Seizures and Epilepsy SDS Jan 2025 PDF

SEIZURE DISORDERS SPRING 2024-25 Marina Gharibian Adra PhD, RN Revised by SDS  DEFINITION Seizures involve sudden, temporary, bursts of electrical activity in the brain that change or disrupt the way messages are sent between brain cells. These electrical bursts can cause involuntary cha...

SEIZURE DISORDERS SPRING 2024-25 Marina Gharibian Adra PhD, RN Revised by SDS  DEFINITION Seizures involve sudden, temporary, bursts of electrical activity in the brain that change or disrupt the way messages are sent between brain cells. These electrical bursts can cause involuntary changes in body movement or function, sensation, behavior or awareness. Most seizures last from 30 seconds to two minutes. Having two or more unprovoked seizures at least 24 hours apart that aren't brought on by an identifiable cause is generally considered to be epilepsy. The abnormal electrical discharges are often in the cerebral cortex. WHAT ARE PROVOKED SEIZURES? A person can have a seizure from a physical cause. This could be an acute medical illness or trauma that begins before the seizure. It could also be related to a substance or event their body is responding to or withdrawing from. In these cases, seizures are called “provoked.” The provoking cause has had an effect on the brain that leads to a seizure. These seizures are not diagnosed as epilepsy. Treatment for provoked seizure should address the underlying cause.  SPECIFIC CAUSES OF SEIZURES Metabolic and toxic The most common High fever, which conditions cause of seizures is can be associated (electrolyte imbalance Hypoxemia; epilepsy. But not every with CNS infections (hyponatremia), person who has a such as meningitis/ acidosis, hypo or hyperglycemia seizure has epilepsy. encephalitis hyper glycemia, dehydration) Medications, such as certain pain relievers (tramal, Autoimmune Head trauma that antidepressants, disorders, including Stroke/ TIA/ causes an area of stimulants), bleeding in the brain SLE and MS & hypertension antidepressants, or Genetic syndromes antibiotics that lower the seizure threshold Use of illegal or Alcohol/drug misuse, recreational drugs, during times of COVID-19 virus Brain tumor such as amphetamines or withdrawal or infection extreme intoxication cocaine WHAT IS NOT A SEIZURE? There are also physical or medical events that may mimic or look like seizures. These are not the same as provoked seizures. They are also not due to changes in electrical activity in the brain seen in an epilepsy seizure. Since these are not seizures, they are often called nonepileptic events. Some of these medical conditions include: Syncope Migraine Movement disorders Sleep disorders  WHAT ARE PSYCHOGENIC NONEPILEPTIC SEIZURES? Psychogenic nonepileptic seizures (PNES) also are not caused by abnormal brain electrical activity. PNES may look like epilepsy seizures. They may include involuntary changes in behavior, movement, sensation or consciousness that usually last longer than epilepsy seizures. PNES are thought to be the body’s response to physical or emotional distress that the brain is detecting. PNES has a psychological origin. A person with PNES is not consciously in control their symptoms. About 4 out of 5 people with PNES have a history of psychiatric problems, such as depression, anxiety and personality disorders. There often is a history of sexual, emotional or physical abuse in people with PNES. About half of people with PNES also have a history of post-traumatic stress disorder (PTSD). Treatment for PNES focuses on addressing underlying causes and helping the person learn new coping skills.  DRUGS THAT CAUSE SEIZURES Antidepressants –known to lower the seizure threshold. Antipsychotics –like clozapine and chlorpromazine can increase seizure risk. Antiepileptic drugs – Ironically, certain antiepileptic drugs, such as tiagabine and vigabatrin, can themselves trigger seizures. Stimulants –like amphetamine, methylphenidate (Ritalin), and cocaine can provoke seizures, especially in high doses. Opioids – Tramadol, especially when overdosed or mixed with other drugs. Antibiotics –penicillin & cephalosporins (Cefepime, ceftriaxone, and cefotaxime); Carbapenems – Meropenem and imipenem/cilastatin, especially in people with kidney dysfunction. Illicit drugs – Ecstasy (MDMA), methamphetamine, and LSD.  P O SS I B L E P R E C I P I TAT I N G FA C T O R S / T R I G G E R S F O R S E I Z U R E S Conditions Factors Physical Overexertion ; Sleep deprivation; loud noises, flashy lights; Recent head trauma Excesses in caffeine, sugar, and other foods Psychosocial/ Stress , Anxiety , Anger ; Depression ; Psychosis emotional Medication or Withdrawal of alcohol / binging or other sedative agents chemical Administration of drugs with pro-convulsant properties (e.g., central nervous system stimulants, such as amphetamines). Most dopamine blocking agents (antipsychotics) ; Toxins Hormonal Menstruation ; Ovulation ; Pregnancy; hormonal Variations changes  THE PHASES OF SEIZURE ACTIVITY ARE PRODROMAL, AURAL, ICTAL, AND POSTICTAL. The prodromal phase involves mood or behavior changes that may precede a seizure by hours or days. Not everyone has these signs. The aura is a premonition of impending seizure activity and may be visual, auditory, or gustatory. It is considered part of the seizure. The ictal stage is characterized by seizure activity, usually musculoskeletal. The postictal stage is a period of confusion/somnolence/irritability that occurs after the seizure.  