 Epilepsy

 Group of disorders characterized by excessive

excitability of neurons in the CNS [cerebral cortex or
gray matter
 Seizure
 Brief episode of abnormal electrical activity
[epileptic event]
 Paroyxmal uncontrolled electrical discharge in
brain that interrupts normal function.
 Convulsion
 Applies only to abnormal motor movement
phenomena.
▪ i.e. jerking movements during a ‘tonic-clonic’ [grand mal]
attack
 Most common: 1st 6 months life: High fevers
[febrile seizures], severe birth injury, congenital
defects involving the central nervous system
(CNS), infections, and inborn errors of
metabolism
 B/2 2& 20 yrs: primary causative factors are
birth injury, infection, trauma, and genetic
factors
 20 & 30 y: primary causative factors are birth
injury, infection, trauma, and genetic factors
 >50y:cerebrovascular lesions (stroke) and
metastatic brain tumors
 Generalized seizures
 Tonic-clonic [Grand mal]-most
Common.
 Absence seizures [Petit mal]
 Myoclonic seizures
 Status epilepticus
 Febrile seizures
 Partial seizures
 Simple partial seizures
 Complex partial seizures
 Secondarily generalized seizures
Other-
Lennox-Gastaut Syndrome [mixed seizures]
Psychogenic seizures
 Prodromal phase
 Signs or activity that precede a seizure
 Aural phase
 Sensory warning
 Ictal phase
 Occurs w/full seizure
 Postictal phase
 Period of recovery after seizures
 Tonic-clonic [Grand mal seizure]
 Manifested as major convulsive activity characterized
by tonic phase [muscle rigidity] followed by
synchronous muscle jerks [clonic phase].

