+Module Two: Recognition and Care of Seizures and EmergenciesThere is an option for the participant to listen to audio

synced to PowerPoint presentation, along with the option to download the modules in PDF format

+Objectives of ModuleTwo:

Upon completion of Module Two-the participant will:

Recognize generalized and partial types of seizures.

Demonstrate basic first aid for seizure types.

Identify when a seizure may become an emergency situation.

+Types of Seizures Generalized

Involves the whole brain from the onset

Types: Absence Myoclonic Clonic Tonic Tonic-clonic Atonic (drop attack)

Partial (also called localization related, focal) Begins in one side of

brain Can spread to other

side

Types: Simple partial Complex partial Secondary generalized

+Revised Terminology and Concepts for Classification of Seizures/Epilepsies Generalized and focal seizures redefined

Generalized: “occurring in and rapidly engaging bilaterally distributed networks”

Focal (partial): occurring “within networks limited to one hemisphere and either discretely localized or more widely distributed”

Types of generalized seizures simplified, while focal seizures described in relation to manifestations

+Parts of a Seizure

Prodrome – changes in behavior, mood or feelings that may occur hours or days before a seizure

Aura - Symptoms correspond to the area of brain affected by the abnormal electrical activity. Most commonly seen with complex partial seizures.

Ictus- What is seen/felt during abnormal electrical activity

Postictal- What is seen/felt until the brain recovers to baseline

+Simple Partial Seizures

Sometimes called ‘auras’, is the first symptom of a seizure

No change in consciousness/awareness

What is seen/felt correlates with abnormal electrical activity in a part of the brain

+Examples of Simple Partial Seizures Sensory

Smells Sensations Visual changes Auditory symptoms

Autonomic Dilated pupils Queasy Stomach Skin flushing Pallor, etc.

Motor Unilateral jerking of face,

arm, and/or leg may spread from one

part of body to others May be unable to speak Can involve any part of

the body

Psychic Dejà-vu, jamais vu, out of

body experience Feelings of fear, anxiety,

happiness, depression

+Nursing Care During Seizure Simple PartialPromote safety

Guide patient to a safe place

Stay within arm’s reach

Stay calm

Observe the patient Speak calmly Assess awareness

Reassure

Time the seizure

Document event

+Complex Partial Seizures May start as simple

partial seizure or start suddenly

Awareness is impaired, though may be difficult to assess

May or may not hear, understand, see, respond or recall events during seizure

Duration: seconds to minutes

Automatisms: unusual and repetitive behaviors

Motor signs include: One or both sides of

body May be stiffening,

jerking, twitching, or absence of movement

May involve any part of the body including jaw, swallowing muscles, shoulders

Can spread from one body area to others

Post-ictal fatigue, confusion, sleepiness, headache

+Nursing Care During Complex Partial Seizure Promote safety

Guide patient away from potential dangers. Do not restrain patient

Patient may become combative if restrained If safe, let patient wander in an enclosed area

Assist patient to lie down if there is a loss of tone

Stay calm Observe behavior and time the seizure Observe post ictal state (patient may be confused

or tired) Reorient and reassure Stay with the patient until he/she returns to baseline

Document

+Secondarily Generalized SeizuresStarts in focal brain area then spreads

from one side to include the other side

That is, the seizure may start as a simple partial seizure or as a complex partial seizure

May spread slowly or rapidly to a generalized seizure, usually causing patient to fall

Electrographically, seizure involves both sides of brain

+Secondarily Generalized Seizures Eyes may roll back, may fall to ground or lean

over

Body becomes rigid (tonic) and then jerks (clonic)

May involve incontinence of bladder and/or bowel

May have forced head turn or eye deviation to side

May involve one side of body more than the other

Lasts 5 minutes or less

+Review of Partial Seizures

Video introducing partial seizures and what they look like from epilepsy.com

Understanding Partial Seizures (available 1/1/2014)

+Primary Generalized Seizures Involve both hemispheres at the onset

Types of primary generalized seizures:AbsenceMyoclonic TonicAtonicClonic Tonic-clonic

