1. Taking charge of seizure activity Critical care nursing

2. 2 Learning objectives 1. Differentiate between partial and generalized seizures. 2. Identify available options to manage seizures. 3. Indicate major patient-education points regarding seizures.

3. 3 What is a seizure? Abnormal stimulus in the CNS causes excessive and chaotic electrical discharge from brain neurons. Temporary changes in cerebral function alter motor or autonomic function, consciousness, or sensation. Someone who has two or more unprovoked seizures because of a chronic underlying condition has epilepsy.

4. 4 Phases of a seizure Aura  May occur before a seizure  Examples: depression, certain smell  Can occur hours or days before seizure Ictus  Period of seizure activity Postictus  Period after a seizure  Patient may be conscious but confused and tired  Can last several minutes to hours  Patient may not remember the seizure

5. 5 Causes of seizures Genetics Idiopathic (about 75% with unidentified cause) Acquired  Acidosis  Electrolyte imbalances  Hypoglycemia  Hypoxia  Alcohol and drug withdrawal  Dehydration  Systemic lupus erythematosus  Hypertension  Septicemia  Tumors  Head trauma

6. 6 Seizure causes related to age Neonates  Brain defect  Birth injury  Meningitis  Hypoglycemia  Hypocalcemia Children  Febrile illness  Lead toxicity  Head trauma Adults  Head trauma  Alcohol withdrawal  Metabolic disorders  Brain tumor  Brain infection or inflammation abscess meningitis encephalitis

7. 7 Nonepileptic seizure activity Abnormal electrical discharge of CNS neurons aren’t involved Examples:  Syncope  Hyperventilation  Pseudoseizures due to psychological conditions, such as panic and anxiety attacks

8. 8 Tracing seizure activity

9. 9 Partial seizures Also known as focal seizures Involve abnormal electrical discharge in only one brain hemisphere Can be simple or complex

10. 10 Simple partial seizure Patient is conscious and fully aware of seizure activity but can’t control it. Jerking movements, localized pain, or feeling of déjà vu. Can progress to a complex or secondary generalized seizure.

11. 11 Complex partial seizure Patient has impaired consciousness without loss of consciousness. Patient appears awake but can’t understand what’s happening. May display bizarre, involuntary automatisms, such as rearranging objects, moving in circles, or repetitively smacking lips together. This type of seizure typically starts in the temporal or frontal lobe.

12. 12 Generalized seizures Involves widespread abnormal electrical discharge across the entire brain cortex Manifestations can range from violent motor activity to less obvious signs. Can be convulsive or nonconvulsive

13. 13 Convulsive generalized seizures Also known as tonic-clonic or grand-mal Loss of consciousness occurs Three phases: 1. Tonic 2. Clonic 3. Postictal

14. 14 Tonic phase Usually lasts 10 to 30 seconds Voluntary muscles contract, arms flex and legs extend Patient may  fall, if standing  make screaming or crying sounds  lose bladder and bowel control Even if her eyes are open, the patient is unresponsive and unaware of her environment.

15. 15 Clonic phase Seldom lasts longer than 2 minutes Rapid, rhythmic muscle contraction and relaxation that cause jerking of various body parts Jerking may be limited to fingers or may involve torso and extremities Saliva pools and causes frothing because patient can’t swallow Secretions or tongue relaxation can lead to airway obstruction Periods of relaxation typically lengthen before the seizure ends

16. 16 Postictal phase Lasts 30 minutes to several hours The patient  lies very still as her brain recovers  may be confused, drowsy, nauseated, and disoriented

17. 17 Febrile seizures Type of convulsive generalized seizure Unrelated to epilepsy Caused by rapid increase in temperature More common in children from 6 months to 5 years old, but can affect adults Typically, rectal temperature is greater than 102° F (38.9° C) 95% to 98% fully recover and never develop epilepsy

18. 18 Nonconvulsive generalized seizures Less obvious manifestations, so harder to recognize Three classifications: 1. Absence seizures 2. Myoclonic seizures 3. Atonic seizures

19. 19 Absence seizures Formerly called petit mal Brief interruption in consciousness without loss of postural control Typically affect children May include periods of staring, lid fluttering, or lip smacking, while awareness and alertness are impaired Patient immediately returns to normal activity at end of seizure A teacher may be the first person to notice absence seizures, commenting that the child daydreams too much or appears to “blank out” frequently.

