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Care of the Patient with Seizures

At the end of this session the participant will:

• Describe convulsive seizures

• Describe non-convulsive seizures

• List 3 nursing actions for a patient having a convulsive seizure

• Describe nursing considerations for select anti-seizure medications.

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SEIZURES• Definition

• An abnormal electro-physiologic phenomenon of the brain resulting in abnormal synchronization of neuronal activity manifested as altered mental state, tonic or clonic movements, convulsions, or various psychic symptoms.

• Incidence• <20 >60 yrs old, occurs before age 20 in >75% of cases.

• Epilepsy versus Seizure Disorder

• Seizure Disorder-usually an underlying cause• Epilepsy-multiple, recurrent unprovoked

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SeizuresTerms:

Aura-occurs before seizure activity, may be depression, irritability, or unusual sensations.

Ictus-the period of seizure activity.

Postictus (post-ictal)-period after the seizure, pt. may or may not be conscious. If conscious, may be confused, disoriented, tired, lethargic, nauseated.

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Precipitating FactorsMetabolic

• Hypoxia• Hypoglycemia• Toxic metabolites• Acidosis• Electrolyte imbalances (Na)• Pregnancy

• (eclampsia/cerebral edema)• Abrupt withdrawal of drugs/ETOH• Drugs that alter seizure threshold

• Structural• Trauma

• Tumors

• Infection

• Hemorrhage

• Stroke, new and old

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Age-related Precipitating Factors

Neonate-may have a brain defect, birth injury, meningitis, hypoglycemia, or hypocalcemia.

Children-febrile illness is a common cause, lead toxicity (lead encephalopathy), or head trauma.

Adult-head trauma, alcohol withdrawal, metabolic disorders, tumor, abscesses, meningitis, or encephalitis

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Generalized, convulsiveGeneralized, convulsive seizures• Generalized, convulsiveGeneralized, convulsive

• Tonic-Clonic• Grand mal - “classic seizure”• Tonic - contraction of voluntary muscles,

stiffening, usually lasts 10-30 seconds.• Clonic - rhythmic contraction, jerking,

frothing, seldom lasts longer than 2 minutes.• Usually associated with loss of

consciousness. Post-ictal phase lasts 30 min. to several hours.

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Generalized non convulsiveGeneralized non convulsive seizures

• Absence Seizure (Petit mal)• Rare, more common in children• Blank stare, eye fluttering, lip smacking- begins

and ends abruptly (approx. 10 seconds), brief

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Generalized non convulsiveGeneralized non convulsive seizures

• Atonic Seizure (akinetic, astatic, “drop attack”)• Sudden collapse of individual, lasts only a few

seconds• The person either doesn’t lose consciousness or

regains it before hitting the ground.

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Partial Seizures

• Arise from a localized portion of the brain or foci

• Consciousness may or may not be impaired

• Types of partial seizures:• Simple partial • Partial sensory• Complex partial

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Partial Seizures

• Simple partial • jerking may begin in one area

of body• no loss of consciousness• cannot control movements• can spread to become

generalized seizure

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Partial Seizures

• Partial Sensory

• may not be obvious

• experiences distorted environment• hallucinations• unexplained feelings

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Partial Seizures• Complex Partial

• starts with blank stare, progresses to chewing, then other random activity

• Patient is unaware of surroundings

EEG during seizure

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SEIZURES

• Treatment• Airway Protection• PREVENT INJURY• Medical Management

• Evaluate for Cause • Describe/document

what is seen including duration

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Nursing ManagementConsiderConsider• IV access, oxygen readiness, available suction• Pad siderails (not a restraint if patient has a convulsive

disorder)• If convulsive seizure occurs

• Protect from harm - pt and staff• Do not restrain patient during seizure• Be prepared to intubate• Don’t put anything in mouth• Evaluate for underlying cause

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Medication ManagementFosphenytoin (Cerebryx)-Dosage: Load 20mg PE/kg at a rate up to 150mg

PE/minute. Converts to phenytoin in the body.Therapeutic Level: Monitored with phenytoin level and

should be 10-20mg/dl. Level to be drawn 2 hours after infusion is completed.

Side Effects: Hypotension.Instructions: May be diluted with equal volume of D5W

or NS and given on a syringe pump or mixed in a bag and given as an infusion at 150mgPE/minute. After mixing, must be refrigerated (max 7days), but can be kept at room temp. for 24 hours.

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Medication ManagementLevetiracetam (Keppra)Dosage:

Subarachnoid Hemorrhage: 500mg IV/PO x 3 days then discontinue.Traumatic Brain Injury: 500mg IV/PO x 7 days then discontinue.

Therapeutic Level: 5-65mg/dl, how to clinically interpret this data is unknown yet.

Side Effects: Agitation, fatigue, GI.Instructions: Must be diluted with NS, D5W, or LR.

Infuse over 15 minutes. Oral and IV doses are equivalent. Use IV ONLY for patients who cannot tolerate PO for first dose.

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Status Epilepticus

Definition: one continuous unremitting seizure lasting longer than 30 minutes or recurrent seizures without regaining consciousness between seizures for greater than 30 minutes.

• Emergency!• Monitor airway, prepare to intubate• Medical treatment includes benzodiazepines,

primarily Lorazepam (Ativan®)

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Seizure Mapping

• For patients with medically intractable seizures (unresponsive to medications)

• Small electrodes, are placed over the surface of the brain or skull/face

• Goal: identify areas causing seizures for possible surgical removal

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References

• http://en.wikipedia.org/wiki/Status_epilepticus

• http://emedicine.medscape.com/article/793708-overview