Seizures and Syncope

Chapter 19

Objectives

• What is the Pathophysiology of Seizures• Discuss the Types of Seizures• Who perform an Assessment of Seizure

Activity• What is Syncope

Pathophysiology of SeizuresSeizure – a sudden and

temporary alteration in brain function caused by massive, continuing electrical discharges in a group of nerve cells in the brain

• Seizures produce changes in mental activity and behavior ranging from brief trancelike periods of inattention to unresponsiveness and convulsions

Pathophysiology of Seizures

• Seizures are a sign of an underlying defect, injury or disease

• Epilepsy – chronic brain disorder characterized by recurrent seizures

• Seizures of various types many cn be mistaken for other conditions

Pathophysiology of Seizures

Seizures are categorized as either primary or secondary• Primary seizures in adults are usually due to a

genetic or unknown cause– Generalized seizures involve both hemispheres of the

brain and the reticular activating system, often resulting in convulsions and loss of consciousness

– Partial seizures are typically related to abnormal activity in just one cerebral hemisphere and are either simple (remain conscious) or complex (altered mental status or unresponsiveness)

Pathophysiology of Seizures

• Secondary or reactive seizures do not result from a genetic cause but occur as the result to an insult to the body (fever, hypoxia, drug intoxication, eclampsia)– Is often generalized in nature– Is extremely dangerous and can result in death

• A patient who suffers generalized motor seizures that last more than 5 minutes or seizures that occur consecutively without a period of responsiveness between them is considered to be in status epilepticus

Types of Seizures - Tonic/Clonic• Tonic/Clonic or grand-mal• Begins with abnormal

electrical activity low in the cerebral cortex that spreads upward, affecting both cerebral hemispheres, and downward, affecting the reticular activating system

Types of Seizures - Tonic/Clonic• Five Stages

– Aura – Warning– Loss of consciousness– Tonic phase – Muscle rigidity– Hypertonic phase – Extreme

muscle rigidity and hyperextension

– Clonic phase – Convulsion– Postictal state - Recovery

• Emergency Care– If postictal, provide reassurance

and conduct assessment– If patient refuses transport,

follow protocols– If in status epilepticus, establish

and maintain airway, ventilation, oxygenation, and circulation

Simple Partial

• Also known as focal motor seizure or Jacksonian motor seizure

• Involves only one cerebral hemisphere• Produces jerky muscle activity in one area of the

body but may spread to another area or progress to a generalized tonic/clonic seizure

• Patient remains awake and aware• Document where seizure activity began and how it

progressed• Emergency Care – Contact Med Control (ALS) if

patient refuses transport and follow local protocols

Complex partial• Also known as psychomotor or temporal lobe seizure• Involves only one cerebral hemisphere• Patient will remain awake but will be unaware of

surroundings• Lasts 1 – 2 minutes and may include blank stare followed by

random activities (chewing, lip smacking, rolling fingers)• Post-seizure confusion may last longer than a few minutes• Emergency Care – Stay with the person until completely

aware of surroundings, follow local protocols if refuses transport

Absence (petit mal) & Febrile seizures

• Mostly common in children• Characterized by blank stare, beginning and ending

abruptly, and lasting one a few seconds• No emergency care is necessary; if it is a first time

observation, recommend medical evaluationFebrile seizures• Caused by high fever, often in children 6 months to

6 years of age• Most often do not need emergency care

Assessment-based ApproachScene size-up• Look for MOI or

prescription medications that may indicate history

• Always begin wit the assumption that the seizure patient needs care

• Follow protocol if patient refuses care

• If patient is seizing upon arrival, be sure patient receives proper care – guide movements rather than restrain

Assessment-based Approach

Primary Assessment• Form general

impression• Postictal state – who is

talking without distress, continue with secondary assessment and realize the patient may not require emergency care

Assessment-based ApproachFor the patient that is actively seizing, unresponsive, or in status

epilepticus;• Open airway with jaw-thrust, or head-tilt, chin-lift • Suction and insert nasopharyngeal airway as needed• Begin PPV if patient is severely cyanotic, the seizure has

lasted for greater than 5 minutes, or the breathing does not become adequate following the episode

• Note skin temperature and color• Ensure pulse is present if patient is unresponsive• Pulseless – Initiate CPR/AED• Determine if patient is transport priority – evidence of head

trauma, pregnancy

Secondary Assessment• If patient is transport priority,

conduct secondary enroute• Assess head for injury and

extremities for paralysis or injury

• Assess and record baseline vitals

• SpO2• BGL• Gather history – when seizure

started, how long it lasted, description of seizure activity

• Be aware seizures can be mistaken for other disorders

Secondary Assessment – Signs/Symptoms

• Convulsions• Rigid muscular contraction or muscle spasm• Bitten tongue, excessive saliva• Urinary or bowel incontinence• Chewing, smacking lips, wringing hands, or other repetitive motions• Localized twitching of muscles• Visual or Olfactory hallucinations

Emergency Care

• Position patient• Maintain patent airway• Suction• Assist ventilation if necessary• Prevent injury to patient• Maintain oxygen therapy• Transport• Reassess

Syncope• Syncope or fainting – sudden and temporary loss of consciousness• Occurs when, for some reason, there is a temporary lack of blood flow to the

brain, and the brain is deprived of oxygen for a brief time• Common cause is the overwhelming influence of the parasympathetic

nervous system that causes blood vessels to dilate throughout the body• Vasovagal Faint - Type of faint in which patient is in a standing or seated

position, allowing blood to pool in the lower extremities

Syncope

• Place the patient in a supine position and conduct primary/secondary assessment – Be alert for spinal injury from fall

• Patient may refuse transport; follow protocol• Remember that syncope could be a sign of a serious illness

or injury, especially in elderly patients

Questions ???