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