+Absence Seizures (Previously called petit mal)Sudden onset of behavioral arrest

May involve eyelid fluttering Duration: 5-30 seconds Usually occurs many times/day, difficult to

identify clinically because of brief duration

Returns to baseline almost immediately Possible anterograde or retrograde amnesia Hyperventilation and/or flashing lights may

precipitate seizures Classic EEG pattern

+Nursing Care: Absence Seizure

Promote safetyStay within

reach Falling unlikely

Stay calm

Observe behavior and time the seizure

Observe postictal behaviorUsually returns to

baseline immediatelyReorient

If photo-sensitive, avoid exposure to flashing lights or patternsDocument seizure

+Tonic-Clonic Seizures (previously called grand mal or major motor)Often begins with an ictal cry (loud

groan)

Body may be tonic – posturing or stiffening of all musclesPerson may appear as if not breathing

as chest muscles are rigid

Clonic movements – rhythmic jerking of head and extremities

May have forced eye deviation upward

+Tonic-Clonic Seizures

Duration: Generally lasts from seconds to 1-2 minutes Excessive salivation(collection of drooling) May involve tongue biting May involve bladder and/or bowel

incontinence May turn dusky or cyanotic Postictally, may have

Confusion Headache Muscle ache Sedation or fatigue for minutes to hours

+Nursing Care: Generalized Tonic-Clonic Seizure Stay calm

Promote safety Cushion fall if possible Support head

Loosen restrictive clothing

Place NOTHING between teeth

NO food or drink until able to swallow

Do not forcefully reposition or restrain the movements

+Nursing Care: Generalized Tonic-Clonic Seizure Promote Safety

Place patient in side-lying position as soon as possible Due to size or location of teenagers and adults,

may need to wait until seizure is subsiding before turning to side

Side-lying position promotes drainage of saliva from mouth May need to reposition head to keep airway clear In hospital, suctioning may help maintain airway,

especially if seizure is long

Observe behavior and time the seizure Assess for injury after the seizure is over

+Post Ictal Nursing Care: Tonic Clonic Seizure

Observe behavior May be sleepy,

confused, combative, difficulty talking, and unable to remember

If sleepy, continue in side-lying position to protect the airway

Gently restrain, if needed, to avoid injury

Reassure/reorient

Assess for injury

Monitor duration of postictal state Confusion may last

minutes Sleepiness may last

minutes to hours NPO until able to

swallow

Document

+Tonic SeizuresSustained bilateral stiffening or

posturing Usually brief but can last minutes May cause fall if standing or sitting

Sudden, very unpredictable Significant risk of injury due to loss of

protective reflexes, ie. cough, righting reflex

May have change in breathing patterns or look like not breathing or may appear pale or cyanotic

Can occur in clusters, sometimes along with other seizure types

+Atonic Seizures Atonic- also called “drop attacks”

Sudden loss of tone Drop of head with or without slight bending of knees Drop of head, trunk or entire body May fall backwards or forward if sitting or standing

Impaired awareness may be present but not discernible

Usually very brief, variable intensity (mild to forceful)

Significant risk of injury High risk for head lacerations, fractures, and other injuries Often require helmets and safety gear

+Myoclonic Seizures Very brief, fast muscle contractions of the head, arms,

legs, face, trunk and/or body Single jerk or clusters Unilateral or bilateral, can be specific muscle groups May cause loss of balance or fall May drop objects

Often occur when drifting to sleep or shortly after awakening

Impaired awareness may not be discernible

Clusters may precede a generalized tonic-clonic seizure

Some myoclonus may not be epilepsy-related

+Nursing Care: Tonic, Atonic and Myoclonic Seizures Stay calm Promote safety

Be sure safety gear is worn, if ordered Cushion fall if possible – support head Clear area of harmful objects or surfaces Loosen restrictive clothing Place NOTHING between teeth

There is no danger of the person swallowing their tongue

NO food or drink until able to swallow Turn to side-lying position if not able to protect

airway Do not forcefully reposition

+Nursing Care: Tonic, Atonic and Myoclonic SeizuresObserve behavior and time the

seizure/seizure cluster

Post ictal care: Observe behavior Reassure and re-orient Assess for injury NO food or drink until able to swallow Assess return to baseline state

