Seizure or Epilepsy

SEIZURE OR EPILEPSY – Types, Etiology, Diagnostic Evaluation and Nursing Management

A seizure is a sudden disruption of the brain’s normal electrical activity accompanied by altered consciousness and other neurological and behavioral manifestations. Epilepsy is a condition characterized by recurrent seizures with symptoms that vary from a momentary lapse of attention to severe convulsions.

TYPES OF SEIZURES

• Grandmal seizures: this type of seizures presents as a generalized tonic-clonic seizures that often begins with a loud cry before the person having the seizure loses consciousness and falls to the ground. The muscles become rigid for about 30 seconds during the tonic phase of the seizure and alternately contract and relax during the clonic phase, which lasts 30-60 seconds. The skin sometimes acquires a bluish tint and the person may bite his tongue, lose bowel or bladder control, or have trouble breathing.  A grand mal seizures last between two and five minutes, and the person may be confused or have trouble talking when the regains consciousness. The period of time immediately or have trouble talking when he regains consciousness. The period of time immediately following a seizure is known as the ‘postictal’ state.
• Primary generalized seizures: this is a primary generalized seizures that occurs when electrical discharges begin in both halves (hemispheres) of the brain at the same time. Primary generalized seizures are more likely to be major motor attacks than to be absence seizures.
• Absence (petit mal) seizures: this type of seizure generally begins at about the age of four, and usually stops by the time the child becomes an adolescent. Petit mal seizures usually begin with a brief loss of consciousness and last between one and 10 seconds. A person having a petit mal seizure becomes very quiet and may blink, stare blankly, roll his eyes, or move his lips. A petit mal seizure lasts 15-20 seconds.  When it ends, the person who had the seizure resumes whatever he was doing before the seizure began. He will not remember the seizures and may not realize that anything unusual has happened.
• Myoclonic seizures: this type of seizure is characterized by brief, involuntary spasms of the tongue or muscles of the face, arms, or legs. Myoclonic seizures are most likely to occur first thing in the morning.
• Simple partial seizures: this type of seizure does not spread from the focal area where they arise. Symptoms are determined by what part of the brain is affected. The patient usually remains conscious during the seizure.
• Complex partial seizures: this type of seizures presents with a distinctive smell, taste, or other unusual sensation (aura) may signal the start of a complex partial seizure. Complex partial seizures start as simple partial seizures, but move beyond the focal area and cause loss of consciousness. Complex partial seizures can become major motor seizures. Although a person having a complex partial seizure may not seem to be unconscious, he does not know what is happening and may behave inappropriately. He will not remember the seizure, but may seem confused or intoxicated for a few minutes after it ends.

ETIOLOGY

Most cases of epilepsy are of unknown origin. Sometimes, however, a genetic basis is indicated, and other cases maybe traceable to birth trauma, lead poisoning, congenital brain infection, head injury, alcohol or drug addiction, or the effects of organ disease. Known causes of epilepsy and other seizure disorders can include:

• Brain tumor
• Cerebral hypoxia
• Cerebrovascular accident
• Convulsive or toxic agents
• Alcohol and drug use withdrawal
• Eclampsia
• Hormone changes during pregnancy and menstruation
• Exogenous factors (sound, light, cutaneous stimulation)
• Fever (especially in children)
• Head injury
• Heatstroke
• Infection (acute or chronic)
• Metabolic disturbances (diabetes mellitus, electrolyte imbalances)
• Withdrawal from, or hereditary intolerance of alcohol
• Kidney failure
• Degenerative disorders (senile dementia)

DIAGNOSTIC EVALUATION

• The first step in diagnosing a seizure disorder is to determine whether or not the patient ‘did’ or ‘did not’ actually have seizures. To do this the following is required:
• Past-medical history
• Careful history of clinical presentation and events related to alleged seizure
• General physical and neurological examination

• Diagnostic testing which include:
• Computed tomography (CT Scan)
• Magnetic Resonance Imaging (MRI)
• Electroencephalogram (EEG)
• Video EEG
• Single Proton Emission Computerized Tomography

MANAGEMENT

Once a seizure disorder of epilepsy has been diagnosed the first line of treatment is usually medication therapy that focuses on reducing the frequency and severity of the seizures.

The goal is to find a medication that will control the seizures but not produce side effects. Because many people will continue on medication for many years, selection of a good first drug is extremely important.

