1 Care of the Patient with Seizures At the end of this session the participant will: Describe convulsive seizures Describe non-convulsive seizures List 3 nursing actions for a patient having a convulsive seizure Describe nursing considerations for select anti- seizure medications.

2 SEIZURES Definition An abnormal electro-physiologic phenomenon of the brain resulting in abnormal synchronization of neuronal activity manifested as altered mental state, tonic or clonic movements, convulsions, or various psychic symptoms. Incidence 60 yrs old, occurs before age 20 in >75% of cases. Epilepsy versus Seizure Disorder Seizure Disorder-usually an underlying cause Epilepsy-multiple, recurrent unprovoked

3 Seizures Terms: Aura-occurs before seizure activity, may be depression, irritability, or unusual sensations. Ictus-the period of seizure activity. Postictus (post-ictal)-period after the seizure, pt. may or may not be conscious. If conscious, may be confused, disoriented, tired, lethargic, nauseated.

4 Precipitating Factors Metabolic Hypoxia Hypoglycemia Toxic metabolites Acidosis Electrolyte imbalances (  Na) Pregnancy (eclampsia/cerebral edema) Abrupt withdrawal of drugs/ETOH Drugs that alter seizure threshold Structural Trauma Tumors Infection Hemorrhage Stroke, new and old

5 Age-related Precipitating Factors Neonate-may have a brain defect, birth injury, meningitis, hypoglycemia, or hypocalcemia. Children-febrile illness is a common cause, lead toxicity (lead encephalopathy), or head trauma. Adult-head trauma, alcohol withdrawal, metabolic disorders, tumor, abscesses, meningitis, or encephalitis

6 Generalized, convulsive Generalized, convulsive seizures Generalized, convulsive Generalized, convulsive Tonic-Clonic Grand mal - “classic seizure” Tonic - contraction of voluntary muscles, stiffening, usually lasts seconds. Clonic - rhythmic contraction, jerking, frothing, seldom lasts longer than 2 minutes. Usually associated with loss of consciousness. Post-ictal phase lasts 30 min. to several hours.

7 Generalized non convulsive Generalized non convulsive seizures Absence Seizure (Petit mal) Rare, more common in children Blank stare, eye fluttering, lip smacking- begins and ends abruptly (approx. 10 seconds), brief

8 Generalized non convulsive Generalized non convulsive seizures Atonic Seizure (akinetic, astatic, “drop attack”) Sudden collapse of individual, lasts only a few seconds The person either doesn’t lose consciousness or regains it before hitting the ground.

9 Partial Seizures Arise from a localized portion of the brain or foci Consciousness may or may not be impaired Types of partial seizures: Simple partial Partial sensory Complex partial

10 Partial Seizures Simple partial jerking may begin in one area of body no loss of consciousness cannot control movements can spread to become generalized seizure

11 Partial Seizures Partial Sensory may not be obvious experiences distorted environment hallucinations unexplained feelings

12 Partial Seizures Complex Partial starts with blank stare, progresses to chewing, then other random activity Patient is unaware of surroundings EEG during seizure

13 SEIZURES Treatment Airway Protection PREVENT INJURY Medical Management Evaluate for Cause Describe/document what is seen including duration

14 Nursing Management Consider IV access, oxygen readiness, available suction Pad siderails (not a restraint if patient has a convulsive disorder) If convulsive seizure occurs Protect from harm - pt and staff Do not restrain patient during seizure Be prepared to intubate Don’t put anything in mouth Evaluate for underlying cause

15 Medication Management Fosphenytoin (Cerebryx)- Dosage: Load 20mg PE/kg at a rate up to 150mg PE/minute. Converts to phenytoin in the body. Therapeutic Level: Monitored with phenytoin level and should be 10-20mg/dl. Level to be drawn 2 hours after infusion is completed. Side Effects: Hypotension. Instructions: May be diluted with equal volume of D5W or NS and given on a syringe pump or mixed in a bag and given as an infusion at 150mgPE/minute. After mixing, must be refrigerated (max 7days), but can be kept at room temp. for 24 hours.

16 Medication Management Levetiracetam ( Keppra) Dosage: Subarachnoid Hemorrhage: 500mg IV/PO x 3 days then discontinue. Traumatic Brain Injury: 500mg IV/PO x 7 days then discontinue. Therapeutic Level: 5-65mg/dl, how to clinically interpret this data is unknown yet. Side Effects: Agitation, fatigue, GI. Instructions: Must be diluted with NS, D5W, or LR. Infuse over 15 minutes. Oral and IV doses are equivalent. Use IV ONLY for patients who cannot tolerate PO for first dose.

17 Status Epilepticus Definition: one continuous unremitting seizure lasting longer than 30 minutes or recurrent seizures without regaining consciousness between seizures for greater than 30 minutes. Emergency! Monitor airway, prepare to intubate Medical treatment includes benzodiazepines, primarily Lorazepam (Ativan®)

18 Seizure Mapping For patients with medically intractable seizures (unresponsive to medications) Small electrodes, are placed over the surface of the brain or skull/face Goal: identify areas causing seizures for possible surgical removal

19 References