Taking charge of seizure activity

Critical care nursing

2

Learning objectives

1. Differentiate between partial and generalized seizures.

2. Identify available options to manage seizures.

3. Indicate major patient-education

points regarding seizures.

3

What is a seizure?

Abnormal stimulus in the CNS causes excessive and chaotic electrical discharge from brain neurons.

Temporary changes in cerebral function alter motor or autonomic function, consciousness, or sensation.

Someone who has two or more unprovoked seizures because of a chronic underlying

condition has epilepsy.

4

Phases of a seizure

Aura May occur before a seizure Examples: depression, certain smell Can occur hours or days before seizure

Ictus Period of seizure activity

Postictus Period after a seizure Patient may be conscious but confused and tired Can last several minutes to hours Patient may not remember the seizure

5

Causes of seizures

Genetics Idiopathic (about 75% with unidentified cause) Acquired

Acidosis Electrolyte imbalances Hypoglycemia Hypoxia Alcohol and drug withdrawal Dehydration Systemic lupus erythematosus Hypertension Septicemia Tumors Head trauma

6

Seizure causes related to age

Neonates Brain defect Birth injury Meningitis Hypoglycemia Hypocalcemia

Children Febrile illness Lead toxicity Head trauma

Adults Head trauma Alcohol withdrawal Metabolic disorders Brain tumor Brain infection or

inflammation abscess meningitis encephalitis

7

Nonepileptic seizure activity

Abnormal electrical discharge of CNS neurons aren’t involved

Examples: Syncope Hyperventilation Pseudoseizures due to psychological

conditions, such as panic and anxiety attacks

8

Tracing seizure activity

9

Partial seizures

Also known as focal seizures Involve abnormal electrical discharge

in only one brain hemisphere Can be simple or complex

10

Simple partial seizure

Patient is conscious and fully aware of seizure activity but can’t control it.

Jerking movements, localized pain, or feeling of déjà vu.

Can progress to a complex or secondary generalized seizure.

11

Complex partial seizure

Patient has impaired consciousness without loss of consciousness.

Patient appears awake but can’t understand what’s happening.

May display bizarre, involuntary automatisms, such as rearranging objects, moving in circles, or repetitively smacking lips together.

This type of seizure typically starts in the temporal or frontal lobe.

12

Generalized seizures

Involves widespread abnormal electrical discharge across the entire brain cortex

Manifestations can range from violent motor activity to less obvious signs.

Can be convulsive or nonconvulsive

13

Convulsive generalized seizures

Also known as tonic-clonic or grand-mal

Loss of consciousness occurs Three phases:

1. Tonic

2. Clonic

3. Postictal

14

Tonic phase

Usually lasts 10 to 30 seconds Voluntary muscles contract, arms flex

and legs extend Patient may

fall, if standing make screaming or crying sounds lose bladder and bowel control

Even if her eyes are open, the patient is unresponsive and unaware of her

environment.

15

Clonic phase

Seldom lasts longer than 2 minutes Rapid, rhythmic muscle contraction and relaxation

that cause jerking of various body parts Jerking may be limited to fingers or may involve

torso and extremities Saliva pools and causes frothing because patient

can’t swallow Secretions or tongue relaxation can lead to airway

obstruction Periods of relaxation typically lengthen before the

seizure ends

16

Postictal phase

Lasts 30 minutes to several hours The patient

lies very still as her brain recovers may be confused, drowsy, nauseated, and

disoriented

17

Febrile seizures

Type of convulsive generalized seizure Unrelated to epilepsy Caused by rapid increase in temperature More common in children from 6 months to

5 years old, but can affect adults Typically, rectal temperature is greater than

102° F (38.9° C) 95% to 98% fully recover and never develop

epilepsy

18

Nonconvulsive generalized seizures

Less obvious manifestations, so harder to recognize

Three classifications: 1. Absence seizures

2. Myoclonic seizures

3. Atonic seizures

19

Absence seizures

Formerly called petit mal Brief interruption in consciousness without loss

of postural control Typically affect children May include periods of staring, lid fluttering, or

lip smacking, while awareness and alertness are impaired

Patient immediately returns to normal activity at end of seizure

A teacher may be the first person to notice absence seizures, commenting that the child daydreams too

much or appears to “blank out” frequently.

