Presentation on theme: "NEUROLOGY FOR NURSES ANDREA VAN LIEROP RN BSN"— Presentation transcript:
1NEUROLOGY FOR NURSES ANDREA VAN LIEROP RN BSN Arkansas Children’s Hospital
2Children with Epilepsy School Issues Children with poor seizure control are more likely to have trouble making friends.Taking medication at school may be associated with a significant decrease in social and peer relationships. Even in children with self reported good seizure control.
3DEFINITIONA seizure is a sudden and stereotyped alteration in motor activity, sensation, behavior or consciousness due to an abnormal electrical discharge of neuronsEpilepsy is a chronic neurological condition characterized by recurrent, unprovoked seizures.
4EpilepsyRecurrent seizures produced by abnormal repetitive neuronal firing in the brainOccurs in 1-2% of the population
6Evaluation of Epilepsy EEG & EpilepsyAwake only ( 30-40% abnormal)Awake and asleep ( 60-70% abnormal)Photic stimulationmay induce generalized spike and wave or occipital spikesHyperventilationmay induce 3/sec. spike and wave (absence)
7Evaluation of Epilepsy NeuroimagingIndicated with:Abnormal neurological examFocal onset seizuresUncertain if focal or primary generalized onsetOnset of seizures after adolescenceMRI is the gold standard (not CT)CT is helpful in the acute settingi.e. persistent alteration of consciousness or abnormal neurologic exam
8General Guidelines for Therapy: Correct classification of seizures leads to correct AED selectionTreat when the benefit of therapy outweighs the riskAvoid polypharmacyMonotherapy usually results in better seizure control and less side effects
9General Guidelines for Therapy: Maximize one medication before changing to the secondTreat the patient, not the EEG or the AED levelUse rational polypharmacy when indicatedIF IT’S NOT BROKEN, DON’T TRY TO FIX IT!!!!!!!!!!
10“Women” of Child Bearing Age on AED’s: All should receive folic acid supplementation with a minimum of 1mg/day, or 4mg/day if they are pregnant or actively trying to become pregnant
16Infantile Spasms Flexion or extension spasms Tend to occur in clusters Cryptogenic vs. symptomaticMany potential causesOnset: Birth to 2 yearsPeak onset: 5-6 months80% develop mental retardation60-70% have lifelong epilepsyHypsarrhythmia pattern on EEG
18Charlie9-year-old boy with long-standing history of intractable epilepsy with tonic-clonic, tonic, myoclonic, atypical absence and atonic seizuresModerate mental retardationFrequent injuries from falls
23Terry2-year-old boy with 3-week history of recurrent episodes of sudden fear or panicInitial frequency of 2-3 per day, now increased to 1 per hour or moreMaintenance of consciousnessLMD felt these could not be seizures
25Gabrielle12 y/o hispanic girl with 1-year history of frequent spells with several dailyDiagnosed with “pseudoseizures”Maintenance of consciousnessEvents are stereotypical with extension of the right arm and turning to the left, followed by agitated movements and vocalization with an abrupt recovery
30Complex Partial Focal onset Aura is common Alteration of consciousness AutomatismsPostictal confusionMay secondarily generalize
31Chelsea 9-year-old girl with 2 seizures during the last 4 months First episode occurred during sleep consisting of a brief generalized convulsionSecond seizure occurred during wakefulness and involved the right face and arm with subsequent secondary generalization
33Benign Focal Epilepsy of Childhood Rolandic (centrotemporal) or occipital spikesNocturnal seizures are commonSeizures are usually infrequentRemits by years of age or earlier
34Benign Focal Epilepsy of Childhood: Treatment *Treatment may not be warranted for uncomplicated, infrequent seizures.If seizures are frequent or tend to secondarily generalize, treatment should be considered.
35Tina13 y/o girl with frequent staring episodes described as a blank stare with unresponsiveness, noted daily at schoolDecreasing school performanceKey question: Is there an acute arrest of activity?
37Absence Brief staring episodes with unresponsiveness Sudden onset with an arrest of activityNo aura or postictal confusionMay have associated eye flutter or simple automatismsGeneralized 3 per second spike and wave80% will have resolution with age20% also have convulsive seizures.
