Seizure

Seizure

1. Diagnostics

   • Electroencephalogram (EEG)- 24hrs
     • may not have EEG abonoral 
   • Comprehensive assessment
   • Magnetoencephalography (greater sensitivity)
   • CBC, metabolic chemistry
   • Liver, kidney function , UA
   • CT or MRI r/o structural Lesion
   • Cerebral angiography, PET scan, MRA

2. Clinical Manifestations

   • Generalized
     • Tonic clonic
       • Tonic 10-20s, clonic 30-40s, excessive salivation, tongue/cheek  biting, Cyanosis- "fall to ground"  * post ictal - muscle soreness, fatigue, pt. may sleep for hours, may not feel normal for hours or days, Nop memory of seizure  
       • Preceded by aura!- this is generalized secondarily
       • Second generalized- Todd's Paralysis (focal weakness)
     • clonic Seizure
       • begin with loss of consciouness and sudden loss of muscle tone, limb jerking, hyperventilation, eye roll back, froth at mouth  
     • Atonic
       • Sudden loss of muscle tone, consciousness returns by the time they hit the ground
     • Myclonic
       • forceful enough to cause fall 
       • Excessive jerking
     • Tonic
       • sudden increase tone, incontinence, breathing cessation, cyanosis, fixed dilated pupils, fall 
     • Absence Seizure
       • Typical
         • children rarely beyond adolescent, cease with maturity or develope into another type, percipitation of flashlights & hyperventilation 
         • Staring spells "daydreaming"
         • percipitated by hyperventilation & lights
         • 3hz per second EEG spike & wave pattern
         • often unnoticed, may be 100x a day, eyelid fluttering, automatisms
       • Atypical
         • Staring spells with other S&S
         • Brief warning
         • Peculiar behavior durning
         • EEG greater or less than 3Hz spike & wave pattern
         • confusion after
         • Longer lasting & loss of postural tone
   • Focal
     • Complex
       • Display strange behaviors, Lip smacking, automatisms- repetitive movement, retrograde amnesia- not daydreaming that is how you differentiate 
     • Simple
       • sudden and unexplaibable feelings, may hear,taste, feel or see things that are not real, psychic symptoms, recurrent muscle contractions, abnormal sensation of hallucinations, Tachycardia, flushing hypotension/hypertension
   • psychogenic
     • Pseudoseizure, Use video EEG 
   • Febrile
     • child transient disorder 
     • Antipyretics
       • acetaminophen, ibuprofen 
     • NO tepid Baths
     • Protect from injury
     • rectal diazepam/diazempam gel (second seizure likely)
   • Phases of seizure
     • (1) Prodromal - signs precede seizure (2) aural- sensory warning  (3) Ictal- active  (4) postictal- recovery after seizure (muscle aches, headache, confusion)

3. Interventions

   • Pharmacotherapy
     • Absence & Myoclonic
       • ethosuzimide, divaleproex, clonazepam , 
     • Tonic clonic & focal
       • phenytoin- peeling rash, Hyperplasia of gums, hirutism in young adults common.  carbamezapine, phenobarbitol, divalproex, primid
     • Broad spectrum
       • gabapentin, lamotrigene, toprimate, tigabine, levitarectam, zonisamide 
     • weened off seizure free 2-5yrs do not stop abruptly , fall rsisk , monitor dizzyness/drowsiness
       • common side effeect- diplopia, drowsiness, ataxia, mental slowing
       • dose missed wait for next dose
       • Toxicity- nystagmus, hand- eye coordination, cognitive functionaing and general alertness
     • Pregabalin
     • Status Epilepticus
       • #1 lorezapam & diazempam
       • follow by long acting
       • intubated, EEG continuous
       • children may need general anasthesia
     • OLDER age & drugs
       • monitor Liver function on phyentoin
       • Phenabarbitol, carbmazepine, primidone effects cognitiion
       • Safer for older
         • gabapentin, levatricetam, oxcarbmazepine, lamotrigene 
   • Nursing management
   • Surgery
     • (1) no satisfaction with drugs (2) define electroclinical syndrome- need to which point (focal)  (3) confirmed epilepsy 
     • anterior temporal lobe resection
   • Vagal nerve stimulation
     • not candidate for surgery alternative
     • Teach pt. to avoid MRIs, microwaves,
     • adverse- cough, hoarseness, dyspnea & tingling at the neck
   • Ketogenic diet/biogenic feedback
     • high fat, low carbohydrate
     • if the pt. has anticoagulant then teach to watch for bleeding
   • Immediate interventions
     • Padded side rails (do not restrain)
     • protect from injury
     • Maintain patent airway/ensure ABC's
     • Establish IV
     • Loosen clothing

4. Complications

   • Status Epilepticus & Tonic- clonic status elipeticus (most dangerous)
     • EMERGENCY 
     • Lorazempam & Diazempam IV bolus
   • Subclinical Seizure
     • sedation (without external signs) 
   • SUDP
     • Sudden unexplainable death of epilepsy 
   • Psychologic - driving sanctions, eployment limitations, & social stigma
   • Severe injury/Death

5. Chapter 59 Chronic Neurologic Problem p. 1419

6. Epilepsy- reoccuring seizures (2 or more)

7. Causes

   • Metabolic distrubances
     • acidosis, electrolyte imbalance, hypoglycemia, hypoxia, dehydration/water intoxication, alcohol & barbituate withdrawal 
   • Extracranial seizures outside the brain
     • hypertension, SLE, DM, septecemia 
   • Generalized, focal, febrile
   • Age- determines most common causes
     • Age after 50 - tumor/stroke 20-30- structural lesion, vascular disease, brain tumor  2-20 birth injury, infection, trauma, genetic factors  6months or younger - birth injury, severe cognential birth defect involving the CNS, infection, inborn errors of metabolism 
   • many are idiopathic cause unknown
   • Gliolsis & change in function of astrocytes
   • Genetic may be a factor