Seizure Disorders:

Seizures/Epilepsy and Status Epilepticus - 2 Nursing CEs

Course Objectives

Upon completion of this course, the student will be able to:

• Describe what the pathophysiology of a seizure
• Differentiate between a Grand Mal and Petit Mal seizure
• List two causes of seizures
• Explain the difference between Phase 1 and Phase 2 video EEG monitoring
• State two additional modes of diagnosing seizure disorders
• Discuss two Anticonvulsant medications and their aim for treatment
• List three common side effects of Anticonvulsant medication
• Describe immediate care of a seizing patient in the acute setting
• List three important assessment and documentation considerations post seizure
• State three initial interventions when someone is in Status Epilepticus

What is a seizure?

A seizure is a sudden disruption of the brain's normal electrical activity accompanied by altered consciousness and/or other neurological and behavioral manifestations. Epilepsy is a condition characterized by recurrent seizures with symptoms that vary from a momentary lapse of attention to severe convulsions.

Types of seizures

Grand-Mal Seizures – This type of seizure presents as a generalized tonic-clonic seizure that often begins with a loud cry before the person having the seizure loses consciousness and falls to the ground. The muscles become rigid for about 30 seconds during the tonic phase of the seizure and alternately contract and relax during the clonic phase, which lasts 30-60 seconds. The skin sometimes acquires a bluish tint and the person may bite his tongue, lose bowel or bladder control, or have trouble breathing.

A grand mal seizure lasts between two and five minutes, and the person may be confused or have trouble talking when he regains consciousness. The period of time immediately following a seizure is known as the “post-ictal” state.

Primary generalized seizures – This is a primary generalized seizure that occurs when electrical discharges begin in both halves (hemispheres) of the brain at the same time. Primary generalized seizures are more likely to be major motor attacks than to be absence seizures.

Absence (petit mal) seizures – This type of seizure generally begin at about the age of four, and usually stops by the time the child becomes an adolescent. Petit Mal seizures usually begin with a brief loss of consciousness and last between one and 10 seconds. A person having a petit mal seizure becomes very quiet and may blink, stare blankly, roll his eyes, or move his lips. A petit mal seizure lasts 15-20 seconds. When it ends, the person who had the seizure resumes whatever he was doing before the seizure began. He will not remember the seizure and may not realize that anything unusual has happened. Untreated, petit mal seizures can recur as many as 100 times a day and may progress to grand mal seizures.

Myoclonic seizures – This type of seizure is characterized by brief, involuntary spasms of the tongue or muscles of the face, arms, or legs. Myoclonic seizures are most likely to occur first thing in the morning.

Simple Partial seizures – This type of seizure does not spread from the focal area where they arise. Symptoms are determined by what part of the brain is affected. The patient usually remains conscious during the seizure and can later describe it in detail.

Complex Partial seizures – This type of seizures presents with a distinctive smell, taste, or other unusual sensation (aura) may signal the start of a complex partial seizure. Complex partial seizures start as simple partial seizures, but move beyond the focal area and cause loss of consciousness. Complex partial seizures can become major motor seizures. Although a person having a complex partial seizure may not seem to be unconscious, he does not know what is happening and may behave inappropriately. He will not remember the seizure, but may seem confused or intoxicated for a few minutes after it ends.

Causes of Seizures?

Most cases of epilepsy are of unknown origin. Sometimes, however, a genetic basis is indicated, and other cases may be traceable to birth trauma, lead poisoning, congenital brain infection, head injury, alcohol or drug addiction, or the effects of organ disease. Known causes of Epilepsy and other seizure disorders can include:

• Brain tumor (Lesions that occupy space)
• Cerebral hypoxia (breath holding, carbon monoxide poisoning, anesthesia)
• Cerebrovascular accident (infarct or hemorrhage)
• Convulsive or toxic agents (lead, alcohol, picrotoxin, strychnine)
• Alcohol and drug use withdrawal
• Eclampsia
• Hormone changes during pregnancy and menstruation
• Exogenous factors (sound, light, cutaneous stimulation)
• Fever (especially in children
• Head injury (highest incidence is found in young adults)
• Heat stroke
• Infection (acute or chronic)
• Metabolic disturbances (diabetes mellitus, electrolyte imbalances)
• Withdrawal from, or hereditary intolerance of, alcohol
• Kidney failure (uremia, phenylketonuria) 
• Degenerative disorders (senile dementia) 

Note: Triggers for the seizures also vary widely. Among the factors that can bring on seizures are certain chemicals or foods, sleep deprivation, stress, flashing lights, menstruation, some prescription and over-the-counter medications, and possibly oral contraceptives.

