Dr. Richard B. Fynn Dormaa Presby Hospital Dept.

of Child Health

 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.

 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.

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.

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.

 Perinatal:

HIE- Hypoxic ischemic encephalopathy

Metabolic

Hypoglycemia, hypocalcemia hypomagnesemia Other

Infections Structural

abnormalities

 Definition:

Seizure in children between the age of 6 months and 3-5 years in association with fever but without evidence of an intracranial infection

Majority

occurs before the age of 3 years Average age of onset: 18 months to 22 months Boys more than girls

 Simple

febrile seizures

Generalise <15min duration Do not recur within 24hrs Prolonged seizures Usually more than one in a 24hr period Or may be focal Indicative of a more serious condition

Complex

 Recurrence

1/3 may have at least one recurrence The younger the age of onset the greater the risk of recurrence Low fever at first seizure Family hx

Risk

of developing epilepsy

2% (vs 1% in gen pop), complex febrile seizure

 Oxygen

and supportive care Benzodiazapines Antipyretics

Do not appear to prevent recurrence

Tepid

sponging Reassure parents

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.

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: 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.

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. Psychomotor sx: Lip-smacking, continuing an activity before seizure began, or fumbling with objects. Psychosensory sx: vertigo, visual or auditory sensations, altered thought processes

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.

Children > 5 years: Typical, generalized tonic-clonic seizure lasts < 5 minutes
Young children and infants: lasts < 10-15 minutes

New evidence points to astrocytes(star-like glial cells) in the brain that provides support to the neurons and clean up debris and also provides the neurons with some chemicals needed for proper functioning and nourishment . may also play an important role in recurring seizures. Astrocytes release some substances 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.

Accurate and comprehensive description of the seizures Patients 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. Thorough patients history & physical examination needed 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) FBC, electrolytes, LFT fasting glucose, BUE & creatinine Lumbar puncture for CSF analysis Electroencephalography (EEG) CT, MRI, PET scan

Other Diagnostic Studies

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 functionbrain damage. Tonic-clonic is the most dangerous hypoxia, cardiac dysrhythmias, hyperthermia, systemic acidosis, and death.

Tonic- Clonic seizures

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

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

Emergent interventions for our patient center around the ABCs 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.

Post-Seizure

Maintenance

Regular meals and snacks in between if feeling shaky, faint, or hungry

Balanced nutrition Good food choices Abstain from alcohol Caffeine in moderation Be knowledgeable about any foods that may be contraindicated with specific medications

During a tonic-clonic seizure it is a good possibility that the patient may experience urinary or fecal incontinence during the ictal phase

Benzodiazepines
Lorazepam 0.1 mg/kg i.v. over 1-2 minutes Diazepam 0.2 mg/kg i.v. or rectal over 1-2 minutes If Seizure persists, repeat every 5-10 minutes

 Lorazepam

Diazepam

Action delayed 2 minutes Anticonvulsant effect 6-12 hrs Less respiratory depression than diazepam

Midazolam

Thus very rapid onset Redistributes rapidly Thus rapid loss of anticonvulsant effect Adverse effects are persistent:

May be given i.m.

Hypotension Respiratory depression

 Phenytoin

20 mg/kg i.v. over 20 min pH 12 Extravasation causes severe tissue injury Onset 10-30 min May cause hypotension, dysrhythmia

Phenobarbital

20 mg/kg i.v. over 10 - 15 min Onset 15-30 min May cause hypotension, respiratory depression

High dose phenobarb for Seizure will prob need icu admission

 Propofol

infusion 5-10 mg/kg/hr after bolus 2

mg/kg Midazolam infusion 1 - 10 mcg/kg/min after bolus 0.15 mg/kg

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)

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.

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

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. 2. 3.

The diagnosis of epilepsy must be confirmed, There must have been an adequate trial with drug therapy without satisfactory results, 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

OTHER THERAPIES: Vagal nerve stimulation Biofeedback

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

 The

primary determinant of mortality and morbidity of SE in children is its aetiology

With

the highest mortality rates caused by an acute neurological condition (infection, trauma, stroke) Accounts for 3-15% of death in children

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 its 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.

 Airway
Breathing Circulation Dont Ever Forget Glucose