EPILEPSY
Seizure: A transient dysfunction
of brain due to an abnormal firing of cerebral neurons, which may or may not
have a clinical manifestation.
OR
Seizures are episodes of abnormal
motor, sensory, autonomic, or psychic activity (or a combination of these) resulting
from sudden excessive discharge from cerebral neurons
EPILEPSY - Definition
The epilepsies are a group of
disorders characterized by chronic recurrent paroxysmal changes in neurologic
function caused by abnormalities in the electrical activity of the brain
OR
Epilepsy is a group of syndromes
characterized by recurring seizures.
Epidemiology
·
Incidence: Developed countries: 40-70 per one
lakh
·
Developing countries: 100-190 per one lakh
·
Prevalence: Developed countries: 4-10 per 10,000
·
Developing countries: 57 per 10,000
·
Partial seizures with or without generalization
is most common.
·
Men affected 1-2.4 times compared to women
Etiology
Primary (idiopathic): Inherited disorder
Secondary- when the cause is known and the epilepsy is a symptom of
another underlying condition.
They are-
·
Birth trauma
·
Asphyxia neonatorum
·
Head injuries
·
Stroke
·
Some infectious diseases (bacterial, viral,
parasitic)
·
Toxicity (carbon monoxide and lead poisoning)
·
Metabolic and nutritional disorders
·
Circulatory problems
·
Fever
·
Drug or alcohol intoxication
·
Brain tumors
·
Abscesses
·
Congenital malformations
·
Complication of pregnancy
Risk factors according to age group
In young adults:
·
Trauma
·
Alcohol withdrawal
·
Illicit drug use
·
Brain tumor
·
Idiopathic causes
Persons older than 35 years
·
Cerebrovascular disease
·
Brain tumor
·
Alcohol withdrawal
·
Metabolic disorders (uremia, electrolyte
imbalance)
·
Alzheimer's disease
·
Neurodegenerative disorders
Revised ILAE (International League Against Epilepsy) Seizure Classification:
1.
PARTIAL
(FOCAL, LOCAL) SEIZURES
a. Simple
partial seizures
b. Complex
partial seizure
c. Partial
seizures evolving to secondary generalized tonic-clonic convulsions (GTC)
2.
GENERALIZED
SEIZURES
a. .Absence
seizures
·
Atypical absence/ Typical absence
b. Clonic
seizures
c. Tonic
seizures
d. Tonic-clonic
seizures
e. Atonic
seizures (astatic)
3.
UNCLASSIFIED
EPILEPTIC SEIZURES
Includes all seizures that cannot
be classified because of inadequate or incomplete data and some that defy
classification in hitherto described categories.
This includes some neonatal
seizures, e.g., rhythmic eye movements, chewing, and swimming movements.
CLASSIFICATION
1.Partial seizures
·
Partial seizures are focal in origin and affect
only part of the brain.
·
Caused by focal irritations
·
Manifest with unilateral manifestations that
arise form localized brain involvement
·
Simple/ complex
·
Simple partial- consciousness is not impaired
·
Complex partial- consciousness is impaired
Simple partial seizures
·
Also known as focal motor/ focal sensory/
Jacksonian
·
Simple motor and sensory phenomenon
·
Less than 1 minute
·
Only a finger or hand may shake, or the mouth
may jerk uncontrollably.
·
The person may talk unintelligibly, may be
dizzy, and may experience unusual or unpleasant sights, sounds, odors, or
tastes, but without loss of consciousness
Complex partial seizures
·
Involves variety of behavioral, emotional, affective
and cognitive functions
·
Usually last longer than 1 minute
·
The person either remains motionless or moves
automatically but inappropriately for time and place
·
May experience excessive emotions of fear,
anger, elation, or irritability.
·
Involves some alteration in consciousness or a
confusion
·
Whatever the manifestations, the person does not
remember the episode when it is over.
2. Generalized seizures:
·
Generalized seizures are nonspecific in origin
and affect the entire brain simultaneously.