Diagnosis:

• The first step in diagnosing a seizure disorder is to determine whether or not the patient “did” or “did not” actually have a seizure. To do this the following is required:
• Past medial history
• Careful history of clinical presentation and events related to alleged seizure
• General physical and neurological examination
• Diagnostic testing which include:
• Computed Tomography (CT Scan)
• Magnetic Resonance Imaging (MRI)
• Electroencephalogram (EEG)
• Video EEG (Phase 1 or Phase 2)
• Single Proton Emission Computerized Tomography (SPECT, can localize not diagnose) 

Note: Not all patients will require all of the above-mentioned tests, the objective is to determine whether systemic or CNS processes in part are seizure activity.

Video EEG Monitoring:

Video EEG Monitoring can be used to determine if a patient is a candidate for surgical treatment. The purpose of this monitoring is to capture a seizure on EEG. Video monitoring has two phases; Phase 1 includes continuous telemetry (waveform) monitoring as well as video and audio monitoring. If Phase 1 monitoring is inconclusive, Phase 2 monitoring which is telemetry and video monitoring with stereotatically implanted depth electrodes or subdural grid electrodes can be done.

When Phase 2 monitoring is required, MRI is used to select targets for depth electrodes and to verify the location of these electrodes within specific anatomical sites in the brain.

If an isolated epileptogenic region can be identified, a resective surgery to remove that particular portion of the brain can be performed.  Most patients undergo a standard anterior temporal lobectomy, but an increasing number are receiving extratemporal cortical resections.

According to the UCLA Seizure Disorder Center, 70% –80% of patients can expect to become free from disabling seizures following temporal lobe surgery, while all but 3%-5% percent experience a worthwhile improvement in seizure frequency, with marked improvement in the quality of their daily lives.

How are seizure disorders treated?

Once a seizure disorder of Epilepsy has been diagnosed the first line of treatment is usually medication therapy that focuses on reducing the frequency and severity of the seizures. The goal is to find a medication that will control the seizures but not produce side effects. Because many people will continue on medication for many years, selection of a good first drug is extremely important.

Anticonvulsants and other prescription agents are usually prescribed based on the type of seizures that the patient is experiencing.  The following medications are frequently prescribed:

• Letvetiracetam (Keppra) - is an anticonvulsant that is a synaptic vesicle protein. It is believed to impede nerve conduction along the nerve synapses and therefore inhibit seizure activity.
• Benzodiazepines – which are a family of drugs, used to treat insomnia, anxiety, panic attacks, muscle spasms, and seizure disorders. Examples include:
  • Clonazepam (Klonipin)
  • Clorazepate (Tranxene)
  • Diazepam (Valium)
• Phenytoin (Dilantin) – a synthetic drug that is classified as a hydantoin. It is used for the treatment of simple partial, complex partial and generalized tonic-clonic seizures. Phenytoin blocks post-tetanic potentiation by influencing synaptic transmission through voltage sensitive sodium channels.
• Carbamazepine (Tegretol) – used as a first line agent for the treatment of simple partial, complex partial and generalized tonic-clonic seizures. The mechanism of action is depression of transmission via the nucleus ventralis anterior thalamus, which acts to decrease the spread of seizure discharge.
• Lamotrigine (Lamictal) – used when seizures are focal in onset, tonic-clonic, atypical absence and/or myoclonic in nature.
• Valproate (Depakote) – used for the management of myoclonic, tonic, atonic, absence and generalized tonic-clonic seizures especially with patients with one or more type of generalized seizure.
• Phenobarbital (Luminal) – Once a mainstay in the treatment of seizures (especially status epilepticus), Phenobarbital is now being replaced by other anticonvulsants but can still be used for the treatment of generalized seizures except for absence and partial seizures. 

Side Effects of Anticonvulsants:

The following are mild side effects that are experienced while taking anticonvulsants.  Often, these side effects will go away as the patient gets used to the medication or can be resolved by adjusting the medication dose. 

• Visual disturbances
• Lightheadedness
• Balance problems
• Confusion
• Mild gastrointestinal dysfunction
• Headaches
• More serious side effects that may require the discontinuation of the drug include:
• Rash
• Easy bleeding (bruising)
• Jaundice (and other symptoms of blood or liver problems) 

Note: Some antiepileptic drugs will require routine monitoring of blood counts and liver function, so that any problems caused by the drugs, however rare, can be caught early.

Diet:

In addition to anticonvulsant medication, a ketogenic diet is a dietary approach based on the observation that ketosis (increased blood levels of ketones) is associated with the reduction of seizures. Ketosis can be produced by a diet high in fat and very low in carbohydrates and protein.

