Thought to be due to chemical changes in the
  brain due to starvation (Temlock, 2002)
• Medication
• Nerve stimulation
• Implantation of a electrical device that
  stimulated the vagus nerve
• UCLA is working on trigeminal nerve stimulator
  (Page, 2006)

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Classic Types of Medication

• GABA agonist
• GABA inhibits/ controls nerve transduction
• Benzodiazepines
• Diazepam (Valium)
• Clonazapam (Klonopin)
• Lorazapam (Ativan)

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Classic Types of Medication

• Blocks Na/Ca
• Phenobarbital (Luminal)-
• Valproic acid (Depakote, Depakene)
• Phenytoin (Dilantin)
• Carbamazepine (Tegretol)

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Pharmaceuticals

• Depakote (divalproex sodium )
• absence, generalized tonic-clonic, simple/complex
  partial, myoclonic
• SA- pancreatitis, liver failure, hair loss,
  tremor
• Diastat (viscous solution of diazepam)
• status or repeated seizures
• Rectal application
• SA-respiratory depression (rare)

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Pharmaceuticals

• Dialantin (phenytoin)
• simple/complex partial, generalized tonic-clonic
• SA Stevens-Johnson rash, body hair increase, gum
  overgrowth, termor, anemia
• Klonopin (clonazepam)
• absence (petit mal), atonic, myoclonic
• SA-abrupt withdrawl causes seizures
• may precipitate tonic-clonic seizures

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Steven-Johnson

• Facial swelling
• Tongue swelling
• Hives
• Skin pain
• A red or purple skin rash that spreads
• Blisters on your skin and mucous membranes,
  especially in your mouth, nose and eyes
• Shedding (sloughing) of your skin

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Newer Meds

• Keppra (levitiracetam)
• Partial and generalized tonic-clonic
• MOA ???
• Midazolam
• Nasal or buccual
• Rescue like Diastat (Rectal)
• Lorazapam
• Nasal microcrystals

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What to do?

• Stay calm
• Time the seizure
• On one side
• Protect the head
• Nothing in mouth
• Loosen ties/shirts
• Area Clear
• Stay with the person untill
• Seizure stops
• Offer to call taxi, friend, or relative if
  disoriented

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Incidence Prevalence

• The lifetime likelihood of experiencing at least
  1 epileptic seizure is about 9, and the lifetime
  likelihood of receiving a diagnosis of epilepsy
  is almost 3. However, the prevalence of active
  epilepsy is only about 0.8.

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Evaluation

• Make a phone call with 1 week to check on
  progress of Safe Parenting Plan
• Talk with husband in two weeks to determine
  confort with parenting by G.H.
• Talk with PT/OT on G.H.s progress on ADL
• Arange for a home visit in one mounth to assess
  progress.

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Status Epilepticus

• two or more sequential seizures without full
  recovery of consciousness between seizures, or
  more than 30 minutes of continuous seizure
  activity
• The most serious complication of epilepsy
• A neurologic emergency associated with high
  mortality and long-term disability
• Can involve any type of seizure
• (Lewis et al, 2007)
• (http//www.aafp.org/afp/20030801/469.html)

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Mortality Rate
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Status Epilepticus

• During repeated seizures the brain uses more
  energy than can be supplied. Neuron become
  exhausted and cease to function
• Tonic-clonic status epilepticus is the most
  dangerous because it can cause ventilatory
  insufficiency, hypoxemia, cardiac arrhythmias,
  hyperthermia, and systemic acidosis, all of which
  can be fatal
• (Lewis, et al 2007 )

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Some data about SE

• An estimated 152,000 cases occur per year in the
  USA
• 42,000 deaths per year
• An inpatient cost of 3.8 to 7 billion per year
• An incidence of 86 per 100,000 persons per year
  among patients older than 60
• 69 percent of episodes in adults and 64 percent
  of episodes in children were partial onset
• generalized status epilepticus in 43 percent of
  adults and 36 percent of children
• http//www.aafp.org/afp/20030801/469.html

