4/12/2016. Seizure description Basic EEG ICU monitoring Inpatient Monitoring Elective admission for continuous EEG monitoring Nursing s Role

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1 Kathleen Rieke, MD Chari Ahrenholz Curt Devos Understand why continuous EEG is being requested in certain patient populations Understand what the EEG can tell us about our patient. Understand nursing role in the treatment of continuous EEG patients. Seizure description Basic EEG ICU monitoring Inpatient Monitoring Elective admission for continuous EEG monitoring Nursing s Role Big burst of electrical activity Normal brain activity is a mixture of on and off signals Seizure is a massive coordinated on signal for everything A seizure by itself is not dangerous to the brain Injury to brain can occur from prolonged or repetitive seizures Metabolic consequences of having seizure can be significant if prolonged Injuries from seizures can occur Seizures may start in one place in the brain (Partial seizure) Seizures may involve the whole brain at the same time (Generalized seizure) Tendency to have unprovoked seizures 1 in 100 people will have a seizure in their life time 1/3 will develop epilepsy Grouped by seizure onset Generalized- starts all over EEG all at once Partial-starts in one place and may or may not spread Categorized by cause Idiopathic- genetic epilepsy which is generalized Juvenile myoclonic epilepsy, absence epilepsy, idiopathic primary generalized epilepsy Symptomatic- seizure with known cause Seizure from stroke or head injury, cerebral palsy, genetic condition like Down s Syndrome Cryptogenic- cause is not known but it is not generalized Temporal lobe epilepsy, frontal lobe epilepsy, Benign Rolandic Epilepsy Multiple unprovoked seizures EEG Abnormal slowing or spikes on the EEG suggest a tendency to have a seizure Normal EEG does not rule out seizures 50% are normal in people with epilepsy MRI Structural abnormality putting you at risk for seizures Most of the time MRI is normal 1

2 Stereotyped events that look similar to one another Seizures are very specific to an individual Most common manifestations Generalized shaking/convulsion Rhythmic jerking of one side of body or whole body Staring with unresponsiveness Unresponsiveness with purposeless behavior like picking at clothing Confusion Normal EEGs have specific frequencies and organization we expect to see Normal brain activity is a coordinated sequence of on/off signals Seizures are a sudden turning on of all the switches with synchronized firing of neurons Routine EEGs are a snapshot in time Done for first time seizure Done for brief evaluation for symptoms that might be seizures like confusion or abnormal movement Last a minimum of 20 minutes up to a few hours Spike of activity that tells us at least a small portion of the brain is able to fire off all at once This means there is a potential for this tissue to produce a seizure Slowing to indicate a portion or the whole brain is not functioning right This information combined with imaging, history and exam allows us to identify patients who may be at risk for seizures 2

3 Comprehensive information More labor intensive and more expensive Allows us to identify seizures that may not be obvious Allows us to identify events that are not epileptic seizures Detect nonconvulsive seizures that clinically appear to be confusion Detect nonconvulsive seizures in comatose or heavily sedated patients Determine if events a patient is experiencing are epileptic or nonepileptic Localize seizures to identify epilepsy surgery candidates Seizure with no outward signs except altered mental status Nonconvulsive status epilepticus-continuous seizure activity or frequent seizures without return to a normal background between seizures (NCSE) Routine EEG will capture 11% of patients in having nonconvulsive seizures ceeg captures NCSE 90% within 24 hours 98% within 48 hours Difficult to differentiate NCSE and Acute encephalopathy without ceeg Prospective studies are on going to help us understand the incidence of NCSE in confused hospital patients We don t yet know the incidence in non-icu patients Risk Factors for development of NCSE Sepsis Renal failure Use of certain medications-tramadol, levofloxacin, cefepime, cyclophosphamide 3

4 Up to 20% of non-cardiac arrest comatose patients in the ICU have NCSE Risk factors for developing NCSE Sepsis Renal failure Brain injury or surgery Early identification and treatment of seizures leads to shorter stays and improved mortality % of hypothermia protocol patients have nonconvulsive seizures ceegbecame a standard part of our hypothermia protocol in 2012 Electrographic seizures are associated with high mortality In most studies patients who had electrographic studies after cardiac arrest were deceased at 30 days We hope to improve mortality by treating seizures aggressively Goal to characterize a person s spells as epileptic or nonepileptic Epileptic seizures are associated with changes on EEG Nonepileptic events (NEE) are not associated with EEG changes May be pseudoseizures (now referred to as nonepileptic seizures) NEE can also be a different medical problem Syncope, narcolepsy, REM behavior disorder, myoclonic jerking from hyperammonemia 20% of Epileptic patients have NEE as well It is important to see all the events as some patient have both epileptic and NES Studies vary on how long it takes to get target events Most patients will have an event within 3 days Patients who have not had an event in five days are unlikely to have a diagnostic study Non-volitional events that may look like seizures Different from malingering which is a conscious choice to fake an illness They are real, just not epileptic Can be as devastating to a person as epileptic seizures Important to be compassionate and understanding May be associated with stress, anxiety, or depression Treated with psychotherapy with or without antidepressants Allows us to stop seizure medication a person may not need Many of these patients have been on medicine for years for presumed seizures For patients with epilepsy and NES we can minimize medicine by not treating NES with additional epilepsy drugs Correct identification can lead to effective treatment 4

5 ceeg is the first step to evaluate intractable epilepsy Identify if all seizures are coming from one spot If so they may be a surgical candidate Refer to a level four epilepsy center for further evaluation If seizures are multifocal then other surgical options may be available like Vagal Nerve Stimulators Assure patient safety during and after the event until patient is back to baseline Accurately assess and document the event so we can match the event to the EEG to determine if the event is epileptic or not Without this information making an accurate diagnosis is extremely difficult Video tells us what patients are doing but if nursing isn t assessing them during and after the event the video by itself isn t all as helpful Evaluate patient during and after seizure Mental status (confusion, aphasia, unresponsiveness) Weakness (arm, leg, generalized) May help localize where seizure started from Movement during seizure Hip thrusting- indicative of NES Jerking or twitching Eyes open or closed during event Eyes are open during epileptic seizures Pupils nonreactive or sluggish Eyes closed is a red flag for a NES Assess breathing, safety first Ask them to remember a color and object purple monkey Assess pupil reactivity Ask them to follow commands like open eyes or squeeze fingers Document what movements or behaviors are seen Assess recall of color and object Assess language including naming and following commands Assess pupils Assess strength of face/arms/legs Looking for focal weakness Assess reflexes After a seizures Babinski reflex should be positive Reflexes may be brisk after a seizure Assess every 5-10 minutes until patient is back to baseline EEG play a valuable role in the care of hospital patients ceegis used for a variety of reasons Reason for evaluation determine when and how long a patient his hooked up for monitoring Early identification of nonconvulsive seizures improves patient outcomes Identifying NES is as important as identifying epileptic seizures Nursing assessment of patients on ceegis critical to accurate diagnosis 5