1/31/2009. Paroxysmal, uncontrolled electrical discharge of neurons in brain interrupting normal function

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1 Paroxysmal, uncontrolled electrical discharge of neurons in brain interrupting normal function In epilepsy abnormal neurons undergo spontaneous firing Cause of abnormal firing is unclear Firing spreads to adjacent or distant areas of the brain If activity involves whole brain, generalized seizure occurs Often symptom of underlying illness May accompany other disorders or occur spontaneously without apparent cause Seizures resulting from metabolic disturbances are not considered epilepsy Metabolic Disturbances Acidosis Electrolyte imbalances Hypoglycemia Hypoxemia Alcohol or barbiturate withdrawal Dehydration or water intoxication Role of heredity in seizure disorders is difficult to determine Some families carry predisposition in the form of low threshold to seizure-producing stimuli Trauma Disease High fever 1

2 Condition in which a person has spontaneously recurring seizures caused by underlying chronic condition Higher incidence in first year of life and in elderly 75% of seizure disorders are considered idiopathic Web.nsf/web/All+About+Epilepsy+- Determined by site of electrical disturbance Divided into two major classes: Generalized and partial May progress through several phases Prodromal phase precede seizure with signs or activity Aural phase with sensory warning Ictal phase with full seizure Postictal phase with rest and recovery Characterized by bilateral synchronous epileptic discharges in brain from seizure onset No warning or aura as entire brain affected Loss of consciousness from seconds to minutes Tonic-clonic: Web.nsf/web/All+About+Epilepsy+- Caused by focal irritations Begin in specific region of cortex May be confined to one side of brain and remain partial or focal in nature May involve entire brain, cumulating in tonic- clonic 2

3 Most common complex partial seizure involves lip smacking and automatisms Called psychomotor seizures No memory of activity during seizure Psychosensory symptoms that may occur during complex partial seizures Distortions of visual or auditory sensations Vertigo Alterations in memory Alterations in thought processes Partial Seizures Web.nsf/web/All+About+Epilepsy+- Status epilepticus State of constant seizure seizures recur in rapid succession without return to consciousness between seizures Neurologic emergency Can involve any type of seizure Causes the brain to use more energy than supplied Neurons become exhausted and cease to function Permanent brain damage can result Tonic-clonic most dangerous can cause ventilatory insufficiency, hypoxemia, cardiac arrhythmias, hyperthermia, and acidosis Status epilepticus p treated with IV benzodiazepines lorazepam (Ativan); diazepam (Valium) Observe and Document Tonic-clonic: loss of consciousness, muscle tightening then jerking, dilated pupils, hyperventilation then apnea, postictal somnolence Absence: Altered consciousness, minor facial motor activity Simple: Aura; focal sensory, motor, cognitive, or emotional phenomena; unilateral marching ; motor seizure Complex: Altered consciousness with inappropriate behaviors, amnesia of event 3

4 Accurate, comprehensive description of seizures with patient s health history EEG sf/web/all+about+epilepsy+- CBC, serum chemistries, liver and kidney function, UA to rule out metabolic disorders CT or MRI in new onset seizure to rule out structural lesion Drug therapy aimed at prevention Stabilize nerve cell membranes and prevent spread of epileptic discharge 70% of patients controlled with medication Monitor drug serum levels Primary drugs for treatment of generalized tonic-clonic and partial seizures Older: phenytoin (Dilantin) carbamazepine (Tegretol), phenobarbital bit divalproex (Depakote) Primary drugs for treatment of generalized tonic-clonic and partial seizures Newer: gabapentin (Neurontin) lamotrigine i (Lamictal) topiramate (Topamax) tiagabine (Gabitril) levetiracetam (Keppra) zonisamide (Zonegran) Used when exhausted all other treatments and patient continues to have seizures Benefits of surgery are reduction or cessation in frequency of seizures Surgical removal of epileptic focus or to prevent spread of epileptic activity in brain Removal of one lobe (usually temporal), cortex, or separation of two hemispheres (corpus callosotomy) 4

5 Vagal nerve stimulation gives intermittent stimulation to brain to reduce frequency and intensity of seizures Biofeedback to control seizures teaches patient t to maintain i a certain brainwave frequency that is refractory to seizure activity Subjective PMH: Birth defects or injuries at birth, Anoxic episodes, CNS trauma, Tumors, Metabolic disorders, Alcoholism, Hepatic or renal failure, seizure history Compliance with antiseizure medications, barbiturate or alcohol withdrawal, cocaine &/or amphetamines Headaches, aura, mood or behavioral changes before seizure Objective: Metabolic acidosis or alkalosis, Hyperkalemia, Hypoglycemia, Dehydration, Water intoxication Bitten tongue, soft-tissue damage, cyanosis Abnormal respiratory rate Apnea (ictal), Absent or abnormal breath sounds, Airway occlusion Hypertension, tachy/bradycardia Bowel/urinary incontinence, excessive salivation Weakness, paralysis, ataxia (postictal) Abnormal CT, MRI, EEG Ineffective breathing pattern Risk for injury Ineffective coping Ineffective therapeutic regimen management Observation and treatment of seizure Maintain patent airway, support head, turn to side, loosen constrictive clothing, ease to floor May require suctioning or oxygen after seizure. If status consider blow by oxygen Administer benzodiazepine 5

6 Be free from injury during seizure Interventions Remove harmful objects from the environment during acute phase. Padded side rails Keep suction, ambu bag, oral or nasopharyngeal airway at bedside to maintain airway and oxygenation if needed Be free from injury during seizure Remain with patient during seizure and protect from injury Record seizure characteristics and body parts involved, motor activity, and seizure progression Monitor postictal period; duration and characteristics Wearing helmet if risk for head injury General health habits (diet, exercise) Assist to identify events or situations precipitating seizures and avoidance if possible Instruct to avoid excessive alcohol, fatigue, and loss of sleep Instruct on importance of adherence to medication, not to adjust dose without physician Keep regular appointments Teach family members emergency management Emotional support and identification of coping mechanisms Medical alert bracelets Referrals to agencies and organizations No injury Verbalization of knowledge of potential injury Acceptance of disorder Acknowledgement seizure has occurred Therapeutic drug levels Compliance with medications 6

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