1. + Module Two: Recognition and Care of Seizures and Emergencies There is an option for the participant to listen to audio synced to PowerPoint presentation, along with the option to download the modules in PDF format

2. + Objectives of ModuleTwo: Upon completion of Module Two-the participant will: Recognize generalized and partial types of seizures. Demonstrate basic first aid for seizure types. Identify when a seizure may become an emergency situation.

3. + Types of Seizures Generalized Involves the whole brain from the onset Types: Absence Myoclonic Clonic Tonic Tonic-clonic Atonic (drop attack) Partial (also called localization related, focal) Begins in one side of brain Can spread to other side Types: Simple partial Complex partial Secondary generalized

4. + Revised Terminology and Concepts for Classification of Seizures/Epilepsies Generalized and focal seizures redefined Generalized: “occurring in and rapidly engaging bilaterally distributed networks” Focal (partial): occurring “within networks limited to one hemisphere and either discretely localized or more widely distributed” Types of generalized seizures simplified, while focal seizures described in relation to manifestations

5. + Parts of a Seizure Prodrome – changes in behavior, mood or feelings that may occur hours or days before a seizure Aura - Symptoms correspond to the area of brain affected by the abnormal electrical activity. Most commonly seen with complex partial seizures. Ictus- What is seen/felt during abnormal electrical activity Postictal- What is seen/felt until the brain recovers to baseline

6. + Simple Partial Seizures Sometimes called ‘auras’, is the first symptom of a seizure No change in consciousness/awareness What is seen/felt correlates with abnormal electrical activity in a part of the brain

8. + Examples of Simple Partial Seizures Sensory Smells Sensations Visual changes Auditory symptoms Autonomic Dilated pupils Queasy Stomach Skin flushing Pallor, etc. Motor Unilateral jerking of face, arm, and/or leg may spread from one part of body to others May be unable to speak Can involve any part of the body Psychic Dejà-vu, jamais vu, out of body experience Feelings of fear, anxiety, happiness, depression

9. + Nursing Care During Seizure Simple Partial Promote safety Guide patient to a safe place Stay within arm’s reach Stay calm Observe the patient Speak calmly Assess awareness Reassure Time the seizure Document event

10. + Complex Partial Seizures M ay start as simple partial seizure or start suddenly Awareness is impaired, though may be difficult to assess May or may not hear, understand, see, respond or recall events during seizure Duration: seconds to minutes Automatisms: unusual and repetitive behaviors Motor signs include: One or both sides of body May be stiffening, jerking, twitching, or absence of movement May involve any part of the body including jaw, swallowing muscles, shoulders Can spread from one body area to others Post-ictal fatigue, confusion, sleepiness, headache

11. + Nursing Care During Complex Partial Seizure Promote safety Guide patient away from potential dangers. Do not restrain patient Patient may become combative if restrained If safe, let patient wander in an enclosed area Assist patient to lie down if there is a loss of tone Sta y calm Observe behavior and time the seizure Observe post ictal state (patient may be confused or tired) Reorient and reassure Stay with the patient until he/she returns to baseline Document

12. + Secondarily Generalized Seizures Starts in focal brain area then spreads from one side to include the other side That is, the seizure may start as a simple partial seizure or as a complex partial seizure May spread slowly or rapidly to a generalized seizure, usually causing patient to fall Electrographically, seizure involves both sides of brain

13. + Secondarily Generalized Seizures Eyes may roll back, may fall to ground or lean over Body becomes rigid (tonic) and then jerks (clonic) May involve incontinence of bladder and/or bowel May have forced head turn or eye deviation to side May involve one side of body more than the other Lasts 5 minutes or less

14. + Review of Partial Seizures Video introducing partial seizures and what they look like from epilepsy.com Understanding Partial Seizures (available 1/1/2014)

15. + Primary Generalized Seizures Involve both hemispheres at the onset Types of primary generalized seizures: Absence Myoclonic Tonic Atonic Clonic Tonic-clonic