20. 20 Myoclonic seizures Triggered by environmental factors, such as flashing lights Can occur at any age Generally don’t cause loss of consciousness Commonly occur before sleep or after awakening Characterized by sudden, sporadic jerking motions of one area or muscle group

21. 21 Atonic seizures Also known as akinetic or astatic seizure Commonly called a “drop attack” Characterized by sudden loss of postural tone that lasts a few seconds Increased risk of head and neck trauma Typically begin in childhood and commonly recur into adulthood

22. 22 Status epilepticus Can occur with any type or seizure, but most commonly a complication of convulsive generalized seizures Identified by either of these criteria:  Two or more consecutive seizures without return of consciousness between them  Continuous seizure activity lasting 5 minutes or more THIS IS A MEDICAL EMERGENCY!  Compromised airway can lead to hypoxia  Neurons begin to die, leading to permanent brain damage

23. 23 Protecting your patient during a seizure Summon help and be prepared to use BLS or ACLS Lower patient to bed or floor Raise side rails Use pads or cushions to protect her head Place her on her side to prevent aspiration Move harmful objects to a safe distance Provide privacy, if able Don’t put anything in her mouth Observe and be aware of potential for status epilepticus Once seizure is over, place her on her side in rescue position When she’s awake and alert, assess and reassure her Prepare for diagnostic testing Document the event Investigate precipitating factors

24. 24 Pinpointing a diagnosis History  Details about the seizure activity  Head trauma, stroke, prior seizures  Family history of seizures  Use of prescribed or recreational drugs Neurologic exam by neurologist or other appropriate practitioner

25. 25 Pinpointing a diagnosis (cont’d) Blood work  Serum glucose, electrolyte, and osmolality levels  Assays of antiepileptic drugs (AEDs)  Liver and renal function tests  Thyroid studies  Arterial blood gases

26. 26 Pinpointing a diagnosis (cont’d) Cardiac studies, such as an electrocardiogram (ECG) Imaging studies, such as computed tomography (CT) scan and magnetic resonance imaging (MRI) Electroencephalogram (EEG) Observation (if low risk for recurrent seizures)

27. 27 Managing seizures: Medications Medications work in two ways  Suppress activity of damaged neurons  Reduce responsiveness of neighboring normal neurons Patient is started on low dose to minimize adverse reactions and prevent toxicity Dosage is increased as needed to control seizures

28. 28 Managing seizures: Medications (cont’d) Drugs used as monotherapy  phenytoin  valproate  carbamazepine  lamotrigine  phenobarbital Drugs used to treat status epilepticus  lorazepam  phenytoin  fosphenytoin  phenobarbital  midazolam  propofol Adjunctive agents  ethosuximide  methsuximide  clonazepam  topiramate  tiagabine  gabapentin  primidone  felbamate  levetiracetam  zonisamide  oxcarbazepine  pregabalin

29. 29 Managing seizures: Surgery Most beneficial when seizures are caused by structural brain abnormalities Complications include infection, bleeding, and paralysis Two main procedures  Resection – removal of a portion of the temporal lobe and small portions of the hippocampus on the affected side  Disconnection – cutting through nerve pathways that let seizures spread

30. 30 Managing seizures: Vagal nerve stimulation Implantation of a device that sends mild electrical pulses to the brain via the vagus nerve Stops the spread of excessive discharge of brain neurons Requires minor surgical procedure every few years to change the battery

31. 31 Patient and family teaching How to care for the patient during a seizure Medications and importance of adhering to the regimen Need for periodic blood work Importance of continued follow-up care Methods to prevent injury Patient and family support groups Understanding state’s law on driving