The Acute Management of an Individual with Epilepsy Classification & Different types of Seizure The Facts Diagnosis Nursing/Medical Management Status Epilepticus Psycho-social implications: more next term

Epilepsy : The Facts Epilepsy is the 2nd most common neurological disorder what is first? The incidence is 1 in 200 a prevalence that is very close to Diabetes Approx 70% of people with epilepsy are controlled on drugs Epilepsy still carries huge stigma Prejudice in job market: others anxieites

More FACTS 2/3rds of people at time of their marriage had not informed their partners of their epilepsy Only 28% of those in full time jobs informed employers 33% of those who disclosed to partner experienced broken realtionship Scrambler & Hopkins (1997)

Definition of Epilepsy A seizure is the synchronous & excessive discharge of a group of neurones Epilepsy is the repetitive occurance of these discharges Seizures are a symptom, not a cause or syndrome

Classification of Seizures Partial seizures: Simple Partial & Complex Partial General seizures

Partial Seizures Simple Partial: consciousness is not impaired & manifestations depend on which group of neurones is involved i.e. seizures with focal motor signs Autonomic symptoms, pallor, flushing Somatosensory symptoms, flashing lights, unpleasant odours, taste Psychic symptoms, dejavu, fear

Complex Partial Consciousness is impaired they may evolve from simple partial seizures or occur with impairment of awareness at onset Automatisms may be involved e.g. chewing, swallowing, fumbling, smaking of lips

Generalised Seizures Absence seizures: brief blank episodes for few seconds ‘petit mal’ Myoclonic seizures: sudden muscle jerks Clonic seizures: without the stiffness Tonic seizures: sudden increase in muscle tone- person may fall like a board

Tonic-Clonic Seizures Grand Mal Tonic phase may start with an expulsion of air resulting in a high pitched cry. Falls, legs extended, arms flexed may be cyanosed Clonic phase: rhythmic movements of arms & legs, tongue biting

Atonic seizures Sudden often brief loss of body tone which may result in a fall Also known as ‘drop attacks’

Diagnosis History: witness account very useful, type aura, how long, post-seizure period EEG: Electroencephalography not always useful particularly if N.A.D. between seizures Videotelmetry: EEG & Video MRI scan to exclude structural cause

Common AED’s Phenytoin Tegretol (Carbamazepine) Gabapentin Lamotrigine Epilim (Sodium Valporate) Phenobarbitone Aim for Monotherapy

Goals of Treatment Seizure freedom: Overall prognosis is good. 20 years after onset 70-80% in remission for 5 years, 50% in remission for at least 5 years and no longer take AED’s To decrease seizure severity. More likely with partial seizures, reduce to simple partial

Intractable Seizures Trick is to try to achieve some sort of balance between side effects of AED’s & seizure control: part of Epilepsy Nurses role

Status Epilepticus Any type of seizure which occurs so frequently that the patient is unable to recover to a normal level of functioning between seizures Most common form is Tonic/Clonic Mortality rate is 3-27% Classed as a medical emergency

Safety Issues Tonic/Clonic seizures classed as medical emergency ?ITU/HDU Aim to stop seizures, IV access, Oxygen Sats Diazepam rectally, IV Lorazepam, IV Phenytoin Airway: Tongue biting, hypoxia, ventilation

Other safety issues Location on ward/unit, near nurses, oxygen & suction Use of cotsides, pillows, safe positioning on side Location of seizure: bathing, hard floor, call bell Oedema, resp arrest, ventilation & ITU

What do I need to know about someones epilepsy?? What types of seizure? Do they have an aura? How long do they last & how frequent? How long does it take to recover? Do they need to sleep after? Are they confused before, during or after? Is there a history of status?

Self Management Keep a diary Managing drug therapy - non-compliance Identifying triggers I.e. stress, alcohol Safety at home, work, medic alert bracelet Voluntary organisations Emphasis on what they can do

Causes of Status AED non-compliance Head injury/surgery Raised ICP Stress Metabolic imbalance i.e. Diabetes, low Sod. Drug/alcohol toxicity Pyrexia

Carol Forde-Johnston Lecturer Practitioner in Neurosciences The Radcliffe Infirmary, Oxford