·
Previously referred to as grand mal seizures,
involve both hemispheres of the brain, causing both sides of the body to react
Tonic clonic seizure-
·
Characterized by loss of consciousness and
falling to the ground if the patient is upright, followed by stiffening of the
body ( tonic phase) for 10-20 seconds and subsequent jerking of the extremities
(clonic phase) for another 30-40 seconds
·
Cyanosis, excessive salivation, Tongue or cheek
biting, Incontinence
·
In the post ictal phase-
o
Muscle soreness, is very tired and may sleep for
several hours
o
Some patients may not feel normal for several
hours or days after seizure
o
The patient has no memory of the seizure
Typical absence seizure / absence
(petit mal) seizure
·
Occurs only in children and rarely continues
beyond adolescence
·
Clinical Features-
·
A brief starting spell that lasts only a few
seconds, so it often occurs unnoticed
·
Brief loss of consciousness
·
When untreated the seizures occur up to 100
times a day
Atypical absence seizure:
·
Characterized by starting spell accompanied by
other signs and symptoms, including brief warning, peculiar behavior during the
seizure or confusion after the seizure
Myoclonic seizure:
Characterized by a sudden, excessive jerk of the body or extremities
·
The jerk may be forceful enough to hurl the
person to the ground
·
Seizures are very brief and may occur in
clusters
Atonic seizures/ drop attack
·
Involves either a tonic episode or a paroxysmal
loss of muscle tone and begin suddenly with the person falling to the ground
·
Consciousness usually returns by the time person
hits the ground
·
Normal activity can be resumed immediately
Phases
l) Prodromal phase-
·
Signs or activity, which precede a seizure
(irritability/ tension)
·
Aural phase- with a sensory warning (some may
experience whereas others may not)
2) Ictal phase- with full seizure
·
Tonic phase- tonic contraction of the voluntary
muscles so that the body stiffens with legs and arms, shrill cry may be heard
·
Clonic phase- characterized by violent rhythmic
muscular contractions accompanied by hyperventilation.
·
The face is contorted, the eyes roll, and there
is excessive salivation with frothing from mouth.
·
Profuse sweating and tachycardia also present.
3) Post ictal phase –
·
It is the period of recovery after the seizure
·
The extremities limp, breathing is quiet, and
pupils (equal/unequal) begins to react to light.
·
On awakening, patients are confused,
disoriented, amnesia of the event, headache, generalized muscle ache and
fatigue, with sleep for several hours.
Pathophysiology
Any
stimulus that causes the cell membrane of the neuron to depolarize
↓
Alteration
in the normal chemical and structural environment of the brain neurons
↓
Astrocytes
or cerebral support cells release glutamate
↓
Triggers
synchronous firing of neurons/ Tendency to spontaneous firing
↓
Firing
spreads by physiological pathways to involve adjacent or distance areas of the
brain
↓
This
activity spreads to involve the whole brain- generalized seizure occurs
Diagnosis
1. History-
·
Birth and Developmental history- events of
pregnancy and childbirth, to seek evidence of preexisting injury.
·
Illnesses or head injuries that may have
affected the brain.
·
Family history
·
Febrile seizures
·
Seizure history -
·
Precipitating factors
·
Seizure description (onset, duration, frequency,
postictal state)
2. Physical and neurologic
evaluations
3. MRI - to detect lesions in the
brain, focal abnormalities, cerebrovascular abnormalities, and cerebral
degenerative changes
4. Electroencephalogram (EEG)
5. Video EEG monitoring: With
noninvasive scalp electrodes or deep invasive electrodes.
6. PET (positron emission
tomography)
7. Single photon emission
computed tomography (SPECT): Is useful for identifying the epileptogenic zone
so that the area in the brain giving rise to seizures can be removed surgically
Medical Management
The management of epilepsy is
individualized to meet the needs of each patient and not just to manage and
prevent seizures.
Management differs from patient
to patient because some forms of epilepsy arise from brain damage and others
are due to altered brain chemistry.
Management of Seizures
·
Initial assessment
o
Airway
o
Breathing
o
Circulation
·
Call for help: Hospital, Neuro, PICU Ask for
more history
·
How long has the patient been seizing?
·
New-onset vs. known seizure disorder
·
Baseline seizure frequency, is this typical or
not?
