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EPILEPSY Neuroscience Nursing Orientation

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Presentation on theme: "EPILEPSY Neuroscience Nursing Orientation"— Presentation transcript:

1 EPILEPSY Neuroscience Nursing Orientation
Johns Hopkins Epilepsy Center Rebecca E. Fisher RN BSN CNRN Alison Griffiths RN ASN

2 Seizure Disorder Definition
A transient disturbance in cerebral function due to paroxysmal neuronal discharges Irritation and excitability Epilepsy Occurrence of two or more seizures

3 Prevalence Single Seizure Epilepsy 10% of the US population
1-2% of the US population by the age of 20. It reaches 3% by the age of 75 5 to 8 in 1000, of approximately 1.25 to 2 million people

4 Incidence Third most common neurological disorder
80% will respond well to treatment Intractable seizures 20-25% Febrile seizures in children 2-5% Close relatives of epilepsy patients have a threefold increase in incidence. 5-10% inherited

5 Etiology Primary (idiopathic) Secondary (organic) 50% of all epilepsy
Birth trauma Head trauma Tumors Infections Biochemical CVA Degenerative Diseases

6 Terms Ictal Post Ictal Interictal The time during a seizure
The time following a seizure Interictal The time between seizures

7 International Classifications of Seizures
Primary Generalized Epilepsy Involves both hemispheres at the start of the seizure (usually starts deep within the brain) Partial Epilepsy Involves a focal area of the brain that may or may not spread

8 Primary Generalized Seizures
Absence- brief staring spells (3-5 secs) Myoclonic- abrupt brief jerking of limbs Clonic- muscle contraction and relaxing Tonic- stiffening, extension of limbs Atonic- “drop attacks”

9 Partial Epilepsy Simple (consciousness is not impaired)
Motor- abnormal movement of arm, leg, hand, and face Somatosensory or special sensory- epigastric feeling, visual symptoms, smell, and auditory Numbness or tingling in limb Autonomic- tachycardia, flushing, and respiration Psychic- déjà vu, and fear Aura is a simple partial seizure

10 Partial Epilepsy Complex (consciousness is impaired)
Most common in adult epilepsy population May or may not start with simple partial May see staring lasting seconds to minutes May see semipurposeful repetitive movements (i.e. fumbling, lip smacking, swallowing, vocalizations, and wandering)

11 Evolving into Secondary Generalized Seizures
May start as simple, or complex seizure, then progress to tonic-clonic movements.

12 Psychogenic Seizures Seizures that originate from an emotional disorder rather than paroxysmal neuronal discharges. EEG will be normal Patients can have a mixture of Epilepsy and Psychogenic seizure activity.

13 Possible clinical signs
Asymmetrical or thrashing of limbs, pelvic thrusting, side to side head movement, gradual onset, multiple manifestations, prolong duration, purposeful activity, initiation or termination by suggestion, lack of amnesia, little postictal period.

14 Treatment Varies depending on psychiatric diagnosis Antidepressants
Psychotherapy Relaxation techniques

15 First Aid Generalized Seizures
Help to lying position with something soft under the head Position to side if possible Remove glasses and loosen tight clothing Clear area of sharp or hard objects Do not restrain of force anything in the mouth Suction airway only if necessary Time event, check vitals and neuro status, examine for injuries, monitor until return to baseline

16 First Aid Complex Partial Seizures
Stay with patient and ensure safety Clear area of sharp and hard objects Do not restrain Monitor patient until return to baseline

17 Notification of MD New onset of seizures
Change in seizure type and frequency or duration Seizure > 5 minutes Failure to return to baseline

18 Status Epilepticus A seizure that persists for a sufficient period of time ( 10 minutes) or is repeated frequently so that recovery between attacks does not occur. Diagnosis for status is at 30 minutes. Patients in status may appear conscious

19 Complications Shock Hypoxia ICP Acidosis Fever Arrythmia Hemorrhage
Neuronal Death

20 Etiology Anticonvulsant withdrawal
Acute metabolic disturbances (hypoglycemia, hyponatremia, hypocalcemia) CVA CNS infection CNS trauma Tumors

21 Treatment Anticonvulsant Start with Benzodiazepines
Diazepam (Valium): 0.25mg/kg up to 20mg IV. Give slowly 1-2mg/min **May also give rectally (Diastat-rectal gel) Lorazepam (Ativan) 0.05mg/kg up to 10mg IV. Give slowly 2mg/min (this is the preferred medication because it lasts longer than the Valium in the body) Midazolam 5-10mg, well absorbed IM

22 Long-acting AED Phenytoin (Dilantin): 18-20mg/kg IV
Do not give faster than 50mg/kg Use only with normal saline Monitor vital signs carefully Avoid IV infiltration (purple glove syndrome) Different institutions have different guidelines concerning the administration of this drug