Surgical Intervention:

If Video EEG has isolated the origin of seizure activity, surgery can be pursued (if all other medical management has proven ineffective). Surgical options for treatment of seizures include cortical excision (lobectomy) or if scar tissue or other focal epileptogenic areas exist a lesionectomy can be done. The most common surgical areas include:

• Temporal Lobectomy (the most common site of seizure focus localization with a mortality rate of less then 1%)
• Frontal Lobectomy (removal of part of the frontal lobe)
• Hemispherectomy (removal of ½ of the brain)
• Corpus Callostomy (splitting of the two hemispheres of the brain) 

Complications of Surgical intervention include:

• Infection
• Hydrocephalus
• Cerebral edema
• Cerebral ischemia
• Hematoma
• Hemiparesis/Hemiplegia
• Aphasia
• Visual field deficits
• Higher level functioning disturbances (cognition, memory, concentration)
• Psychosocial impairment (family interpersonal dynamics, self-esteem) 

Placement of a Vagus Nerve Stimulator (VNS):

A VNS is an implantable device that is used to decrease seizure frequency. In some cases it eliminates seizure activity altogether. It is a surgically implanted device that is placed in the chest wall (similar to a pacemaker), with a wire that is threaded to the Vagus nerve in the neck. Once in place the Vagus Nerve Stimulator is programmed (using a magnet), to stimulate the Vagus nerve at pre-set intervals. Patients are sent home with a magnet as well to trigger the device at the onset of a seizure. 

Note: The actual mechanism of action with a Vagus Nerve Stimulator for preventing seizures is actually uncertain

Nursing care and management of seizures in the acute setting:

Before (and During) Seizure Care: 

• If the patient is seated when a major seizure occurs, ease them to the floor
• Provide privacy if possible
• If patient experiences an aura, have them lie down to prevent injury
• Remove eyeglasses and loosen restrictive clothing
• Do not try to force anything into the mouth
• Guide the movements to prevent injuries (do not restrain patient)
• Stay with the patient throughout the seizure to ensure safety
• Time the seizure (seizure events often seem much longer then they really are)
• Verbalize events as they happen to assist with more accurate recall later
• If not already available have someone retrieve O2 and suction 

Post Seizure Care: 

• Position patient on their side to facilitate drainage of secretions
• Provide adequate ventilation by maintaining a patent airway
• Suction secretions if necessary to prevent aspiration
• Allow the patient to sleep post seizure
• On awakening, orient patient to what has occurred 

Nursing Assessment/Documentation Post Seizure (consider the following when organizing information and documentation regarding a seizure):

• Was the seizure witnessed from the start?
• Were there any warning signs?
• Where did the seizure begin and how did it proceed?
• What type of body movement was noted?
• Where their pupil changes or was there conjugate gaze deviation?
• Was the patient unconscious throughout the seizure?
• Was there urinary incontinence?
• What was the person’s behavior before and after the seizure?
• Was there any weakness or paralysis of the extremities post seizure?
• Were there any injuries noted?
• Did the patient sleep (post-ictal) after the seizure and for how long? 

Note: These observations should be noted in narrative fashion in the nurse’s notes or placed on a separate seizure activity sheet if one is available at your facility. All nursing interventions such as positioning , suction, O2 and physician notification must also be documented.

Nursing care and management for Status Epilepticus in the acute setting (defined as seizures lasting at least 5minutes or two or more seizures in a row without complete recovery in between)

Initial  Nursing Management:

• ABC’s of life support
• Position patient to avoid aspiration or inadequate oxygenation
• If possible as soft oral airway can be placed (again do not force teeth apart)
• Suction and O2 must be available
• Monitor respiratory function with ongoing pulse oximetry
• IV access should be secured
• Frequent monitoring of neuro exam and vital signs
• Monitor ABG’s (profound metabolic acidosis can occur during seizures)
• Monitor Glucose (hyperglycemia followed by hypoglycemia is common)
• Treat hyperthermia (occurs often with status epilepticus) aggressively 

Anticonvulsant therapy for management of Status Epilipticus:

The following drug therapy regimen assumes that the previous administered drug was not successful in terminating the seizures.

• Time 0-3 minutes: Lorazepam (Ativan) 4mg-8mg IVP (2mg/min)
• Time 4-23 minutes: Phenytoin (Dilantin) 20mg/kg (about 1 gm) in NS at (50mg/min)
• Time 22-33 minutes: Phenytoin (Dilantin) additional dose 5-10mg/kg
• Time 37-58 minutes: Phenobarbital 20mg/kg IV (50-75mg/min)
• Time 58-68 minutes: Phenobarbital additional dose 5-10mg/kg 

Note: If patient remains in Status Epilepticus despite the above drug therapy regimen, consider anesthesia with Midazolam or Propofol.

Note: Patient must be in the Intensive Care Unit for Anticonvulsant therapy for Status Epilepticus.

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