·
Events leading up to this episode
·
Meds/triggers
·
History of status
·
Consider rapid work-up for underlying etiologies
·
CNS infection
·
Metabolic disease
·
Electrolyte imbalance
·
TBI
·
Drugs, intoxications, poisonings
·
Cerebrovascular event
PHARMACOLOGIC THERAPY
·
Medication therapy controls rather than cures
seizures.
·
Medications are selected on the basis of the
type of seizure being treated and the effectiveness and safety of the
medications
Benzodiazepines
Lorazepam (Ativan)
·
0.05-0.1 mg/kg IV q 10-15 min, max dose 4 mg
·
Less respiratory depression than diazepam, longer
duration of action, slower onset (2 min)
Midazolam (Versed)
·
0.15 mg/kg IV then continuous infusion of 1
mcg/kg/min
·
Other formulations available: IM, buccal,
intranasal, oral, and rectal
·
Short half life, faster onset (l min)
Diazepam (Valium)
·
0.05-0.3 mg/kg IV ql 5-30 min, max dose 10 mg
·
Quick onset (10-20 sec),
·
higher risk of respiratory depression
·
Not considered first line
·
Lower efficacy
·
Increased respiratory depression
Anti-convulsants
Fosphenytoin (Cerebyx)
·
15-20 mg PE/kg IV/IM, may infuse 3 mg/kg/min (max
150 mg/min), max dose 1500 mg PE/24 hours
·
Prodrug of phenytoin which has fewer side
effects
·
Can cause cardiac arrhythmias
·
Avoid for status with myoclonic seizures or
absence seizures
·
Consider alternatives in seizures associated
with illicit drug use
Phenytoin (Dilantin)
·
Not used first line as there are many side
effects
·
Cardiac arrhythmias/hypotension
·
Local pain, venous thrombosis, skin necrosis,
limb ischemia amputation
Barbiturates
Phenobarbital (Luminal)
·
15-20 mg/kg IV/IM may repeat 5 mg/kg IV q15-30
min, max dose 40 mg/kg
·
Prolonged sedation, respiratory depression,
hypotension
·
Generally used after failure of benzodiazepines
and fosphenytoin
Pentobarbital (Nembutal)
·
12 mg/kg IV followed by 5 mg/kg/hr infusion
·
Titrate to EEG inactivity
·
Used for refractory status epilepticus
·
Other agents
Propofol (Diprivan)
·
Rapid onset, short duration of action
·
Mechanism of action is unclear
·
Hypotension, apnea and bradycardia are common
·
Intubation and ventilation are required for the
use of this medication
·
Prolonged use can result in hypertriglyceridemia
and pulmonary edema
·
Associated with fatal acidosis
Other agents
Anti- Epileptic Drugs with some
data to suggest use in refractory SE
Valproic acid (Depakote): not yet
approved for SE, some data to support its use
Topiramate (Topamax): PO only
Levetiracetam (Keppra): adult
data only
SURGICAL MANAGEMENT
Indicated for patients whose
epilepsy results from intracranial tumors, abscess, cysts, or vascular
anomalies.
Excision of the brain in which
the seizures originate without producing significant neurologic deficits
The removal of the area
generating the seizures may produce long-term control and improvement
1.Sectioning of corpus callosum —
2.Hemispherectomy or callosotomy
3.Vagal nerve stimulation-
·
Electrode is placed around the left vagus nerve
in the neck
·
Connected to a battery placed beneath the skin
in the upper chest
·
Device is programmed to deliver intermittent
electrical stimulation to the brain to reduce the frequency & intensity of
seizures
·
Exact mechanism of action is unknown
·
Stimulation may interrupt synchronization of
epileptic brain wave activity
NURSING DIAGNOSES
1. Ineffective breathing pattern
related to neuromuscular impairment.
2. Risk for injury related to
seizure activity
3. Fear related to the
possibility of seizures
4. Ineffective individual coping
related to stresses imposed by epilepsy
5. Ineffective therapeutic
regimen related to lack of knowledge
6. Deficient knowledge related to
epilepsy and its control
NURSING CARE DURING A SEIZURE
·
Provide privacy and protect the patient from
curious on-lookers.
·
Ease the patient to the floor, if possible.
·
Protect the head with a pad to prevent injury
(from striking a hard surface).
·
Remove patients eye glasses and loosen
constrictive clothing.