23 Follow up with long-acting AEDs
Fosphenytoin (Cerebyx): prodrug of phenytoin Water soluble (does not contain propylene glycol) fewer IV site and cardiac complications Dispensed in phenytoin equivalents (1 PE of fosphenytoin=1 mg of Dilantin) Loading dose PE/kg Max rate is 150 PE/min IV with cardiac and BP monitoring May be given IM (large volumes i.e. 20ccs split in two IM sites)

24 Long-acting AED Fosphenytoin continued
Side effects- same as phenytoin (hypotension, cardiac arrthymias, rash, dizziness, and itching groin) Each institution has specific guidelines concerning administration of this drug

25 Long-acting AED Phenobarbital: 10-20mg/kg
Do not give faster than mg/min. Caution following BZD (increase risk of respiratory depression and hypotension)

26 Depacon (Valproate Sodium Injection)
For use in Myoclonic Status and when unable to take po Valproic Acid Dispensed in Valproic Acid equalents (500mg po = 500mg IV) Administer over 60 minutes In 50ccs (Normal Saline, LR, or D5W) No more than 20mg/minute Give the same frequency as po Some institutions has a policy and procedure concerning administration

27 Side effects of Depacon
Not like po-wt gain and hair loss Somnolence Dizziness Paresthesia Nausea H/A Pain at injection site

28 Other Treatments Petobarbital coma, propofol Supportive Care Airway
Protection Lab tests (CBC, BMP, ABGs, AED levels) Fluids VS, EKG Drug Therapy Investigate Cause

29 Other options Keppra IV option coming in the near future

30 Diagnostic Studies History Physical Exam Blood work
Epilepsy Protocol MRI-structural changes 3Tesla MRI fMRI- language function CT Epilepsy monitoring unit EEG (don’t seizure on demand) PET-metabolism changes WADA-side of language and memory dominance Neuropsych/Cognitive functioning testing MRS-biochemical SPECT-perfusion changes MEG-localization of interictal epileptiform activity with focal seizures used with MRI and EEG

31 Treatment Anticonvulsant Therapy Ketogenic Diet/Atkins Diet
Vagus Nerve Stimulator Surgery

32 Potential Efficacy of AEDs
Carbamazepine Simple Complex Complex Partial Tonic Clonic Phenytoin Simple Partial

33 Potential Efficacy continued
Valproate Simple Partial Complex Partial Tonic-Clonic Atonic Myoclonic Atypical Absence Absence

34 Potential Efficacy continued
Gabapentin Simple Partial Complex Partial Tonic-Clonic Lamotrigine Atonic Myoclonic Absence and atypica absence

35 Potential Efficacy continued
Topiramate Simple Partial Complex Partial Tonic-Clonic Lennox-Gastaut Infantile Spasms Primary generalized

36 Potential Efficacy Continued
Tiagabine Simple Partial Complex Partial Tonic-Clonic Infantile Spasms Levetiracetam Absence Myoclonic

37 Potential Efficacy Continued
Oxcarbazepine Simple Partial Complex Partial Tonic-Clonic Zonisamide Absence Infantile spasms Myoclonic

38 Potential Efficacy Continued
Pregablin - Simple partial - Complex partial

39 Dilantin Capsules 100mg, 30mg Brand name Dosing 200-500mg
Half life 22 hours Blood levels (if no side effects MDs may push the top level) High incidence of drug interaction with all other medications Side effects Ataxia Rash Blood changes Osteomalacia Cosmetic changes Dental changes

40 Tegretol, Tegretol XR, & Carbatrol
Tabs 100mg, 200mg, 300mg (Carbatrol), & 400mg (Tegretol XR) Dose mg Half life hrs Levels 4-12 XR & Cabatrol BID dosing Side effects Weight gain GI upset Ataxia Blurred vision Decreased WBC Hyponatremia Hepatotoxicity

41 Depakene, Depakote, &Depakote ER
Caps 125mg,250mg, 500mg Dose mg Half life 8-12 hrs Blood levels May be used for migraine management Interacts with Lamictal First line drug for myoclonic seizures (IV) Side effects Weight gain Tremors Uterine changes Sedation Disturb menses Hair loss H/A Dizziness Increase ammonia levels

42 Phenobarbital Tabs 15mg, 30mg, 60mg, & 100mg Dosing 30mg or 100mg
Half life 72 hrs Blood levels 15-40 Side effects Sedation Hyperactivity Confusion Mood changes

43 Mysoline (Metabolizes to Primidone & Phenobarbital)
Tabs 250mg Dose mg Half life PRM 3-12hrs PBB 72 hrs Levels PRM 6-12 PBB 15-40 Side effects Sedation Hyperactivity Mood changes