16. + Absence Seizures (Previously called petit mal) Sudden onset of behavioral arrest May involve eyelid fluttering Duration: 5-30 seconds Usually occurs many times/day, difficult to identify clinically because of brief duration Returns to baseline almost immediately Possible anterograde or retrograde amnesia Hyperventilation and/or flashing lights may precipitate seizures Classic EEG pattern

17. + Nursing Care: Absence Seizure Promote safety Stay within reach Falling unlikely Stay calm Observe behavior and time the seizure Observe postictal behavior Usually returns to baseline immediately Reorient If photo-sensitive, avoid exposure to flashing lights or patterns Document seizure

18. + Tonic-Clonic Seizures (previously called grand mal or major motor) Often begins with an ictal cry (loud groan) Body may be tonic – posturing or stiffening of all muscles Person may appear as if not breathing as chest muscles are rigid Clonic movements – rhythmic jerking of head and extremities May have forced eye deviation upward

19. + Tonic-Clonic Seizures Duration: Generally lasts from seconds to 1-2 minutes Excessive salivation(collection of drooling) May involve tongue biting May involve bladder and/or bowel incontinence May turn dusky or cyanotic Postictally, may have Confusion Headache Muscle ache Sedation or fatigue for minutes to hours

20. + Nursing Care: Generalized Tonic-Clonic Seizure Stay calm Promote safety Cushion fall if possible Support head Loosen restrictive clothing Place NOTHING between teeth NO food or drink until able to swallow Do not forcefully reposition or restrain the movements

21. + Nursing Care: Generalized Tonic- Clonic Seizure Promote Safety Place patient in side-lying position as soon as possible Due to size or location of teenagers and adults, may need to wait until seizure is subsiding before turning to side Side-lying position promotes drainage of saliva from mouth May need to reposition head to keep airway clear In hospital, suctioning may help maintain airway, especially if seizure is long Observe behavior and time the seizure Assess for injury after the seizure is over

22. + Post Ictal Nursing Care: Tonic Clonic Seizure Observe behavior May be sleepy, confused, combative, difficulty talking, and unable to remember If sleepy, continue in side-lying position to protect the airway Gently restrain, if needed, to avoid injury Reassure/reorient Assess for injury Monitor duration of postictal state Confusion may last minutes Sleepiness may last minutes to hours NPO until able to swallow Document

23. + Tonic Seizures Sustained bilateral stiffening or posturing Usually brief but can last minutes May cause fall if standing or sitting Sudden, very unpredictable Significant risk of injury due to loss of protective reflexes, ie. cough, righting reflex May have change in breathing patterns or look like not breathing or may appear pale or cyanotic Can occur in clusters, sometimes along with other seizure types

24. + Atonic Seizures Atonic- also called “drop attacks” Sudden loss of tone Drop of head with or without slight bending of knees Drop of head, trunk or entire body May fall backwards or forward if sitting or standing Impaired awareness may be present but not discernible Usually very brief, variable intensity (mild to forceful) Significant risk of injury High risk for head lacerations, fractures, and other injuries Often require helmets and safety gear

25. + Myoclonic Seizures Very brief, fast muscle contractions of the head, arms, legs, face, trunk and/or body Single jerk or clusters Unilateral or bilateral, can be specific muscle groups May cause loss of balance or fall May drop objects Often occur when drifting to sleep or shortly after awakening Impaired awareness may not be discernible Clusters may precede a generalized tonic-clonic seizure Some myoclonus may not be epilepsy-related

26. + Nursing Care: Tonic, Atonic and Myoclonic Seizures Stay calm Promote safety Be sure safety gear is worn, if ordered Cushion fall if possible – support head Clear area of harmful objects or surfaces Loosen restrictive clothing Place NOTHING between teeth There is no danger of the person swallowing their tongue NO food or drink until able to swallow Turn to side-lying position if not able to protect airway Do not forcefully reposition

27. + Nursing Care: Tonic, Atonic and Myoclonic Seizures Observe behavior and time the seizure/seizure cluster Post ictal care : Observe behavior Reassure and re-orient Assess for injury NO food or drink until able to swallow Assess return to baseline state Document