Seizures are broadly categorized as either generalized, focal in onset, or Unknown onset CLASSIFI CATION Generalized onset Focal onset OF Unknown onset SEIZURE (unclassified) S The symptoms vary depending upon the part of the brain involved in the epileptic discharge  DEFINITION OF TERMS Tonic Stiffening, a state of muscle contraction with excessive muscle tone Sudden loss of muscle tone: drooping eys, jaw and limbs Atonic (called drop Falling to the ground- forward attacks) Can result in injuries to face or head Lasts seconds Repetitive, rhythmic alternating muscle contraction and relaxation involving both sides Clonic of the body Myoclonic Sporadic rigid violent jerking of muscles in face, torso (trunk), extremities Lasts 60-90 seconds Tonic-Clonic Loss of consciousness (formerly called grand Bladder and bowel incontinence mal) Cyanosis Tongue biting  Three Major Groups of Seizures Generalized Focal onset Unknown onset Onset Seizures seizure seizure These seizures affect Focal seizures start in one When the beginning of a area or group of cells in one seizure is not known. both sides of the side of the brain. brain or groups of Focal Onset Aware cells on both sides of Seizures: When a person is A seizure could be called awake and aware during a an unknown onset if it’s the brain at the same seizure. This used to be not witnessed or seen by time. This term called a simple partial anyone, for example when includes seizures seizure. seizures happen at night Focal Onset Impaired or in a person who lives types like Awareness: When a person alone. Tonic-Clonic is confused or their Absence awareness is affected in As more information is some way during a focal seizure, it’s called a focal learned, an unknown onset impaired awareness seizure. seizure may later be  Face, head, arm, leg or body twitches, spasms, repetitive body mvts. or jerking INITIAL Unusual or erratic eye movements. SYMPTOMS Tingling, see flashing lights, and even OF A FOCAL get dizzy A change in sensation, such as a SEIZURE strange taste or smell. Mumbling or drooling. CAN INCLUDE: Decreased awareness. Loss of consciousness. GENERALIZED SEIZURES Absenc Tonic Clonic e Myoclo Tonic- Atonic nic clonic  ABSENCE SEIZURE- NON MOTOR Absence Seizures - The seizure starts suddenly in the middle of an activity and ends just as abruptly. The person usually zones out or daydream for a few seconds and is not aware of surroundings. An absence seizure is a generalized onset seizure, which means it begins in both sides of the brain at the same time. The seizures usually last less than 10-20 seconds. "Absence seizures are so brief they are often The eyes might also flutter for a few seconds and look up blankly. The person is missed." not conscious of what is going on, and after the seizure, the person carries on with the activity he or she was busy doing.  In a tonic seizure, the person may become suddenly stiff and fall like a "tree trunk“ to the back. In an atonic seizure, there's a loss of TONIC VS. muscle tone and the person may fall ATONIC limply forward, like a "rag doll." (rare type of seizure). Can result in injuries to SEIZURES the face and head. Lasts seconds Since there is usually no warning and it occurs quickly, there is often no time to protect the person from hurting themselves. MYOCLONUS, DEFINITION Myoclonus refers to a quick, involuntary muscle jerk. This type of seizure is where the arms and legs jerk rapidly. There are brief muscle twitches in the upper arms, shoulders, or neck. The movements are on both sides of the body simultaneously. Is common in teenagers.  There are many studies that show over the years that CBD specifically works effectively for seizures. HOW CAN The studies were not easy to fulfill due to the strict regulations, but studies done on those CANNABIS struggling from JME show great promise. HELP IN The endocannabinoid system plays a JUVENILE significant role in the ictal (period of seizure) control and neuronal balance. Cannabis has the MYOCLONI ability to reduce seizure frequencies. C CBD also has anticonvulsant effects and also slows down the potential action to ignite a EPILEPSY? seizure. CBD helps to let the child sleep better and reduce hyperactivity. It makes the child calmer and more relaxed. TONIC CLONIC SEIZURES EPILEPSY EPILEPSY Is one of the most common disorders of the central nervous system, affecting 65 million people worldwide—3.4 million in the United States. Epilepsy is the fourth most common neurological disorder in the world It can occur with or without a known cause (60% of cases have no known cause) and is diagnosed when seizures are spontaneous and recurrent (two or more unprovoked seizures). One of the fastest-growing population developing epilepsy is veterans who sustained complicated traumatic brain injuries (TBIs) as a result of exposure to explosive blasts and post- traumatic stress disorder.  