1. Epilepsy & Pharmacology
Intro
References: Lilley Pharmacology
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2. History of Epilepsy
Epilepsy was one of the first brain disorders to be described in history
It was mentioned in ancient Babylon more than 3,000 years ago
Through the ages, the strange behavior caused by some seizures has led to the creation of numerous superstitions and prejudices
The term epilepsy is derived from the Greek word 
epilam-banein, meaning to attack or seize.
People once thought that epileptic individuals were being visited by demons or gods
However, in 400 b.c., the early physician Hippocrates suggested that epilepsy was a disorder of the brain— and he was right.
Ref

3. Epilepsy Manifestations
Seizures can last from a few seconds to a few minutes…what is an exception?
Patients and health care professionals do not always recognize the signs or symptoms, which can include convulsions, a loss of consciousness, blank staring, lip smacking, or jerking movements of the arms and legs
A seizure has a clear beginning, middle, and end.
Ref

4. Epilepsy Seizure Convulsion Epilepsy
Brief episode of abnormal electrical activity in nerve cells of the brain
Convulsion
Involuntary spasmodic contractions of any or all voluntary muscles throughout the body, including skeletal, facial, and ocular muscles
Epilepsy
Chronic, recurrent pattern of seizures
types

5. Epilepsy Primary (idiopathic) Secondary (symptomatic)
Cause cannot be determined
Roughly 50% of epilepsy cases
Secondary (symptomatic)
Distinct cause is identified
Trauma, infection, cerebrovascular disorder
A severe, penetrating head trauma or injury is associated with almost a 50% risk of subsequent epilepsy.
In older patients, Alzheimer’s disease and stroke may precipitate epilepsy.

6. Diagnosis
Any patient who has a possible seizure disorder should undergo EEG evaluation as soon as possible
Almost all patients with new-onset seizures should have a brain imaging study to detect any underlying structural abnormalities
 MRI is superior to CT for detecting cerebral lesions associated with epilepsy Dx

7. Seizure Types Partial (focal) seizures
Simple partial (with motor, sensory, autonomic, or psychic signs;
consciousness is not impaired)
Complex partial (consciousness is impaired)
Partial seizures evolving to secondarily generalized seizures
Primarily generalized seizures
Myoclonic
Clonic
Tonic
Tonic–clonic (grand mal)
Atonic
Absence seizure (petite mal)
Unclassified seizures
Neonatal seizures
Infantile spasms
Patients may have seizures intermittently, with periods of months to years between seizures.

8. Partial Seizures
Partial- Partial seizures are confined to discrete areas of the cerebral cortex; only a certain area of the body is usually involved, at least at the start 
By contrast, generalized seizures are noted in diffuse regions of the brain.
Simple partial seizures cause motor, sensory, autonomic, or psychic symptoms without an obvious alteration in consciousness
These seizures may also be manifested as changes in somatic sensation (e.g., paresthesias or tingling), vision, equilibrium, or autonomic function- olfactory changes, and hearing.
Partial

9. Partial Seizures Continued
Complex Partial Seizures are characterized by focal seizure activity, accompanied by transient impairment of the patient’s ability to maintain normal contact with the environment
Partial seizures can spread to involve both cerebral hemispheres and may produce a generalized seizure, usually of tonic–clonic variety
Notes

10. Generalized & Absence Seizures
Generalized: Generalized seizures arise from both cerebral hemispheres simultaneously
Absence Seizures (once called petit mal) are characterized by sudden, brief lapses of consciousness without loss of postural control.
The absence seizure typically lasts for only seconds; consciousness returns as suddenly as it was lost, and there is no postictal confusion.
Notes:

11. Observation of a Tonic-Clonic Seizure
Tonic Seizures
During a tonic seizure, the person’s muscles initially stiffen and they lose consciousness. The person’s eyes roll back into their head as the muscles (including those in the chest, arms and legs) contract and the back arches. As the chest muscles tighten, it becomes harder for the person to breathe – the lips and face may take on a bluish hue, and the person may begin to make gargling noises. 
Many observers have the misconception that the person is in danger of “swallowing their tongue,” so they attempt to put something in the person’s mouth. Swallowing your tongue is actually impossible, and any attempt to open the now tightly clenched jaw may cause more harm than good.
Clonic Seizures
During a clonic seizure, the individual’s muscles begin to spasm and jerk.  The elbows, legs and head will flex, and then relax rapidly at first, but the frequency of the spasms will gradually subside until they cease altogether. As the jerking stops, it is common for the person to let out a deep sigh, after which normal breathing resumes.
Tonic-Clonic