·
Push aside any furniture that may injure the
patient during the seizure. If the
patient is in bed, remove pillows and raise side rails.
·
If an aura precedes the seizure, insert an oral
airway to reduce the possibility of the tongue or cheek being bitten.
·
Do not attempt to try open jaws that are
clenched in a spasm to insert anything. Broken teeth and injury to the lips and
tongue may result from such an action.
·
No attempt should be made to restrain the
patient during the seizure because muscular contractions are strong and
restraint can produce injury.
·
If possible, place the patient on one side with
head flexed forward, which allows the tongue to fall forward and facilitates
drainage of saliva and mucus.
·
If suction is available, use it if necessary to
clear secretions.
·
Stay with the patient throughout the seizure to
ensure safety.
NURSING CARE AFTER THE SEIZURE
·
Keep the patient on one side to facilitate
drainage of secretions and prevent aspiration.
·
Make sure the airway is patent.
·
Suctioning may be necessary
·
Allow the patient to sleep after the seizure
·
There is usually a period of confusion after a
grand mal seizure. A short apneic period may occur during or immediately after
a generalized seizure. The patient, on awakening, should be reoriented to the
environment.
·
If the patient becomes agitated after a seizure
(postictal), use calm persuasion and gentle restraint.
HOME CARE
·
Take medications daily as prescribed to keep the
drug level constant to prevent seizures.
·
The patient should never discontinue
medications, even when there is no seizure activity.
·
Keep a medication and seizure chart, noting when
medications are taken and any seizure activity,
·
Notify the patient's physician if patient cannot
take medications due to illness.
·
Have antiseizure serum levels checked regularly.
·
Avoid activities that require alertness and
coordination (driving, operating machinery) until after the effects of the
medication have been evaluated.
·
Report signs of toxicity so dosage can be
adjusted. (drowsiness, lethargy, dizziness, difficulty walking, hyperactivity,
confusion, inappropriate sleep, and visual disturbances)
·
Avoid over-the-counter medications unless
approved by the patient's physician.
·
Avoid seizure triggers, such as alcoholic
beverages, electrical shocks, stress, caffeine, constipation, fever,
hyperventilation, hypoglycemia.
·
Carry a medical alert bracelet or identification
card specifying the name of the patient's antiseizure medication and physician.
·
Take showers rather than tub baths to avoid
drowning if seizure occurs; never swim alone.
·
Exercise in moderation in a
temperature-controlled environment to avoid excessive heat. Develop regular sleep patterns to minimize
fatigue and insomnia.
Complication:
Physical
·
Status epilepticus
·
Permanent brain damage
·
Ventilatory insufficiency
·
Hypoxemia
·
Cardiac dysrhythmias
·
Systemic acidosis
·
Severe injury/ trauma & death
Psychosocial
·
Effect on the patients lifestyle
·
Ineffective coping
·
Social stigma
STATUS EPILEPTICUS
Status epilepticus (acute
prolonged seizure activity) is a series of generalized seizures that occur
without full recovery of consciousness between attacks
The term has been broadened to
include continuous clinical or electrical seizures lasting at least 30 minutes,
even without impairment of consciousness.
It is considered a medical
emergency.
Factors that precipitate status epilepticus
·
Withdrawal of ant seizure medication
·
Fever
·
Concurrent infection
·
Withdrawal from alcohol, sedatives or other
drugs
·
There is some respiratory arrest at the height
of each seizure that produces venous congestion and hypoxia of the braine
·
Repeated episodes of cerebral anoxia and edema
may lead to irreversible and fatal brain damage.
Medical Management
·
Airway and adequate oxygenation
·
If the patient remains unconscious and
unresponsive- endotracheal tube intubation
·
IV- diazepam (Valium), lorazepam (Ativan), or
fosphenytoin (Cerebyx)
·
Other medications (phenytoin, phenobarbital) are
given later to maintain a seizure-free state.
IV line is established, and blood samples are obtained to monitor serum
electrolytes, glucose, and phenytoin levels
·
EEG monitoring
·
Vital signs and neurologic signs are monitored
·
IV infusion of dextrose is given if the seizure
is due to hypoglycemia.
·
If initial treatment is unsuccessful, general
anesthesia with a short-acting barbiturate may be used.
COMMENTS