40Primary Generalized Convulsive No warning; abrupt onsetTonic, clonic, tonic-clonic or clonic-tonic-clonic activityBowel and bladder incontinence commonPostictal unresponsiveness or confusionGeneralized spike and wave
43Bubba13-year-old boy who had a single generalized convulsion 3 weeks agoNo previous history of seizuresKey question: Do you ever have small jerks of your arms, especially early in the morning?Answer: “Oh yeah, I’ve been doing that for a couple of years”
45Myoclonic Sudden single jerks of the arms and head May occur in clustersNo alteration in consciousnessMay progress to a clonic-tonic-clonic seizureGeneralized multispike waveValproate, Clonazepam, Zonisamide
47Juvenile Myoclonic Epilepsy Autosomal dominant inheritanceChromosome 6Myoclonic seizures with onset in late childhood or adolescenceMay develop generalized convulsive or absence seizures
48The Rescue DrugDiastat Acudial is a diazapam rectal gel intended for the management of seizure patients who require intermittent use of Diazepam for seizure activity greater than 5 min.10mg diastat Acudial can be dialed to 5mg 7.5mg or 10mg20mg Diastat Acudial can be dialed to 12.5mg 15mg 17.5mg and 20mg2.5mg diastat is still available
49MAD Nasal Drug Delivery System Fast and Effective Controlled Delivery No NeedlesMidazolam/ VersedDosage .2mg/Kg up to max of 10mg50kg = 10mg/2mlDeliver slowly in one side of nostril,hold other side closed
50WHEN DO YOU CALL 911If a patient has been given Diastat or versed and is not recovering after 3 min.If the patient has turned cyanotic and is not breathingIf the patient is having cycles of seizures even after receiving rescue medication.
51Alternative Therapy for Epilepsy Ketogenic dietVagus nerve stimulatorEpilepsy surgery
52Ketogenic Diet First described by Wilder, Mayo Clinic Bulletin, 1921 Mark 9:29 “This kind can come forth by nothing, but by prayer and fasting.”Typically reserved for children with severe, debilitating and intractable seizures4:1 (Fat: Protein + Carbohydrates)75-90% of caloric intake as fatUrinary ketosis millimolar
53Ketogenic Diet: Efficacy 150 children prospectively evaluatedAge range: 4 months - 16 yearsAverage of 410 seizures per monthResults after 1 year:55% remained on the diet1/2 had > 50% reduction in seizures1/4 had > 90% decrease in seizuresFreeman, Vining, et.al. Pediatrics, December, 1998
54Vagus Nerve Stimulator: Rule of Thirds 1/3 - marked improvement1/3 - some improvement1/3 – little/no improvementPotential benefitsfewer seizures, less severe seizures, shorter recovery period, decreased meds and side effects, less fear and anxiety, more control
55Epilepsy Surgery: Criteria for Consideration Seizures must be medically intractableSeizures must be debilitatingThere should be no chance for spontaneous resolution
56Epilepsy Surgery Temporal lobectomy Extratemporal lesional resection 75-90% seizure freeExtratemporal lesional resection50-75% seizure freeExtratemporal non-lesional resection< 50% seizure freeFunctional hemispherectomyCorpus callosotomyEspecially for atonic and brief tonic seizures
57Monica14 year old girl with 1 week history of new onset convulsive seizuresHospitalized and loaded with phenytoin with worsening seizuresNormal EEG
59NES in Children: Psychosocial Stressors #1 Sexual or physical abuseOthers:Death of a family memberForced separation from family membersPhysical disability or illness of a parentSignificant family conflictMajor illnessFinancial stressorsMovingRelational difficulties
60CASE HISTORYAn 8 year old girl in 3rd grade has recently been noted to have staring episodes at school. She also has a recent decline in grades.
61Case history 2A 9th grader has a generalized convulsion in the school lunch room. He had been very stressed with exams and was extremely tired. Upon questioning you learn that he also has jerks of his arms, especially in the morning.
62Case history 3 A 6 year old has experienced 2 seizures. The first occurred 3 months ago during sleep. His parents took him to the ER. His CT and labs were normal. He was scheduled for an outpatient EEG but did not keep apt. His second seizure happened during nap time, his kindergarten teacher noticed he had initial twitching of the right face and arm followed by a brief generalized convulsion.