 Febrile seizure
 Atonic [Drop attack]
 Sudden loss of myo tone
 Begins suddenly as person falls to ground
 Head drop can occur if seizure activity is limited
 Drop attack if myos of limbs and trunk involved
causing pt to collapse
 Risk for head injury & requires that helmet be
worn
 Occur in children
 Subclinical seizures-form of status epilepticus
 Sedated patient seizes but w/out external
signs due to sedative effects of medications.
 i.e. sedated for ventilatory support experiencing
seizure without physical movements
 Status epilepticus-most dangerous
complication can cause ventilatory insufficiency,
hypoxemia, cardiac dysrhythmias, hyperthermia
and systemic acidosis
 Lasts 30 minutes or longer, continuous
 Continuous seizure activity in rapid successions
w/out return to consciousness between seizures
 Neurologic emergency
 Permanent brain damage can occur
 Myoclonic
 sudden, excessive jerk of the body or extremities. The
jerk may be forceful enough to hurl the person to the
ground.
 Absence [petit mal]
 LOC for 10-30 seconds
 Mild, symmetrical motor activity [i.e. eye blinking,
brief staring lasting few seconds]
 Occurs in children and may cease during early teens
 Precipitated by hyperventilation and flashing lights
 Known as ‘Anticonvulsants’
 Goal of tx: control or prevent seizures while
maintaining a reasonable quality of life
 Many patients must take for ‘life’
 Abrupt discontinuation can cause withdrawal
seizures
 If 1st agent not effective, must be tapered slowly
while 2nd is introduced
 Depending on agent, therapeutic drug
monitoring of serum levels must be done to
assess effectiveness of therapy and avoid
toxicities or under treatment
 Classified into
 Traditional AED
 Newer AED
 Classes
 Barbiturates
 Hydantoins
 Iminostilbenes plus valproic acid
 Phenobarbital [generic] oldest – Sch IV- B
 Carbamazepine [Tegretol]- I
 Phenytoin [Dilantin]-H
 Pimidone [Mysoline]-B
 Valproic acid [Depakene, Depakote,
Depakote ER]-unspecified
 Exthosuximide [Zarontin]-Succinimide
 Gabapentin [Neurontin]-used to treat neuropathic
pain also
 Lamotrigene [Lamictal]
 Levetiracetam [Keppra]-**sleepiness
 Pregabalin [Lyrica]-Schedule V; also for
neuropathic pain & postherpetic pain
 Tiagabine [Gabitril]
 Topiramate [Topamax]
 Zonisamide [Zonegram]
 Lacosamide [Vimpat]
 Banzel [rufinamide]
 Onfi [Clobazam] 2011 U.S.
Oxacarbazepine-Trileptal
Gabapentin-Neurontin
Lamotrigine-Lamictal
Levetiracetam-Keppra
Topamax
Gabitril, Zonegram, pregbalin-Lyrica
 1. increase threshold activity in area of brain
called motor cortex
 2. limit spread of seizure discharge from its
origin
 3. decrease speed of nerve impulse
conduction within a given neuron
 Pheno: sedation/drowsiness [most common],
lethargy, depression, learning impairment,
physical dependence, poryphyria
 Valporic acid-hepatoxicity, pancreatitis
 Phenytoin-gingival hyperplasia,
sedation/drowsiness,nystagmus, diplopia,
ataxia, cognitive impairment, skin rash,
dyrsrhythmias [IV]
 Topiramate [Topamax]-met. Acidosis,
hypohidrosis [reduced sweating], close-angle
glaucoma
 Zonisamide [Zonegram]- nephrolithiasis, psych
effects
 Pregabalin [Lyrica]-blurred vision, somnolence,
rhabdomyolysis [rare], dependence
 Lamotrigine [Lamictal]-life threatening rashes-
SJS, toxic epidermal necrolysis
 Oxcarbazepine [Trileptal]- hyponatremia [less
125 mEq/L], fatal skin rashes, mult-iorgan
hypersensitivities
 Pregnancy:
 AEDS: teratogenic BUT
 Benefits must outweigh the risks
 Common malformations
 Valproic acid-spina bifida & other neural tube
defects
 Uncontrolled seizures
▪ Safety concern
▪ Induce labor
▪ Injury to baby during last month
 Carbamazepine [Tegretol]-
 Traditional/first generation
 Uses: partial and general tonic-clonic; trigeminal
neuralgia
 DO NOT GIVE w/GRAPEFRUIT-increased
toxicity of antiepileptic medication
 Instruct patient to report visual abnormalities.
 Instruct patient that abrupt withdrawal after
long-term use may precipitate seizures
 Must monitor drug levels: 4-12 mcg/mL
 A/E: bone marrow suppression, fatal aplastic
anemia
 1st line drug-Protypical-HYDANTOIN
 Used: tonic-clonic/partial seizures
 Most common adverse effects are lethargy, abnormal
movements, mental confusion, and cognitive changes.
 Gingival hyperplasia is a well-known adverse effect of long-
term oral phenytoin therapy.
 Scrupulous dental care can help prevent gingival
hypertrophy.
 Long-term=gingival hyperplasia, acne, hirsutism, and
hypertrophy of subcutaneous facial tissue resulting in an
appearance known as Dilantin facies.
 Another long-term consequence of phenytoin therapy is
osteoporosis.
 Need Vitamin D supplements
 Therapeutic drug levels are usually 10 to 20
mcg/mL.
 Above 20 mcg/mL: Toxic levels: nystagmus,
ataxia, dysarthria, and encephalopathy.
 Phenytoin can interact with other medications
for two main reasons.
 First, it is highly bound to plasma proteins and
competes with other highly protein-bound
medications for binding sites.
 Second, it induces hepatic microsomal enzymes,
mainly cytochrome P-450
 Route: PO, IV
 Should be given slow IVP [not to exceed 50
mg/min in adults]
 Must be diluted in NORMAL SALINE for IV
infusion & a filter must be used.
 Follow each dose by saline flush to avoid local
venous irritation
 Loading dose: 1 gram IV: pt needs to be on a
CARDIAC monitor.
Gingival inflammation
 injectable prodrug of phenytoin [Dilantin]
 Route: intramuscularly or intravenously—by IV push or
continuous infusion—without causing burning on injection
Fosphenytoin is dosed in phenytoin equivalents (PE)
Fosphenytoin is given at a rate of 150 mg PE/min or less to avoid
hypotension or cardiorespiratory depression.
 If dysrhythmias or hypotension occur, discontinue the infusion.
 Implement fall prevention measures after infusion of either
phenytoin or fosphenytoin because of possible ataxia and
dizziness.
 Take vital signs up to 2 hours after infusion.
 two of the most commonly used antiepileptic
drugs were the barbiturates phenobarbital and
primidone (Mysoline)
 Phenobarbital-Schedule IV
 used for the management of status epilepticus and
is an effective prophylactic drug for the control of
febrile seizures
 Most common effect: sedation
 Therapeutic serum drug levels: 10-40 mcg/mL.
 Long half-life-50-120 hours
 Route: PO, Injectible
 Benzodiazepines-Status epilepticus
▪ Lorazepam [Ativan]-preferred
 Phenytoin [Dilantin] loading 1 gram IV
 Diazepam [Valium]
 Phenobarbital [rarely used]
 SAFETY ALERT

 During a seizure, you should do the following:

 Maintain a patent airway.

 Protect the patient's head, turn the patient to the side,

loosen constrictive clothing, ease patient to the floor, if
seated.

 Do not restrain the patient.

 Do not place any objects in the mouth.

 When a seizure occurs, you should carefully
observe and record details of the event
because the diagnosis and subsequent
treatment often rest solely on the seizure
description.
 All aspects of the seizure should be noted.
 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?
 Monitor serum drug levels
 Baseline and periodic lab studies as ordered
 O2 as ordered
 IV access essential
 Maintain seizure precautions
 Through neuro/respiratory assessment
 Instruct patient not to abruptly stop
 Instruct patient regarding worsening effects
 Instruct to administer same time each day
 IV pump for IV infusions
 Follow agency protocol for dilantin
 Cardiac monitoring as indicated esp.
w/dilantin loading [1 gram IV]
 Instruct to check whether driving is allowed-
most states driving is not allowed for a
specific period of time
 All safety precautions