Seizure Disorders

• Seizures are characterized by abnormal, sudden, and explosive electrical impulses discharged from cerebral neurons, leading to abnormal motor, sensory, autonomic, or psychic activity.
• Seizures can involve part or all of the brain.
• There are two main types of seizures: partial and generalized.
• Partial seizures begin in one part of the brain.
• Generalized seizures involve electrical discharges throughout the whole brain.

Generalized Seizures: Grand Mal

• May be preceded by an aura and involve both hemispheres of the brain.
• Tonic phase involves limb contraction or stiffening, pupil dilation, eye roll to one side, glottis closure, and possible incontinence.
• The tonic phase occurs simultaneously with a loss of consciousness and lasts 20-40 seconds.
• Clonic phase presents as repetitive movements like elbows, legs, and head flexing and relaxing.
• Increased mucus production along with an epileptic cry are characteristic of the clonic phase.
• Tongue chewing and urinary/fecal incontinence may occur.
• After the seizure, the patient relaxes, lies in a deep coma, and breathes noisily.
• Seizure ends with a postictal period of confusion and drowsiness.
• Many patients report headache, sore muscles, fatigue, and depression post-seizure.

Generalized Seizures: Petit Mal (Little Seizure)

• Not preceded by an aura.
• May involve little or no tonic-clonic activity.
• There is a sudden cessation of ongoing physical activities with a blank facial expression, automatism like lip-chewing, or lip smacking.

Generalized Seizures: Myoclonic Seizures

• These seizures are associated with brain damage.
• There is generalized jerking or stiffening of extremities (arms and shoulders).
• Sudden muscle jerks can appear as "jumps".

Generalized Seizures: Akinetic Seizures

• Related to organic brain damage.
• There is a sudden, brief loss of postural tone and temporary loss of consciousness; also known as drop attacks.

Generalized Seizures: Febrile Seiuzres

• Only occur when a fever is rising.
• Common in children ages 6 months to 5 years.
• Convulsions brought on by fever in infants or small children.
• Most Febrile seizures last a minute or two, although some can be as brief as a few seconds while others last for more than 15 minutes.
• The majority of children with febrile seizures have temperatures greater than 102°F (38.9°C).
• Commonly occur during the first day of a child’s fever.

Partial/Focal Seizures: Simple Partial Seizures

• Produces sensory symptoms accompanied by motor symptoms that are localized or confined to a specific area where a finger or hand may shake, or the mouth may jerk uncontrollably.
• The person may talk unintelligibly, feel dizzy, and experience unusual or unpleasant sights, sounds, odors, or tastes with no loss of consciousness.

Partial/Focal Seizures: Complex Partial Seizure/Psychomotor Seizures

• May follow trauma, hypoxia, or drug use.
• Characterized by periods of altered behavior that the client is not aware of.
• Aura might be present, creating a dreamlike state.
• Client loses consciousness for a few seconds, remains motionless or moves automatically but inappropriately for time and place.
• Patients can experience excessive emotion: fear, anger, elation, or irritability.

Abdominal Seizure

• Accompanied by autonomic symptoms or signs.
• Abdominal discomfort or nausea may rise to the throat (epigastric rising).
• Stomach pain, rumbling sounds of gas in the intestines (borborygmi), belching, flatulence, and vomiting may occur.
• Also referred to as abdominal epilepsy.

Specific Causes of Seizures

• Idiopathic is defined as arising spontaneously or from an obscure or unknown cause.
• Acquired causes:
  • Cerebrovascular disease
  • Hypoxemia of any cause
  • Fever
  • Head injury
  • Hypertension
  • CNS infections
  • Metabolic and toxic conditions
  • Brain Tumor
  • Drug & alcohol withdrawal
  • Allergies

Nursing Management: Before & During a Seizure

• Observe & record the sequence of signs
  • The circumstances before the seizure
  • Occurrence of an aura
  • The first thing the client does in the seizure
  • Type of movements in the body involved
  • Pupil size & If the eyes are open
  • Automatisms
  • Incontinence of urine or stool
  • Duration of each phase of seizure
  • Duration of unconsciousness
  • Obvious paralysis or weakness
  • Inability to speak after the seizure
  • Cognitive status