Epilepsy is a disorder of the brain characterized by an enduring predisposition to generate epileptic seizures, with cognitive, psychological, and social consequences. After two unprovoked seizures, the risk of a 3rd by 60 months is 73% Anyone can develop epilepsy ( 1/26 persons develop epilepsy in the US). More men than women have EPILEPSY epilepsy overall by a small amount. A diagnosis of epilepsy does not define the cause or the outlook. Epilepsy is a spectrum disorder. There are many different types of seizures and types of epilepsy syndromes. Risk of epilepsy is highest during 1st year of life and increases at onset of puberty and after age 55. THE PATHOPHYSIOLOGY The electrical discharges could be due to: - Excess of excitatory neurotransmitters like glutamic acid, aspartic acid - Lack of inhibitory neurotransmitters like GABA-Gamma-aminobutyric acid  CLINICAL PRESENTATION Aura. An aura (unusual sensations) precedes seizures in about 20% of people who have a seizure disorder. Short duration. Almost all seizures are relatively brief, lasting from a few seconds to a few minutes; most seizures last 1 to 2 minutes. Postictal state. When a seizure stops, people may have a headache, sore muscles, unusual sensations, confusion, and profound fatigue; these after- effects are called the postictal state. Todd paralysis. In some people, one side of the body is weak, and the weakness lasts longer than the seizure (a disorder called Todd paralysis). Visual hallucinations. Visual hallucinations (seeing unformed images) occur if the occipital lobe is affected. Convulsions. A convulsion (jerking and spasms of muscles throughout the body) occurs if large areas on both sides of the brain are affected.  DIAGNOSTICS Comprehensive neurological exam: Electroencephalogram (EEG). This is the most common test used to diagnose epilepsy to study brain waves. Brain Imaging: Computerized tomography (CT) scan / MRI. These can detect tumors, bleeding or cysts in the brain that might be causing epilepsy. A CT scan uses X-rays to obtain cross-sectional images of your brain. Magnetic resonance imaging (MRI). provides a more detailed look at the brain than a CT scan. Neuropsychological tests. These tests assess thinking, memory and speech skills. The test results help determine which areas of the brain are affected by seizures.  Occurs with any type of seizure Status epilepticus occurs when a seizure lasts STATUS more than 5 minutes or when seizures occur very close together and the person doesn't EPILEPTI recover consciousness between them Two or more without full recovery of consciousness CUS between seizures Causative factor is often non-compliance with medications. Very long seizures (those lasting 30 minutes or longer) are dangerous and even increase the risk of death. Therefore, it is important to recognize status epilepticus, so it can be treated before the risk of harm increases.  STATUS EPILEPTICUS  After 30-60 min Decompensation occurs because increased metabolic demands are not met o Decreased CBF Failure of cerebral o Hypotension autoregulation o Increased ICP  Cerebral hypoxia and aspiration  Metabolic and respiratory acidosis from hypoxemia  Hypoglycemia from depleted energy stores  Cardiac arrythmias ALERT! STATUS EPILEPTICUS IS A MEDICAL EMERGENCY Medications such as diazepam ( valium) 5 to 10 mg or midazolam (Dormicum) 1 to 5 mg can be administered as rescue medications intravenously to stop the seizure If the seizure lasts longer than 30 minutes, other medications such as phenytoin ( Epanutin), propofol or general anesthesia may be used.  Main goal is to maintain safety until the seizure WHAT stops. Here's how:  A. Maintain airway TO DO 1-Turn patient to their side when seizure is over to allow secretions to drain and prevent DURING aspiration 2-Use suction if needed A 3- Loosen clothing if constricting, especially around neck. Remove eyeglasses if present SEIZURE 4- Do not insert anything (such as a tongue blade) into mouth to try to pry mouth open 5- Do not attempt to artificially ventilate unless patient does not breath after the seizure stops 6- Assess breathing pattern  7- Protect the person from injury 8- Support and cushion their head 9- Do not restrain their activity or What to Do movement During a 10- Stay calm and be reassuring 11- Time the length of the seizure Seizure and note the types of movements and apneic periods, if any, to record later 12- Give IV diazepam 13- Provide privacy as much as possible for the individual during and after seizure activity.  