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Common causes

• Withdrawal from medication or noncompliance with
  the regimen
• Most common in the very young and the very old.
  The lowest incidence at age 15-40
• In very young, febrile seizures are a leading
  cause
• Later in life, stroke is a common cause
• In adults, the major causes are low level of
  antiepileptic drugs (34) and cerebrovascular
  disease (22)
• http//www.aafp.org/afp/20030801/469.html
• http//www.epilepsyfoundation.org/about/types/type
  s/statusepilepticus.cfm

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Diagnostic test

• Complete neuro exam
• EEG
• Skull x-rays
• CT, MRI
• CBC, lytes, BUN, glucose
• EKG

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Nursing Care

• Airway management
• Ensure IV access patent
• Protect from injury, DO NOT RESTRAIN
• Loosen restrictive clothing
• Provide emotional support, orientation
• Administer prescribed medications
• If EEG, wash hair before and after

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Case Study

• You are the nurse on a medical unit taking care
  of a 40-year-old man, T.Z., who has been admitted
  with peptic ulcer disease (PUD) secondary to
  chronic alcoholism. You enter T.Z.s room and
  find him having a generalized convulsive
  (tonic-clonic) seizure.
• 1. List five things you would do

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Case study

• Protect from injury. Clear the area of furniture
  or other objects that may cause injury.
• Turn the person to the side
• Position the head to prevent the tongue from
  blocking the airway
• Loosen restrictive clothing
• Ensure IV access patent
• Time the seizure
• Dont hold the person down or try to stop his
  movements
• Providing emotional support
• (http//www.nlm.nih.gov/medlineplus/ency/article/0
  00695.htm)

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Case study

• Placing any objects, including an airway, into
  the patients mouth at this point is
  contraindicated because of the possibility of
  patient or caregiver harm.
• T.A.s seizure activity does not appear to be
  subsiding, and he is becoming cyanotic. The
  physician is notified and orders lorazepam
  (Ativan) 4mg IV over 2 to 5 minutes, repeat once
  in 1- to 15 minutes prn (as needed)
• 2. What is rationale for giving T.Z. lorazepam?

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Case study

• Lorazepam is a benzodiazepines which is one of
  the most effective drugs in the treatment of
  acute seizures and status epilepticus
• Lorazepam acts rapidly enough to interrupt
  seizures quickly
• It has a more prolonged anticonvulsant effect
• http//professionals.epilepsy.com/page/managing_lo
  ra.html

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Case study

• 3. What is status epilepticus?
• two or more sequential seizures without full
  recovery of consciousness between seizures, or
  more than 30 minutes of continuous seizure
  activity
• (http//www.aafp.org/afp/20030801/469.html)

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Case study

• 4. List one thing you would be particularly alert
  for when giving lorazepam intravenously.
• Lorazepam can cause excessive sedation which can
  cause respiratory distress. So make sure airway
  is patent
• (http//en.wikipedia.org/wiki/Lorazepam)

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Case study

• By the time the physician arrives, T.Zs seizure
  activity has not subsided. The physician
  administers an additional 4mg lorazepam, without
  effect. Fifteen minutes have elapsed since you
  found T.Z. having seizure activity.
• 5. What is the significance of this?
• T.Z. may has Tonic-clonic status epilepticus
  which is the most dangerous SE because it can
  cause ventilatory insufficiency, hypoxemia,
  cardiac arrhythmias, hyperthermia, and systemic
  acidosis, all of which can be fatal

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Case study

• The physician decides to administer
  succinylcholine (Anectine) and intubate T.Z. to
  protect his airway
• 6. What is succinylcholine, and why is it being
  administered to T.Z.?
• Succinylcholine is a muscle relaxant. It is
  usually used to relax muscle during surgery or
  when using a breathing machine (ventilator). T.Z.
  uses this drug because he will be intubated.
• (http//www.drugs.com/cdi/succinylcholine.html)