Document

+Febrile Seizures

Frequency 2% - 5% of children

in United States

Most often in children aged: 3 mos-5 years

Associated with fever ≥ 101

Prolonged 13% > 10 minutes

5% > 30 minutes

A prolonged 1st febrile seizure, implies the next seizure will likely be prolonged

+ Febrile Seizures Simple febrile seizure

Generally lasts a few minutes and does not require treatment

Occurs within 24 hours of fever onset Usually generalized tonic clonic seizure No localizing deficits afterwards No prior history of non-febrile seizures No current intracranial infection No other neurological/developmental abnormalities No family history of non-febrile seizure

Complex febrile seizure Last > 15 minutes Have focal features or Recur within 24 hours

+Responding to Seizures: Summary of General First Aid

Stay calm/speak quietly

Time the seizure

Promote safety Help person to floor or

safe place, Prevent or cushion fall if

possible Support head Remove harmful objects Make comfortable

Maintain open airway Place nothing in

mouth between teeth

Keep onlookers away

Stay with person until seizure ends

Reorient and reassure patient

Assess frequently until back to baseline May need to sleep/rest Nothing to eat or drink until

able to swallow Assess for injury

+Review of Generalized SeizuresVideo introducing generalized seizures

and what they look like from www.epilepsy.com

Understanding Generalized Seizures

(available January 2014)

+TIPS FOR SEIZURE OBSERVATION AND RECORDINGWhen watching a seizure, observe:

What happens before, during and after the event

Write down what happened as soon as you can

Include as much information as possible

Download Tips for Seizure Observation and Recording by clicking here

(available January 2014)

© 2007 epilepsy.com A service of the Epilepsy Therapy Development Project

+Tips for Seizure Observation

What was person doing at time of event

Change in mood or behavior hours or days before

‘Warning’ or ‘aura’ shortly before event

Possible triggers or precipitants

When seizures occurs – date, time, duration

Before the Seizure

+Tips for Seizure Observation: During the Seizure

Change in awareness, alertness, confusion

Ability to talk and understand

Changes in thinking, remembering, emotions, perceptions

Sensations – changes in seeing, hearing, smells, tastes, feelings

Facial expression, pupil size, eye blinking or position, drooling

Changes in muscle tone

Movements – jerking or twitching, unable to move, body turning, falls

Automatic or repeated movements – lip smacking, chewing, swallowing, picking at clothes, rubbing hands, tapping feet, dressing or undressing

Walking, wandering, running

Changes in color of skin, sweating, breathing, loss of bladder or bowel control

PART OF BODY INVOLVED

+Tips for Seizure Observation

Response to voice or touch

Awareness of name, place, time

Memory for events

Ability to talk or communicate

Weakness or numbness

Changes in mood or how person acts

Fatigue, sedation

What Happens After Event

+ Tips for Seizure Observation

Duration of aura, seizure, after-effects or postictal phase

How long before person returns to normal activity

© 2007 epilepsy.com A service of the Epilepsy Therapy Development Project

Adapted with permission from the Comprehensive Epilepsy Center, Beth Israel Deaconess Medical Center, Boston, Massachusetts, 2006.

How Long It Lasted

+Post Ictal Nursing Care: All PatientsMonitor until returns to baseline Assess cognitive stateSpeak calmly and quietly –reorient and

reassureAllow to sleep if desiredDo not restrain: may cause aggression in

some people Assess for injury, postictal paralysis, mood

or behavior change Document

+When to Seek Medical Attention

History of seizure recurrence in person with rare or well-controlled seizures

Person with known epilepsy but occurrence of new seizure type

Persistent side effects of treatment bothersome to patient

+

When to Call for Emergency Help When seizures..

approach 5 minutes in duration or per patient’s seizure action plan

one seizure occurs after another

last longer than typical events

When person.. doesn’t return to

baseline in usual period of time

has first seizure has suspected injury is pregnant or diabetic

When observer is unsure or uncomfortable

+Injuries from Seizures

Immediate Lacerations Bruises Burns Head trauma Fractures Drowning/near

drowning

Delayed Fever Aspiration

pneumonia Subdural

hematomas Fractures (delayed

recognition) Change in seizures

or seizure emergencies

Seizure Assessment Algorithm

Reprinted with permission from the American Association of Neuroscience NursesReprinted with permission from the American Association of Neuroscience Nurses

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