Characteristics of the seizure: frequency, duration, what happens before, during and after the seizure. SEIZURES Neurological state before, after ASSESSM and in between seizures ENT Information regarding precipitating factors/ triggers, aura, urinary or bowel incontinence, and duration of the seizure GUIDELINES FOR SEIZURE CARE  Keep side rails up  Pad side rails  Lower the bed  Remove all restrictive clothing and jewelry   After the seizure ends, patient will enter the postictal phase WHAT  1- Note how long this lasts and ask patients how TO DO  2- Does he/she have muscle aching? Fatigue? Any they feel AFTER A  3- Do not offer food or fluids until the person is signs of paralysis? SEIZURE fully awake, able to sit upright, and can swallow easily  4- You may need to reorient the person to the day, time, and surroundings  5- Temporary amnesia and weakness can occur with seizures  MANAGEMENT OF SEIZURES First line Second line Third line Phenytoin (Epanutin/ Barbiturates: Diazepam Dilantin) Pentobarbital (Valium) IV bolus Phenytoin is mixed only Short-acting barbiturate with saline and is with sedative, hypnotic, Diazepam is not stable in solution only and anticonvulsant for 20 min properties mixed with other Phenytoin drug levels Used in refractory status solutions. need to be monitored when other agents have with laboratory testing failed Depresses the Lliver function testing subcortical areas and a complete blood Patients need intubation of the CNS count (CBC) also need to and respiratory support. be followed  PHENYTOIN ADMINISTRA TION PROTOCOL AT AUBMC Administration of Phenytoin by IV Push, by intramuscular or subcutaneous injection is prohibited. Phenytoin solutions must be administered through an infusion line either with a pump and a 22 microne filter, or by slow injection to be done exclusively by a physician. If given IVP quickly it can cause cardiovascular collapse and CNS depression. Can produce tissue necrosis upon extravasation. Monitor the patient’s cardiovascular COMMON DRUGS USED IN EPILEPSY Levetiracetam – Keppra Lamotrigine - Lamictal Valproic acid- Depakin Carbazepine- Trileptal Clonazepam – Rivotril Pregabalin – Lyrica Topiramate- Topamax COMMON DRUGS  SURGICAL MANAGEMENT  Surgery is indicated when epilepsy results from intracranial tumors, abscesses, cysts, or vascular anomalies or those who are resistant to medications.  Surgical removal of the epileptogenic focus is done for seizures that originate in a well-circumscribed area of the brain that can be excised without producing significant neurologic defects IMPACT OF EPILEPSY ON LIFE Education Relationships with peers, memory, concentration and career choices are affected Employment and under employment Unemployment among people with epilepsy is 46% as opposed to 19% in people of the same demographic without epilepsy Driving; swimming Prohibited by law until the person is free of seizures for one year PATIENT EDUCATION to carry an emergency medical identification card or Instruct wear an identification bracelet to avoid driving, alcohol, & swimming alone (showers Instruct are favored over tub baths) Instruct to sleep in regular patterns to comply strictly to medication regimen and notify Instruct physician if unable to take medications due to illness patient and family about medication side effects and Instruct toxicity specific guidelines to assess and report signs and Provide symptoms of medication overdose gingival hyperplasia, a side effect of phenytoin Prevent or (Dilantin) therapy, by teaching patient to perform control thorough oral hygiene and gum massage & seek regular dental care  Ineffective tissue perfusion related to continuous seizure activity Ineffective breathing pattern related to hypoventilation SEIZURES Ineffective airway clearance related to seizure : activity NURSING Risk for trauma related to seizure activity DIAGNOS Disturbed thought process related to postictal ES state Situational low self – esteem elated to the stigma associated with the condition. Deficient knowledge related to information misinterpretation. CASE STUDY: SEIZURES AND EPILEPSY Patient Profile: Name: Ahmed Mansour Age: 22 years old Gender: Male Medical History: No significant medical issues until recently Social History: University student, lives with parents, non-smoker, no drug use SCENARIO: Ahmed is a 22-year-old male who was brought to the emergency department by his parents after experiencing a sudden seizure while studying at home. According to his parents, he was sitting at his desk when he suddenly fell to the floor, became unresponsive, and exhibited jerking movements of his arms and legs. The episode lasted approximately two minutes. He appeared confused and fatigued afterward, taking about 20 minutes to regain full awareness. This was the first known seizure for Ahmed. Upon arrival, he complained of a headache but no other symptoms. His vital signs were stable, and his neurological examination was normal. The emergency team ordered blood tests, a CT scan of the brain, and an EEG (electroencephalogram). The blood tests showed no abnormalities. The CT scan was normal. The EEG revealed generalized epileptiform discharges, consistent with a diagnosis of epilepsy. Ahmed was admitted for further observation and started on antiepileptic medication (levetiracetam). QUESTIONS AND ANSWERS: 1. What are the possible causes of Ahmed’s seizure? In Ahmed's case, the normal CT scan and blood tests suggest idiopathic epilepsy as the most likely cause. 