44 Neurontin Caps 100mg, 300mg, & 400mg, Tabs 600mg & 800mg
Dose 3600mg (no research telling how high to go) Dosing TID or QID Half life 5-8 hrs Blood levels-not done Use in management of migraines Side effects Sedation Ataxia Dizziness

45 Lyrica Capsules 25mg, 50mg, 75mg, 100mg, 150mg, 200mg, 225mg, 300mg
Newest drug Dosage for Epilepsy mg/day Dosing BID Half Life No blood levels Medication is also used for pain management Side effects -Double vision -Ataxia -Edema -Weight gain - Dry mouth - Trouble concentrating

46 Benzodiazepines Valium Ativan Tranxene Klonopin Side effects
Drowsiness Fatigue Ataxia Slurred speech Diplopia

47 Lamictal Tabs 25mg, 100mg, 150mg, & 200mg Dosage 300-500mg
If miss a dose may double up on next dose Half life hrs Blood levels 4-20 Depakote increases Lamictal Needs to be adjusted if birth control is added May make JME worse Side effect Rash (slow titration stops this) Depression Dizziness Somnolence H/A Blurred vision Nausea/vomiting

48 Topamax Tabs 25mg, 50mg, 100mg, & 200mg Half life 21 hrs
Dose mg May increase Dilantin May decrease Carbatrol, Phenobarb, i.e. Side effects Memory problems Word finding difficulties Kidney stones Dizziness Ataxia Somnolence

49 Trileptal Tabs 150mg, 300mg, & 600mg Dose 900-2400mg Dosage BID
Developed to improve on Tegretol’s side effects If Allergic to Tegretol 20% chance to become allergic to Trileptal Side effects Somnolence H/A Dizziness Rash Weight gain Alopecia Nausea Hyponatremia

50 Keppra Tabs 250mg, 500mg, & 750mg Dose 500-4000mg Dosing BID
Blood levels are drawn but results depend on the pt a “good” level can be from 20s-30s Side effects Mood changes (use of vitamin B6) Lose of appetite Weight lose Diarrhea

51 Zonegran Caps 25mg, 50mg, & 100mg Dose mg and can be pushed higher Dosing BID or Daily Levels 10-30 Side effects This is a Sulfa drug Kidney stones Drowsiness Loss of appetite GI disturbance Mania Depression Dizziness Irritability

52 Ketogenic Diet High fat, low carbohydrate, limited protein diet
Simulates metabolism of a fasting state (ketosis) Ketosis has an anticonvulsant effect Used in young children here at Johns Hopkins Epilepsy Center Currently Thomas Jefferson has a program for adults

53 Nursing issues Avoid medication preparations containing sugar
Need daily sugarless multivitamin with iron and calcium Monitor urine ketones Give only allotted noncaloric liquids (may have diet decaffeinated soda)

54 Vagus Nerve Stimulator
Stimulation wires placed around left vagus nerve in the neck. Subclavicular placement of transformer Nerve stimulus is typically on for 30 seconds and off for 5 minutes in cycles (like a buzz) Need to evaluate over 6 months Often palliative treatment (add on to current medications) Magnet swiped over the transformer will cause the buzz to occur longer in order to stop the seizure.

55 VNS continued Magnet held over the transformer will turn off the VNS. Once the magnet is removed it will turn back on. We in the Epilepsy Center can turn the generator completely off. Status may result from turning off the VNS May be around microwaves and cell phones, etc. Cannot be around MRI unless the VNS is turned off.

56 Epilepsy Monitoring Performed at large teaching hospitals
Most Epilepsy patients respond well to medication Monitoring and visits to Epilepsy Centers is usually reserved for those pts whose seizures are unresponsive to medication

57 Epilepsy Monitoring Admission for 2-7 days to a special unit
Epilepsy medications are reduced before and during admission (if seizures are infrequent) Clinical events (seizures) are recorded and EEG is reviewed and evaluated Type of Epilepsy is diagnosed and seizure onset is lateralized and localized (if possible)

58 Surgical Management Depth electrodes Epidural Electrodes
Subdural Electrodes (Grid) Brain mapping Lobectomy Temporal most common, extratemporal resection Corpus Callosal Atonic or GTC Hemispherectomy

59 Epilepsy Surgery Some patients may need to have depths placed.

60 Epilepsy Surgery If not well localized pt may need to have bilateral strips placed to aid in localizing and lateralizing seizure onset

61 Epilepsy Surgery If pt seizure focus is in or near an area of high function then a subdural grid may be placed to help map area of function and aid in surgery design

62 Teaching the family and patient
About their seizures First Aid Medication and Compliance Diagnostic tests, blood test, surgery Effects on Depression, Memory, Cognitive Function Disability and Work Emotional Support Assist in Problem Solving Their State Driving Laws Support Groups for all ages and their families