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Case study

• T.Z. has been intubated the physician orders a
  phenytoin (Dilantin) 20mg/kg IV loading dose and
  transport to ICU.
• 7. What is the rationale behind giving phenytoin?
• Phenytoin is one of the most effective drugs for
  treating acute seizures and status epilepticus.
  The main advantage of phenytoin is the lack of a
  sedating effect.
• (http//www.aafp.org/afp/20030801/469.html)

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Case study

• 8. List two problems related to T.Z.s care.
• T.Z. is cyanotic. At the beginning, maintaining
  oxygenation and circulation are necessary. So
  oxygen should be administrated to prevent hypoxia
• Phenytoin is contraindicated to alcohol. T.Z. is
  a chronic alcoholism.

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Case study

• 9. Given T.Z.s history, state at least two
  possible causes for his grand mal seizure.
• Chronic alcoholism
• Peptic ulcer disease (PUD) which can cause
  electrolytes imbalances
• Nutritional deficiencies- from PUD
• Kidney problems which can cause toxic
  accumulation of wastes-from chronic alcoholism
• (http//www.nlm.nih.gov/medlineplus/ency/article/0
  00695.htm)

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Case study

• T.Zs seizure is successfully treated with
  lorazepam and phenytoin, and he has no further
  seizure activity. As you are writing up his
  discharge papers, you overhear T.Z. telling his
  girlfriend to have his car brought to the
  hospital so he can drive home.
• 10. How should you respond to this situation

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Case study

• The nurse should inform T.Z. the side effects of
  lorazepam. It can cause severe sedation. The side
  effects of phenytoin are dizziness, drowsiness,
  difficulty focusing (vision). Although his
  seizure is treated, he may has recurrent seizure
  when he is on the way home. For all these
  reasons, T.Z. should not drive car by his own.

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Nursing Diagnosis

• Diagnosis Risk for injury r/t uncontrolled
  movements during seizure, falls
• Outcome Patient has no injury in the next 8
  hours
• Nursing Intervention
• 1. Protect from injury. Clear the area of
  furniture or other objects that may cause injury
• 2. Avoid moving or restraining patient during
  a seizure to prevent bone or soft tissue injury
• 3. Assess for trauma to mouth, cheek,
  tongue, lips abrasions, bruises broken bones
  burns because these injuries may occur during
  seizure activity
• Lewis, Heitkemper Dirksen

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Nursing Diagnosis

• Diagnosis Ineffective breathing pattern r/t
  neuromuscular impairment secondary to prolonged
  tonic phase of seizure or during postictal period
  AEB abnormal respiratory rate, rhythm or depth.
• Outcome patient will have appropriate rate,
  rhythm and depth of respirations in the next 8
  hours
• Nursing Intervention
• 1. Loosen constricting clothing to avoid
  restricting breathing
• 2. Turn the person to the side if patient
  has vomiting to prevent aspiration
• 3. Position the head to prevent the tongue
  from blocking the airway
• 4. Provide oxygen when necessary to prevent
  hypoxia
• 5. Assess breathing pattern, observing for
  labored respiration, tachypnea, bradypnea,
  dyspnea, and apnea to determine presence and
  extent of problem and to initiate appropriate
  interventions
• (Lewis et al ,2007)

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Nursing Diagnosis

• Diagnosis Risk for injury r/t uncontrolled
  movements during seizure, falls
• Outcome Patient has no injury in the next 8
  hours
• Nursing Intervention
• 1. Protect from injury. Clear the area of
  furniture or other objects that may cause injury
• 2. Avoid moving or restraining patient during
  a seizure to prevent bone or soft tissue injury
• 3. Assess for trauma to mouth, cheek,
  tongue, lips abrasions, bruises broken bones
  burns because these injuries may occur during
  seizure activity
• (Lewis et al ,2007)