2. What is the difference between a seizure and epilepsy? 3. What are some key nursing interventions for a patient having a seizure? 4. What should Ahmed and his family be educated about regarding epilepsy? 5. What are the possible side effects of levetiracetam, the antiepileptic medication Ahmed is prescribed? 6. What should the nurse include in a care plan for Ahmed during hospitalization? ANSWERS Answer 1: Seizures can have various causes, including:Idiopathic epilepsy (no identifiable cause) Structural brain abnormalities (e.g., tumors, trauma, stroke) Metabolic disturbances (e.g., hypoglycemia, electrolyte imbalances) Infections (e.g., meningitis, encephalitis) Drug or alcohol withdrawal Genetic factors  Answer 2: Seizure: A single, sudden, and uncontrolled electrical disturbance in the brain, which can result in changes in behavior, movements, or consciousness. Epilepsy: A chronic neurological condition characterized by recurrent, unprovoked seizures. Ahmed’s EEG findings and seizure episode support the diagnosis of epilepsy. Answer 3 : Protect the patient from injury (e.g., clear the area, place padding under the head). Do not restrain the patient or place objects in their mouth. Turn the patient onto their side to maintain an open airway and prevent aspiration. Time the duration of the seizure. Monitor for postictal symptoms (e.g., confusion, fatigue). Document the characteristics of the seizure (e.g., movements, duration, triggers).  Answer 4: Medication adherence: Emphasize the importance of taking antiepileptic medication regularly to reduce the risk of seizures. Seizure triggers: Avoid potential triggers like sleep deprivation, stress, flashing lights, or alcohol. Safety precautions: For example, avoid swimming alone or engaging in activities like climbing without supervision. Emergency response: Teach the family how to respond if Ahmed has another seizure, including when to seek emergency care (e.g., if the seizure lasts longer than 5 minutes or if multiple seizures occur without recovery). Follow-up care: Stress the importance of regular visits to a neurologist and periodic testing (e.g., EEG, blood levels of medication). Answer 5: Common side effects include drowsiness, dizziness, irritability, and fatigue. Less common but serious side effects can include mood changes, depression, or suicidal thoughts. Nurses should educate Ahmed to report any unusual symptoms to his healthcare provider promptly.  Answer 6: Assessment: Monitor for seizure activity, neurological status, and side effects of medication. Interventions: Administer antiepileptic medication as prescribed, provide a safe environment, and ensure Ahmed has emotional support. Education: Teach Ahmed and his family about epilepsy, medication use, and safety measures. Discharge planning: Arrange follow-up appointments with a neurologist and provide resources for support groups or counseling if needed. Drug Action Common Side Effects Nursing Considerations Modulates neurotransmitter Monitor mood changes, educate about Levetiracet Drowsiness, dizziness, release by binding to potential drowsiness, and emphasize am fatigue, irritability synaptic vesicle adherence to dosing schedule. protein SV2A Stabilizes neuronal Gingival hyperplasia, Monitor therapeutic levels (10-20 mcg/mL), membranes by Phenytoin nystagmus, rash, assess oral hygiene, and watch for toxicity reducing sodium dizziness, ataxia symptoms. influx Increases GABA Nausea, tremor, weight Monitor liver function tests, educate about Valproic availability and blocks gain, hair loss, avoiding alcohol, and observe for signs of Acid sodium and calcium hepatotoxicity, pancreatitis. channels pancreatitis Blocks sodium Drowsiness, dizziness, Monitor for signs of bone marrow Carbamaze channels to reduce blurred vision, rash, suppression, assess for rash (Stevens- pine neuronal excitability blood dyscrasias Johnson Syndrome), and check CBC. Inhibits sodium Rash, dizziness, Titrate dose slowly to reduce rash risk, Lamotrigin channels and reduces headache, blurred educate about reporting skin changes, and e glutamate release vision monitor mood. Modulates calcium channels to decrease Drowsiness, dizziness, Educate about sedation effects, monitor for Gabapentin excitatory fatigue, peripheral swelling, and assess for misuse potential (off- neurotransmitter edema label uses). release Thank you