20

Myoclonic seizures

Triggered by environmental factors, such as flashing lights

Can occur at any age Generally don’t cause loss of consciousness Commonly occur before sleep or after

awakening Characterized by sudden, sporadic jerking

motions of one area or muscle group

21

Atonic seizures

Also known as akinetic or astatic seizure Commonly called a “drop attack” Characterized by sudden loss of

postural tone that lasts a few seconds Increased risk of head and neck trauma Typically begin in childhood and

commonly recur into adulthood

22

Status epilepticus

Can occur with any type or seizure, but most commonly a complication of convulsive generalized seizures

Identified by either of these criteria: Two or more consecutive seizures without return of

consciousness between them Continuous seizure activity lasting 5 minutes or more

THIS IS A MEDICAL EMERGENCY! Compromised airway can lead to hypoxia Neurons begin to die, leading to permanent brain damage

23

Protecting your patient during a seizure

Summon help and be prepared to use BLS or ACLS

Lower patient to bed or floor Raise side rails Use pads or cushions to

protect her head Place her on her side to

prevent aspiration Move harmful objects to a

safe distance Provide privacy, if able Don’t put anything in her

mouth

Observe and be aware of potential for status epilepticus

Once seizure is over, place her on her side in rescue position

When she’s awake and alert, assess and reassure her

Prepare for diagnostic testing

Document the event Investigate precipitating

factors

24

Pinpointing a diagnosis

History Details about the seizure activity Head trauma, stroke, prior seizures Family history of seizures Use of prescribed or recreational drugs

Neurologic exam by neurologist or other appropriate practitioner

25

Pinpointing a diagnosis (cont’d)

Blood work Serum glucose, electrolyte, and osmolality

levels Assays of antiepileptic drugs (AEDs) Liver and renal function tests Thyroid studies Arterial blood gases

26

Pinpointing a diagnosis(cont’d)

Cardiac studies, such as an electrocardiogram (ECG)

Imaging studies, such as computed tomography (CT) scan and magnetic resonance imaging (MRI)

Electroencephalogram (EEG) Observation (if low risk for recurrent

seizures)

27

Managing seizures: Medications

Medications work in two ways Suppress activity of damaged neurons Reduce responsiveness of neighboring normal

neurons Patient is started on low dose to minimize

adverse reactions and prevent toxicity Dosage is increased as needed to control

seizures

28

Managing seizures: Medications (cont’d)

Drugs used as monotherapy phenytoin valproate carbamazepine lamotrigine phenobarbital

Drugs used to treat status epilepticus lorazepam phenytoin fosphenytoin phenobarbital midazolam propofol

Adjunctive agents ethosuximide methsuximide clonazepam topiramate tiagabine gabapentin primidone felbamate levetiracetam zonisamide oxcarbazepine pregabalin

29

Managing seizures: Surgery

Most beneficial when seizures are caused by structural brain abnormalities

Complications include infection, bleeding, and paralysis

Two main procedures Resection – removal of a portion of the temporal

lobe and small portions of the hippocampus on the affected side

Disconnection – cutting through nerve pathways that let seizures spread

30

Managing seizures: Vagal nerve stimulation

Implantation of a device that sends mild electrical pulses to the brain via the vagus nerve

Stops the spread of excessive discharge of brain neurons

Requires minor surgical procedure every few years to change the battery

31

Patient and family teaching

How to care for the patient during a seizure Medications and importance of adhering to

the regimen Need for periodic blood work Importance of continued follow-up care Methods to prevent injury Patient and family support groups Understanding state’s law on driving