28. + Febrile Seizures Frequency 2% - 5% of children in United States Most often in children aged: 3 mos-5 years Associated with fever ≥ 101 Prolonged 13% > 10 minutes 5% > 30 minutes A prolonged 1 st febrile seizure, implies the next seizure will likely be prolonged

29. + Febrile Seizures Simple febrile seizure Generally lasts a few minutes and does not require treatment Occurs within 24 hours of fever onset Usually generalized tonic clonic seizure No localizing deficits afterwards No prior history of non-febrile seizures No current intracranial infection No other neurological/developmental abnormalities No family history of non-febrile seizure Complex febrile seizure Last > 15 minutes Have focal features or Recur within 24 hours

30. + Responding to Seizures: Summary of General First Aid Stay calm/speak quietly Time the seizure Promote safety Help person to floor or safe place, Prevent or cushion fall if possible Support head Remove harmful objects Make comfortable Maintain open airway Place nothing in mouth between teeth Keep onlookers away Stay with person until seizure ends Reorient and reassure patient Assess frequently until back to baseline May need to sleep/rest Nothing to eat or drink until able to swallow Assess for injury

31. + Review of Generalized Seizures Video introducing generalized seizures and what they look like from www.epilepsy.com Understanding Generalized Seizures (available January 2014)

32. + TIPS FOR SEIZURE OBSERVATION AND RECORDING When watching a seizure, observe: What happens before, during and after the event Write down what happened as soon as you can Include as much information as possible Download Tips for Seizure Observation and Recording by clicking here Download Tips for Seizure Observation and Recording by clicking here (available January 2014) © 2007 epilepsy.com A service of the Epilepsy Therapy Development Project

33. + Tips for Seizure Observation  What was person doing at time of event  Change in mood or behavior hours or days before  ‘Warning’ or ‘aura’ shortly before event  Possible triggers or precipitants  When seizures occurs – date, time, duration Before the Seizure

34. + Tips for Seizure Observation: During the Seizure Change in awareness, alertness, confusion Ability to talk and understand Changes in thinking, remembering, emotions, perceptions Sensations – changes in seeing, hearing, smells, tastes, feelings Facial expression, pupil size, eye blinking or position, drooling Changes in muscle tone Movements – jerking or twitching, unable to move, body turning, falls Automatic or repeated movements – lip smacking, chewing, swallowing, picking at clothes, rubbing hands, tapping feet, dressing or undressing Walking, wandering, running Changes in color of skin, sweating, breathing, loss of bladder or bowel control PART OF BODY INVOLVED

35. + Tips for Seizure Observation Response to voice or touch Awareness of name, place, time Memory for events Ability to talk or communicate Weakness or numbness Changes in mood or how person acts Fatigue, sedation What Happens After Event

36. + Tips for Seizure Observation Duration of aura, seizure, after-effects or postictal phase How long before person returns to normal activity © 2007 epilepsy.com A service of the Epilepsy Therapy Development Project Adapted with permission from the Comprehensive Epilepsy Center, Beth Israel Deaconess Medical Center, Boston, Massachusetts, 2006. How Long It Lasted

37. + Post Ictal Nursing Care: All Patients Monitor until returns to baseline Assess cognitive state Speak calmly and quietly –reorient and reassure Allow to sleep if desired Do not restrain: may cause aggression in some people Assess for injury, postictal paralysis, mood or behavior change Document

38. + When to Seek Medical Attention History of seizure recurrence in person with rare or well-controlled seizures Person with known epilepsy but occurrence of new seizure type Persistent side effects of treatment bothersome to patient

39. + When to Call for Emergency Help When seizures.. approach 5 minutes in duration or per patient’s seizure action plan one seizure occurs after another last longer than typical events When person.. doesn’t return to baseline in usual period of time has first seizure has suspected injury is pregnant or diabetic When observer is unsure or uncomfortable

40. + Injuries from Seizures Immediate Lacerations Bruises Burns Head trauma Fractures Drowning/near drowning Delayed Fever Aspiration pneumonia Subdural hematomas Fractures (delayed recognition) Change in seizures or seizure emergencies

41. Seizure Assessment Algorithm Reprinted with permission from the American Association of Neuroscience Nurses Return to index