12. Observation of Seizures Continued
Tonic-clonic (once called grand mal) seizures
A tonic seizure is typically accompanied by a clonic seizure – it is rare to experience one without the other. When both are experienced at the same time, this is known as a tonic-clonic
Notes

13. Antiepileptic Drugs (AEDs)
Also known as anticonvulsants
Goals of therapy
To control or prevent seizures while maintaining a reasonable quality of life
To minimize adverse effects and drug-induced toxicity
AED therapy is usually lifelong
Combination of drugs may be used
Notes

14. Antiepileptic Drugs
Single-drug therapy is usually started before multiple-drug therapy is tried
Serum drug concentrations must be measured
Therapeutic drug monitoring
Patients who are seizure free for 1 to 2 years may be able to discontinue antiepileptic therapy
Notes

15. Mechanism of Action and Drug Effects
Exact mechanism of action is not known
Pharmacologic effects:
Reduce nerve’s ability to be stimulated
Suppress transmission of impulses from one nerve to the next
Decrease speed of nerve impulse conduction within a neuron
Notes

16. Antiepileptic Drugs: Indications
Prevention or control of seizure activity
Long-term maintenance therapy for chronic, recurring seizures
Acute treatment of convulsions and status epilepticus
Other uses
Other uses include migraine prevention

17. Antiepileptic Drugs: Adverse Effects
Numerous adverse effects—vary per drug
Adverse effects often necessitate a change in medication
Black box warning as of 2008
Suicidal thoughts and behavior
Long-term therapy with phenytoin (Dilantin) may cause gingival hyperplasia, acne, hirsutism
Dilantin facies (if taken during pregnancy- baby may develop short nose, flat face, large head).
Notes

18. Classroom Response Question
A patient in a long-term care facility has a new order for carbamazepine (Tegretol) for seizure management. The nurse monitors for auto- induction-enzymes formed that lower drug concentration) which will result in
toxic levels of carbamazepine (Tegretol).
lower than expected drug levels.
gingival hyperplasia.
cessation of seizure activity.
Correct answer: B
Rationale: Carbamazepine (Tegretol) is associated with autoinduction of hepatic enzymes. Autoinduction is a process in which, over time, a drug stimulates the production of enzymes that enhance its own metabolism, which leads to lower than expected drug concentrations.
Elsevier items and derived items © 2009, 2005, 2001 by Saunders, an imprint of Elsevier Inc.

19. A Few First-Line Antiepileptic Drugs
carbamazepine (Tegretol)
phenobarbital
phenytoin (Dilantin)
primidone (Mysoline)
valproic acid
First line means primary drug of choice…meds work for different types of seizures

20. Second-Line Antiepileptic Drugs (Adjunct or supplemental)
acetazolamide (Diamox)
levetiracetam (Keppra)
topiramate (Topamax)
zonisamide (Zonegran)
tiagabine (Gabitril)
pregabalin (Lyrica)
ethosuximide (Zarontin)
gabapentin (Neurontin)
lamotrigine (Lamictal)
diazepam (Valium)
clonazepam (Klonopin)
clorazepate (Tranxene)
Notes

21. Medications
Both new and earlier AEDs are generally equally effective in new-onset epilepsy
Newer drugs tend to have fewer adverse effects
Patients with newly diagnosed epilepsy can begin treatment with a standard AED (carbamazepine, phenytoin, valproic acid/divalproex, phenobarbital) or with a newer agent (gabapentin, lamotrigine, oxcarbazepine, topiramate)
The choice depends on each patient’s characteristics
Notes

22. Classroom Response Question
The nurse is assessing the current medication list of a newly admitted patient. The drug gabapentin (Neurontin) is listed, but the patient states that he does not have any problems with seizures. The nurse suspects that the patient
is unaware of his own disease history.
has been taking his wife’s medication by mistake.
may be taking this drug for neuropathic pain.
is reluctant to admit to having a seizure disorder.
Correct answer: C
Rationale: Gabapentin is commonly used to treat neuropathic pain.
Elsevier items and derived items © 2009, 2005, 2001 by Saunders, an imprint of Elsevier Inc.

23. Nursing Implications Assessment
Health history, including current medications
Drug allergies
Liver function studies, CBC
Baseline vital signs
Seizure precautions
Nursing

24. Classroom Response Question
Before a patient is to receive phenytoin (Dilantin), the nurse practitioner orders lab work. Which lab result is of greatest concern?
High white blood cell count
Low serum albumin levels
Low platelet levels
High hemoglobin levels
Correct answer: B
Rationale: Phenytoin is highly bound to plasma proteins. If serum albumin levels are low, more free drug will be available to exert an effect, and toxicity may occur.
Elsevier items and derived items © 2009, 2005, 2001 by Saunders, an imprint of Elsevier Inc.