Nursing Care During Seizure

• Patient Care includes:
  • Privacy
  • Preventing Injury
  • Supporting the patient physicially and psychologically
• Place patient on the floor if possible
• Protect the head with a pad
• Loosen constrictive clothing
• Push aside any furniture
• Raise side rails if the patient is in bed
• Insert oral airway equipment if an aura precedes the seizure
• There should be no attempt to open jaws clenched during spasm or insert anything.
• Do not restrain during the seizure
• Place patient on one side with head flexed forward, if possible.

Nursing Management: After the Seizure

• Keep the patient on one side to make sure the airway is patent.
• Expect a period of confusion after a grand mal seizure.
• A short apneic period may occur during or immediately after a generalized seizure.
• Reorient the patient to their environment
• Use persuasion & gentle restraint if patient becomes agitated afterwards.

Seizure First Aid

• Stay with the person until they are awake and alert.
• Monitor the time of the seizure, remain calm and check for medical ID.
• Keep the person safe and move or guide away from harm.
• If not awake, turn the person onto their side while keeping the airway clear.
• Loosen sight clothing around neck and put something small and soft under the head.
• Call 911 if the seizure lasts longer than 5 minutes, person doesn't return to their usual state, person is injured/pregnant/sick, seizure recurs, this is a first-time seizure, difficulty breathing or occurs in water.
• Do not restrain or put any object in mouth.
• Rescue medications can be given only if prescribed by doctor.

Epilepsy

• A group of syndromes characterized by unprovoked, recurring seizures.
• Seizures that repeatedly continue after the underlying problem is treated, the condition is called epilepsy.
• Can be primary or secondary.

Cause of Epilepsy

• Inherited/Idiopathic
• Birth trauma/Asphyxia neonatorum
• Head injuries
• Infectious diseases
• Toxicity/Circulatory problems
• Fever/Metabolic & nutritional disorders
• Drug or alcohol intoxication
• Brain tumors, abscesses, congenital malformations

Pathophysiology of Epilepsy

• Neurons carry messages from within the body that create occasional impulses whenever a nerve cell performs a task.
• Permanent changes that occur in brain tissue, which becomes too excitable or jumpy.
• Sends out abnormal, recurring, and uncontrolled signals that lead to repeated, unpredictable seizures.

Clinical Manifestations of Epilepsy

• Simple staring spells
• Violent shaking and loss of alertness
• The type of seizure depends on the part of the brain affected and cause of epilepsy.
• Strange sensation

Diagnostic Tests to look for

• EEG: electrical activity in brain
• Blood chemistry- Increase Prolactin
• Blood sugar
• Kidney function tests (electrolytes)
• Head CT & MRI
• Lumbar Puncture: procedure to collect and look at CSF (cerebrospinal fluid)
• Test for infectious diseases

Medical Management

• Pharmacologic Therapy
  • Aim to achieve seizure control with minimal side effects.
• Medication therapy controls rather than cures seizures.
• Major antiseizure medications include:
  • Carbamazepine, clonazepam, gabapentin, phenobarbital, phenytoin, valproate

Surgical Management

• Surgical management is indicated for patients whose epilepsy results from intracranial tumors, abscesses, cysts, or vascular anomalies.

Status Epilepticus

• An acute, prolonged seizure activity that is a medical emergency
• A series of generalized seizures that occur without full recovery of consciousness between attacks.
• Tonic-clonic seizure lasting longer than 5 minutes.
• Repeated episodes of cerebral anoxia & edema may lead to irreversible and fatal brain damage.

Management of Status Epilepticus

• Stop seizures as quickly as possible with IV diazepam (Valium) or lorazepam (Ativan).
• Insure adequate airway & oxygenation.
• Establish IV line & obtain blood samples.
• Perform EEG monitoring.
• Monitor Vitals signs & neurologic signs.
• Monitor for Cardiac & respiratory depression.