Title: CNS
1CNS Antiepileptic Drugs
- Compare and contrast the terms seizure,
convulsion and epilepsy. - Discuss the indications for antiepileptic therapy
(AED). - Compare and contrast the first line drugs of
choice for AED. - Discuss the nursing process related to the care
of the patient receiving AEDs in acute and
chronic situations.
2CNS Antiepileptic DrugsInternational
Classification of Seizures
- Partial Seizures short alterations of
consciousness repetitive unusual movements
(chewing or swallowing) psychologic changes
confusion - Simple Seizures No impaired consciousness
motor symptoms of face, arm or legs
hallucinations of sight, hearing, or taste
tingling sensation ANS changes personality
changes - Complex Seizures Impaired consciousness memory
impairment behavioral effects purposeless
behaviors aura, unreal feelings, bizarre
behavior - Generalized Seizures Temporary lapses in
consciousness staring off into space rhythmic
movements of eyes, head, or hands may have
tonic, clonic, myoclonic, atonic, or tonic-clonic
seizures brief loss of consciousness without
confusion head drop or falling down symptoms
3CNS Antiepileptic DrugsSyndrome of CNS
Dysfunction
- Convulsion Involuntary spasmodic contractions
of any or all voluntary muscles throughout the
body, including skeletal and facial muscles.
Postictal state - Seizures Brief episode of abnormal electrical
activity in the nerve cells of the brain --
detected on EEG - Epilepsy Chronic, recurrent pattern of seizures
4CNS Antiepileptic Drugs /Anticonvulsant
Drugs
-
- Terms overlap and are used interchangeably to
achieve the goal of maintaining a reasonable
quality of life. - Antiepileptic Drugs management of all types of
epilepsy, not just convulsions (AED Therapy) - Anticonvulsant Drugs used to prevent the
seizures typically associated with epilepsy.
5CNS Antiepileptic DrugsMechanism of Action
- ION Theory movement of K, Na, Ca, Mg
- Stabilizes neurons
- from becoming hyperexcited
- prevents excessive impulses to adjacent neurons
- 1. Increase threshold of activity in the motor
cortex - Makes it more difficult to excite reduces
response - 2. Depress the seizure discharge from its origin
- Suppress transmission of impulses from one nerve
to the next - 3. Decrease the speed of nerve impulse
conduction within a given neuron
6CNS Antiepileptic DrugsIndications
- Prevention or control of seizure activity
- Long-term maintenance treatment of epilepsy
- Acute treatment of convulsions and status
epilepticus - Status epilepticus common seizure disorder
- life-threatening emergency characterized by
tonic-clonic convulsions that occur in
succession. - Loss of consciousness, hypotension, hypoxia,
cardiac dysrhythmias brain damage and death may
quickly result - Once controlled, long term therapy is begun to
prevent future seizures - Brain Surgery - Head injuries prophylactic AED
Therapy
7CNS Antiepileptic DrugsContraindications
- Known drug allergy
- Pregnancy consider risks to mother infant if
untreated
8CNS Antiepileptic DrugsDrugs of First Choice
AED Therapy Therapeutic Level (mcg/mL) Adverse Effects
carbamazepine (Tegretol) 3-14 N/V drowsiness dizziness orthostatic hypotension hypertension dyspnea edema nephrotoxicity hepatotoxicity blood dyscrasias dermatologic reactions
phenytoin (Dilantin) 10-20 Cardiac dysrhythmias hypotension N/V indigestion sedation, drowsiness, dizziness, blurred vision, fatigue, lethargy confusion gingival hyperplasia hyperglycemia blood dyscrasias hepatoxicity dermatologic reactions
primidone (Mysoline) 5-12 Sedation drowsiness dizziness blurred vision blood dyscrasias paradoxical excitability
valproic acid (Depakote) 50-100 Drowsiness N/V tremor weight gain transient hair loss blood dyscrasias hepatotoxicity pancreatitis
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10CNS Antiepileptic Drugs
Treatment of Status Epilepticus
AED Therapy Dose mg/kg Onset Adverse Effects
diazepam (Valium) 0.3-0.5 3-10 mins Apnea, hypotension, somnolence
Fosphenytoin (Cerebyx) 15-20 15-30 mins Cardiac dysrhythmias, hypotension
Lorazepam (Ativan) 0.05-0.1 1-20 mins Apnea, hypotension, somnolence
Phenobarbital 15-20 10-30 mins Apnea, hypotension, somnolence
Phenytoin (Dilantin) 15-20 5-30 mins Cardiac dysrhythmias, hypotension
11CNS Antiepileptic DrugsBenzodiazepines
- Actions
- Not fully understood
- May enhance the inhibitory effects of GABA in
postsynaptic clefts between nerve cells - Uses
- Diazepam (Valium), clonazepam (Klonopin),
- clorazepate (Tranxene), lorazepam (Ativan)
- Diazepam - drug of choice for status epilepticus
- must be given intravenously -- slowly
- never mixed with any other medication
- Therapeutic outcomes
- Reduced frequency of seizures, reduced injuries
- Minimal adverse effects from therapy