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Nursing Diagnosis

• Diagnosis Ineffective therapeutic regimen
  management r/t lack of knowledge about management
  of seizure disorder AEB verbalization of lack of
  knowledge, inaccurate perception of health
  status, noncompliance with prescribed heath
  behavior
• Outcome Patient will have therapeutic drug level
  of antiseizure medication and be compliance with
  therapeutic regimen in one week
• Nursing Intervention
• 1. Providing teaching to patient and family
  about seizure activity and therapeutic management
  including diagnosis, treatment, lifestyle, and
  community resources so that patient and family
  can make necessary lifestyle modifications to
  manage a chronic disease.
• Lewis, Heitkemper Dirksen

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Nursing Diagnosis

• Knowledge deficit r/t seizures, nerological
  impairment and childcare AEB husbands fear of
  allowing J.G to care for child.

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Interventions

• Assist J.G./Husband to create a Safe Parenting
  Plan
• Use creditable web resoruce to increse
  prepairedness
• Work with J.G./Husband to develop a system to
  ensure compliance with medications
• Consult with PT/OT to adapt environment as needed.

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Outcomes

• For J.G. not to exibit signs that pose risk to
  her or her baby and do notfoster distrust of
  capibilitys form husband
• For J.G. to remain seizure free for next year
• For J.G. to continue with PT until ability
  reaches plataeu state
• For J.G and husband to develop a Safe Parenting
  Plan (Rousseau, 2008)

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Nursing Diagnosis

• Ineffective coping r/t perceived loss of control
  and denial of diagnosis
• Social isolation r/t unpredictability of
  seizures, community-imposed stigma
• Risk for disturbed thought process r/t effects of
  anticonvulsant medications
• Ackley Ladwig

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References

• Stevens-Johnson-Syndrome http//www.mayoclinic.com
  /health/stevens-johnson-yndrome/DS00940/DSECTION2
  updated Feb 8, 2008 Accessed 5/10/08
• Kossoff, E. 2008 Do ketogenic diets work for
  adults with epilepsy? Yes!
• Barborka CJ. Epilepsy in adults results of
  treatment by ketogenic diet in one hundred cases.
  Arch Neurol 19306904-914.
• Vining EPG, Freeman JM, Ballaban-Gil K, et. al. A
  multicenter study of the efficacy of the
  ketogenic diet. Arch Neurol 1998551433-1437.
• TEMLOCK, A 2002. THE KEY INTO KETOGENIC DIETS.
  http//www.vanderbilt.edu/ans/psychology/health_ps
  ychology/ketogenic_diets.htm Accessed 5-10-08
•  Axon, M. 2007 Epilepsy, learning disabilities
  and the nurse prescriber Nurse Prescribing 511,
  481-484. 2007.
• Shafer, P.O. Schachter S. C., SEIZURES AND
  TEENSUsing Technology to Develop Seizure
  Preparedness. 66 November 2007 EP MAGAZINE/
  www.eparent.com Accessed 5/10/08
• Eskandar E. N Epilepsy Surgery for Tumors,
  Vascular Malformations, Trauma and
  Cerebrovascular Disease. Http//neurosurgery.mgh.h
  arvard.edu/functional/EpilepsySurgery.htm. May
  11, 2005 Accessed 5/10/2008
• http//www.ilae-epilepsy.org/
• Cavazos, J.E Lum,F. Spitz, M . Seizures and
  Epilepsy Overview and Classification
  http//www.emedicine.com/neuro/TOPIC415.HTM.
  updated Nov 30, 2007 accessed 5/10/2008.
• Lewis, S.L., Heirkemper, M.m., Dirkson, S.R.,
  Obrain, P.G., Bucher, L. (2007) Medical-surgical
  Nursing, Assessment and Management of Clinical
  Problems. Mosby 2007.
• http//www.nlm.nih.gov/medlineplus/ency/article/00
  0695.htm
• http//professionals.epilepsy.com/page/managing_lo
  ra.html
• http//www.aafp.org/afp/20030801/469.html
• http//en.wikipedia.org/wiki/Lorazepam
• http//www.drugs.com/cdi/succinylcholine.html