63 Pregnancy Counseling should be done prior to conception age
Birth defects (increase by 1-2% above general population) Counseling on AEDs and contraception Interactions AED changes now prior to conception Seizure control on AEDs with only dosage changes during pregnancy AEDs with lowest Birth defect information Folic Acid daily (may be a higher dose) Neural tube development Planned pregnancies

64 Once Pregnant High Risk OB
Increased number of clinic visits with Epilepsy Doctors Communication between OB and Epilepsy MD Teamwork Monthly blood levels with already predetermined target blood level(s) High level of communication with expected mother. (Teaching) Pregnancy Registries (Harvard, Lamictal and Keppra Registries)

65 Epilepsy Research at Johns Hopkins
Neuropace Atkins for Adults Schwarz SP754 Progesterone

66 Not all patients are surgical candidates
For these pts with intractable Epilepsy current research offers hope

67 Neuropace Surgical Implant
A small generator is implanted with electrodes going to various seizure focci

68 Neuropace Strip or depth leads are placed (1 or 2 leads)
A cranial defect is created for the device Each lead can send out an electrical signal to stop seizure activity

69 Neuropace Age 18-65 years 4 seizures per month or more
Able to localize seizure focus 2 or more Epilepsy meds tried VNS will have to be turned off Live locally (lots of clinical visits)

70 Atkins trial for Adults
Age 18 years or older 2 or more seizures per week No heart, kidney, cholesterol problems No major psychiatric problems Need to visit Johns Hopkins 4 times in 6 months Not have tried Ketogenic or Atkins diets prior to this trial

71 Atkins Pts are placed on a carefully planned Atkins diet and followed for 6 months to evaluated whether their seizure frequency is reduced. All labs, clinic visits and dietitian expenses are funded by the study

72 Schwarz SP754 Medication trial

73 Inclusion/Exclusion Inclusion (see attached) Age 16-70 years
Partial onset seizures and or complex partial seizures Must have had partial onset seizures for at least 2 years Exclusion (See attached) Hx of drug and or alcohol abuse Medical or psychiatric condition Primary generalized seizures

74 Benefits Schwarz SP754 Patients are closely followed and evaluated
All lab and clinic visits are fully funded by the study Helping a new medication to be developed

75 Progesterone Therapy for Women with Epilepsy
Study Hypothesis: Adjunctive cyclic natural progesterone therapy significantly improves the course of epilepsy in women. Women ages with intractable seizures that occur in relation to changes in reproductive hormone levels (catamenial epilepsy) despite trials of at least two AEDs

76 Inclusion Documentation of focal paraoxysmal EEG discharges
2 seizures/month during previous 3 months Stable optimal AEDs for 2 months Nl breast exams and PAP smears 9 months prior for all over 21 Menstrual cycle intervals between 23 and 35 days during 6 month prior Sexually active women will use barrier and/or spermicidal forms of contraception

77 Exclusion Pregnancy, lactation Progressive Neurological disorder
Abnl Liver function test Major tranquilizer or reproductive hormones 3 months prior to study Sensitivity to natural progestrone Unable to document seizures or follow protocol Hx of thromboembolic, thrombophlebitis disorders, CVA Malignancy of breast, uterus or ovary Vaginal bleeding

78 If interested in participating in a study
Call You will then be referred to the appropriate office

79 Bill of Rights for People Living with Epilepsy
Sponsored by Novartis Pharmaceuticals Corporation

80 The goal of the Bill Of Rights is to help you:
Encourage the patient’s involvement in managing many aspects of living with their epilepsy, including making informed choices and activity participating in decisions about care Empower them to ask questions and seek answers from their or their loved one’s healthcare team Help them access information and support resources Encourage them to speak up for their or their loved one’s rights and needs

81 A first-of-its kind initiative
Designed to educate, empower, and increase understanding of epilepsy A guide to managing life with epilepsy that was developed by the community for the community It is not a legal document- these rights are aspirational goals that the epilepsy community is trying to achieve None of the information should be used as medical or legal advice

82 Goals of the Bill of Rights
Goal #1: Educate and empower the people affected by epilepsy Goal #2: Increase understanding of epilepsy among the general public

83 Includes guidance on topics, such as:
Social aspects of living with epilepsy Communicating with your healthcare team Current information on epilepsy and treatment options Rights at school Rights in the workplace

84 Enroll in the SHARE (Support, Hope, And Resources for Epilepsy)
Program to receive Bill of Rights materials and additional information about living with epilepsy from Novartis Complete and mail your business reply card Visit Call toll-free ERIGHTS

85 Resources Epilepsy Foundation of America 1-800-332-1000
American Epilepsy Society American Association of Neuroscience Nurses

86 Resources continued MedicAlert Foundation 1-888-633-4298
Food and Drug Administration 1-888-INFO-FDA

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