-
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13CNS Antiepileptic DrugsHydantoins
- Actions mechanism unknown
- phenytoin (Dilantin) most commonly used
- ethotoin (Peganone)
- fosphenytoin (Cerebyx)
- Uses
- Anticonvulsants used to control tonic-clonic
seizures - CAUTION
- Phenytoin must be administered slowly
- Do not mix with other medications in the same
syringe - Dilute only with 0.9 NaCl to avoid precipitation
- Infuse slowly lt150mg/min
- CAUTION toxicity may cause nystagmus
- CAUTION infiltration causes sloughing of tissue
- Therapeutic outcomes
- Reduced frequency of seizures, reduced injuries
- Minimal adverse effects from therapy
14CNS Antiepileptic DrugsCarbamazepine
- Actions -- carbamazepine (Tegretol)
- Blocks up the reuptake of norepinephrine
- Decreases release of norepinephrine and rate of
dopamine and GABA turnover - Mechanisms of action as anticonvulsant are
unknown - Uses
- Used in combination with other anticonvulsants to
control tonic-clonic seizures - Not effective for myoclonic or absence seizures
- Should not be given with grapefruit increased
levels of the AED - Therapeutic outcomes
- Reduced frequency of seizures, reduced injuries
- Minimal adverse effects from therapy
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16CNS Antiepileptic Drugs Succinimides
- Actions ethosuximide (Zarontin),
- methsuximide (Celontin)
- Mechanism of action unknown
- Uses
- To control absence (petit mal) seizures
- Therapeutic outcomes
- Reduced frequency of seizures, reduced injuries
- Minimal adverse effects from therapy
17CNS Antiepileptic Drugs Topiramate
- Actions topiramate (Topomax)
- Mechanisms of action are unknown
- May prolong blockade of sodium channels, enhance
activity of GABA, and antagonize certain
neurotransmitter receptors - Uses
- Used in combination with other anticonvulsants to
control tonic-clonic seizures - Prevention of migraine headaches
- Therapeutic outcomes
- Reduced frequency of seizures and injuries
- Minimal adverse effects from therapy
18CNS Antiepileptic Drugs Primidone
- Actions primidone (Mysoline)
- Metabolized into phenobarbital and PEMA - both
active anticonvulsants - Exact anticonvulsant mechanism of action is
unknown - Uses
- Used in combination with other anticonvulsants to
treat tonic-clonic seizures - Therapeutic outcomes
- Reduced frequency of seizures and injuries
- Minimal adverse effects from therapy
19CNS Antiepileptic DrugsGabapentin
- Actions gabapentin (Neurontin)
- Mechanisms of action are unknown
- Does not appear to enhance GABA
- Uses
- Used in combination with other anticonvulsants to
control partial seizures - Therapeutic outcomes
- Reduced frequency of seizures
- Minimal adverse effects from therapy
- Also used for pain reduction shingles,
peripheral neuropathy nerve pain
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21CNS Antiepileptic DrugsNursing Implications
- Nurses may play an important role in diagnosis
and treatment - Comprehensive history allergies/medication
reconciliation - Describe seizures precipitating events,
duration/frequency, intensity of the seizure
activity, postictal behavior observe record - Safety positioning assist pt during seizure,
proper supplies - Medication administration guidelines specific
for IV meds - Lab values check therapeutic blood levels on
admission - Patient and family support discuss lifestyle and
feelings with patient
22CNS Antiepileptic DrugsPatient Education
- Medication
- adherence to prescribe regimen
- Do not Stop Abruptly Life Time Treatment -
Rebound Convulsions - Medic Alert Bracelet
- Protective environment
- Driving physician prescription/State laws
- Sedating effects of the drugs may decrease with
time - Avoid alcohol cigarettes
- Photosensitivity with certain AEDs sunscreen
protective clothing - Avoid stimulants
- Oral hygiene hyperplasia
23CNS Antiepileptic DrugsReview
- When caring for a patient with epilepsy who was
hospitalized and successfully treated for status
epilepticus, a precaution that the nurse
institutes includes - a. placing oxygen and suction equipment at the
bedside. - b. assigning an assistant to stay with the
patient at all times. - c. keeping an airway available to insert as
needed. - d. instructing the patient to stay in bed and
call for assistance - to go to the bathroom.
24CNS Antiepileptic DrugsReview
- A nurse witnesses a patient with a seizure
disorder as he suddenly jerks his arms and legs
with tonic-clonic type movement, falls to the
floor, temporary loss of consciousness, which he
regains immediately. The type of seizure
demonstrated by this patient and that the nurse
documents is - a. atonic seizure
- b. myoclonic seizure
- c. complex partial seizure with automatisms
- d. generalized seizure