25. Nursing Implications Oral drugs Take regularly, same time each day
Take with meals to reduce GI upset
Do not crush, chew, or open extended-release forms
If patient is NPO for a procedure, contact prescriber regarding dosage
Teaching

26. Classroom Response Question
A patient with unstable epilepsy is receiving IV doses of phenytoin (Dilantin). The latest drug level is 12 mcg/mL. Which administration technique will the nurse use?
Administer the drug by rapid IV push
Infuse slowly, not exceeding 50 mg/min
Mix the medication with dextrose solution
Administer via continuous infusion
From lecture- what is normal Dilantin level?
Correct answer: B
Rationale: Phenytoin should be mixed only with normal saline, and it should be given by slow IV infusion (but not as a continuous infusion).
Elsevier items and derived items © 2009, 2005, 2001 by Saunders, an imprint of Elsevier Inc.

27. Nursing Implications phenytoin
Intravenous forms
Follow manufacturer’s recommendations for IV delivery—usually given slowly
Monitor vital signs during administration
Avoid extravasation of fluids
Use only normal saline with IV phenytoin (Dilantin)
Notes

28. Nursing Implications Teach patients to keep a journal to monitor:
Response to med(s)
Seizure occurrence and descriptions
Adverse effects
Instruct patients to wear a medical alert tag or ID
Anti-epileptic drugs should not be discontinued abruptly
Follow driving recommendations
Notes

29. Nursing Implications
Teach patients that therapy is long term and possibly lifelong (not a cure)
Monitor for therapeutic effects
Decreased or absent seizure activity
Monitor for adverse effects
Mental status changes, mood changes, changes in level of consciousness or sensorium
Eye problems, visual disorders
Sore throat, fever, blood dyscrasia may occur (imbalance of components in blood)
Many other adverse effects especially with other meds
Notes

30. Classroom Response Question
Which information will the nurse provide to the patient who is receiving antiepileptic drug therapy?
If you feel sleepy when taking the drug, decrease the dose by one half
Take the drug on an empty stomach
Call your health care provider if you experience a sore throat or fever
Patients with epilepsy are not able to hold a job and work, so you should apply for benefits
Correct answer: C
Rationale: To prevent complications, patients should be taught to call the health care provider if they experience fever, sore throat, excessive bleeding or bruising, and new onset of nosebleeds. Drowsiness is a common side effect of these drugs; the dose should never be altered without consulting the prescriber. These medications should be taken with food to decrease GI upset. Most patients with seizure disorders are able to work and are protected by the Americans with Disabilities Act.
Elsevier items and derived items © 2009, 2005, 2001 by Saunders, an imprint of Elsevier Inc.

31. Aura is the term used to describe symptoms that may occur before a seizure and may include:
Visual changes. Examples include:
Bright lights.
Zigzag lines.
Slowly spreading spots.
Distortions in the size or shape of objects.
Blind or dark spots in the field of vision
Hearing voices or sounds (auditory hallucinations)
Strange smells (olfactory hallucinations).
Feelings of numbness or tingling on one side of your face or body.
Feeling separated from your body.
Anxiety or fear.
Nausea
An aura is often the first sign that a patient is going to have a seizure. An aura may last from several seconds up to 60 minutes before a seizure. Most people who have auras have the same type of aura every time they have a seizure.

32. Case Scenario Patient
Notes

33. Patient Has a One Year History of Epilepsy -co-workers observed seizure at work and called 911 Please organize a concept map- also refer to speaker notes for more information about the patient
1.Admit to neuro unit 2.Code status: Full code 3.Continuous cardiac monitoring and pulse oximetry, maintain 02 sat >94% 4.Neurologic assessment and vital signs every 2 hours 5.Seizure precautions 6.Up as tolerated 7.Start saline lock 8.Regular diet 9. Tegretol 200 mg by mouth 3 times per day 11. Complete blood cell count, magnesium, and basic metabolic panel STAT 12. Valproic Acid level STAT  13. Call provider with laboratory values 14. For seizure activity, administer lorazepam 2 mg IV STAT, may repeat dose once if initial dose is ineffective; notify provider 15. Give loading dose of fosphenytoin IV 15 mg/kg at a rate of no more than 150 mg/minute
DOB 11/12/80, Ht 6.0” Wt 165 lbs, NKMA, developed epilepsy 1 year ago after a car accident, has been taking valproic acid at home, can’t recall the dose, but if he misses a does, he “doubles up the next time”
VS T 37, BP 120/60, P 100, RR16, 02 Sat 95% room air
Document on the map what orders are missing or incorrect
Document on the map what questions you will ask the patient and co-workers who witnessed the seizure. What education does this patient need?