• Anticonvulsants and other prescription agents are usually prescribed based on the type of seizures that the patient is experiencing. The following medications are frequently prescribed:

Benzodiazepines examples include: clonazepam, clorazepate, diazepam

Phenytoin (Dilantin): A synthetic drug that is classified as a hydantoin. It is used for the treatment of simple partial, complex partial and generalized tonic-clonic seizures.

Carbamazepine: used as a first line agent for the treatment of simple partial, complex partial and generalized tonic-clonic seizures

Lamotrigine: used when seizures are focal in onset, tonic-clonic, atypical absence or myoclonic in nature

Valproate: used for the management of myoclonic, tonic, atonic, absence and generalized tonic-clonic seizures especially with patients with one or more type of generalized seizure

Phenobarbital: once a mainstay in the treatment of seizures (especially status epilepticus), Phenobarbital is now being replaced by other anticonvulsants but can still be used for the treatment of generalized seizures except for absence and partial seizures

• Surgical Intervention:

The most common surgical areas include:

Temporal lobectomy

Frontal lobectomy

Hemispherectomy

Corpus clallostomy (splitting of the two hemispheres of the brain)

• Placement of a Vagus Nerve Stimulator (VNS): A VNS is an implantable device that is used to decrease seizure frequency. In some cases it eliminates seizure activity altogether. It is a surgically implanted device that is placed in the chest wall (similar to a pacemaker), with a wire that is threaded to the Vagus nerve in the neck. Once in place the Vagus Nerve Stimulator is programmed (using a magnet), to stimulate the Vagus nerve at preset intervals. Patients are sent home with a magnet as well to trigger the device at the onset of seizure

Nursing Care and Management of Seizures in the Acute Setting

Before (and During) Seizure Care

• If the patient is seated when a major seizure occurs, ease them to the floor
• Provide privacy if possible
• If patient experiences an aura, have them lie down to prevent injury
• Remove eyeglasses and loosen restrictive clothing
• Do not try to force anything into the mouth
• Guide the movements to prevent injuries (do not restrain patient)
• Stay with the patient throughout the seizure to ensure safety
• Time the seizure
• Verbalize events as they happen to assist with more accurate recall later
• If not already available have someone retrieve O₂ and suction

Postseizure Care

• Position patient on their side to facilitate drainage of secretions
• Provide adequate ventilation by maintaining a patent airway
• Suction secretions if necessary to prevent aspiration
• Allow the patient to sleep post seizure

Status Epilepticus: Seizures lasting at least 5 minutes or two or more seizures in a row without complete recovery in between are termed as status epilepticus.

Initial Nursing Management

• ABCs of life support
• Position patient to avoid aspiration or inadequate oxygenation
• If possible as soft oral airway can be placed (again do not force teeth apart)
• Suction and O₂  must be available
• Monitor respiratory function with ongoing pulse oximetry
• IV access should be secured
• Frequent monitoring of neurological examination and vital signs
• Monitor ABGs
• Monitor Glucose
• Treat hyperthermia

Anticonvulsant Therapy for Management of Status Epilepticus

The following drug therapy regimen is used to status epilepticus

Time 0-3 minutes: Lorazepam 4-8 mg IVP (2mg/min)

Time 4-23 minutes: Phenytoin (Dilantin) 20 mg/kg (about 1 gm) in NS at (50 mg/min)

Time 22-33 minutes: Phenytoin (Dilantin) 5-10 mg/kg

Time 37-58 minutes: Phenobarbital 20 mg/kg IV

Time 58-68 minutes: Phenobarbital 5-10 mg/kg

Patient and Family Education for Seizures or Epilepsy

General Health

• Trigger signs (patient specific if possible)
• Regular exercise
• Regular sleep patterns
• Showers or bath
• Good oral hygiene (some anticonvulsant can cause gingival hyperplasia)
• Eat well rounded meals at routine times
• Avoid excess sugar, caffeine or other trigger foods
• Noisy environments should be avoided
• Avoid bright flashing or fluorescent lights
• Use a screen filter on the computer screen to avoid glare
• Do not use recreational or street drugs
• Avoid work/recreation that could cause injury if a seizure was to occur
• Swim with a friends only and avoid be alone in pool
• Avoid contact sports
• Avoid emotional stress
• Counselling for stress reduction or depression may be warranted