Epilepsy 101 Aileen Rodriguez ARNP-BC Comprehensive Epilepsy Program Aileen.Rodriguez@mch.com
About Me: 2006 BSN from UM School of Nursing Started working @ MCH (3 south nights)july 2006 Worked Days shift on 3 south for 2 years Worked 8 months with Neurosurgery Team: multidisciplinary clinical coordinator August of 2011 Graduated from University of Phoenix with my MSN December of 2011 Started Clinical Educator for 3 south September of 2014 started as the RN epilepsy Coordinator and started the ARNP PEDS Post Masters November 2016- Hired as ARNP for the Comprehensive Epilepsy Program
Statistics 2.3 million Americans lives with Epilepsy 50 million world-wide live with Epilepsy 181,000 new cases diagnosed each year 10% of the population will experience a seizure in their lifetime 3% will develop epilepsy by age 75 1 in every 4 of all newly-diagnosed people will have persistent seizures despite treatment
What is Epilepsy? SEIZURE A sudden alteration in behavior or motor function caused by an electrical discharge from the brain Certification: Seizure (convulsion) is defined as paroxysmal involuntary disturbance of brain function that may be manifested as an impairment of loss of consciousness, abnormal motor activity, behavioral abnormalities, sensory disturbances, or autonomic dysfunction Individual attacks are called seizures Repeated attacks are called seizure disorders or epilepsy
Causes
Spectrum
Clinical Findings I. Partial seizures caused by abnormal electric discharges, no interruption in consciousness with simple seizures; usually impaired with complex seizures a. Simple partial 1. Consciousness usually maintained 2. Abnormal movements of an arm or leg (Jacksonian march); orderly sequence of movements 3. Olfactory or auditory sensations 4. Tachycardia, diaphoresis, flushing, pallor, nausea 5. Anger, fear or hallucinations 6. Length of seizure approx. 10 20 seconds
Clinical Findings b. Complex partial- originates in a circumscribed portion of one cerebral hemisphere with impaired level of consciousness 1. May begin with a simple partial seizure and progress to brief unconscious period 2. Or child may demonstrate altered states of consciousness; may have no other symptoms 3. An aura consisting of visual or auditory sensations (unpleasant feelings), nausea, vomiting, weakness is present in 1/3 of child with simple and complex seizure 4. Automatisms are common feature (picking at bed linens, clothing, 5. Rubbing objects repetitively, nondirective walking, running 6. Length of seizure 1 2 minutes
COMPLEX PARTIAL SEIZURES
Clinical Findings II. Generalized seizures bilateral cerebral cortical involvement always accompanied by some degree of unconsciousness A. Absence (petit mal- old name) 1. Brief period of unconsciousness (lasting seconds) with cessation of any motor activity; 2. transient staring episode may be only manifestation 3. Automatisms such as lip smacking or eye blinking (Atypical absent) 4. May occur several times a day 5. Often mistaken as learning disability, inattention or behavioral problem 6. Uncommon prior to age 5 years and are more common in girls
GENERALIZED ABSENCE SEIZURE
Seizures- cont. Generalized tonic-clonic (grand mal) 1. Most common seizure; may be preceded by an aura 2. Tonic phase characterized by rigidity, extension of extremities and fixed jaw; cessation of respirations; nonreactive dilated pupils; usually lasts less than 1 minute. 3. Clonic phase follows tonic phase and is characterized by rhythmic jerking of all extremities; expiratory grunts may be evident in addition to bowel and bladder incontinence; usually lasts several minutes, but may vary 4. Postictal phase- semiconscious initially and may sleep for a few minutes to several hours a. May be associated with visual and speech difficulties b. May awaken with severe headache, fatigue and generalized muscle soreness 5. May be precipitated by infections, fatigue, fever, stress, drugs
Seizures cont- III. Myoclonic- generalized brief abrupt muscle contractions with duration of a few seconds; seizures may be clustered with several in one day or can be seizure free for weeks IV. Atonic- sudden loss of muscle tone with possible loss of consciousness; may cause child to drop to the floor ( drop attacks ) V. Infantile spasms rare disorder with onset during first year of life 1. Brief flexion of neck, trunk and/or legs lasting for a few seconds 2. Peak age of onset between ages 4 and 12 months 3. May experience hundreds each day 4. Prognosis for normal development is poor; 75 to 90% are abnormal 5. May mimic colic VI. Febrile seizures 1. Occur in the context of extremes in temperature (fever going up fast or coming down fast) 2. Normal till age 6-7 3. Not treated with AED
MYOCLONIC SEIZURES
Seizure Treatments Medications Surgery Ketogenic Diet Vagus Nerve Stimulator
Medications PARTIAL Carbamazepine Oxcarbazepine Lamotragine Valproate Fycompa Gabapentin Zonisamide Levatracetam (IV/PO) Lacosamide (IV/PO) Tegretol GENERALIZED Valproate (IV/PO) Lamotrigine Topiramate Levatracetam (IV/PO) Zonisamide Topiramate Rafinamide Sabril Clobazam Steroids (ACTH)
Rescue AED Ativan (Lorazepam): 0.05-0.2 mg/kg IV Valium (Diazepam): 0.1-0.3 mg/ kg IV Diastat (Diazepam Rectal): see chart Versed (ICU): 0.1-0.3 mg/ kg IV (Drip) Intranasal Buccal Clonazepam
Failed 2 medications Less than 10% chance another medication will work Need to looks for alternative treatments
Seizure Treatments Medications Surgery Ketogenic Diet Vagus Nerve Stimulator
Phase I admission MRI, fmri, DTI, 3D MRI VEEG- to capture seizures Neuropsych testing (if testable) Pet/Spect TMS Genetics work up Elective admission 5 days (Monday to Friday) Surgery Work up
MRI
fmri
DTI
VEEG Used to capture seizures and brain activity simultaneously Usually stop medications- risk for status Having a working IV (check it often) Seizure logs: Give them out on admission Pick them up every day @ 6am Do not make it up* Patient needs to be on camera Ask techs to move camera if needed Keep wires out of the way (tripping hazard) Get child life/ medical library to help with activities
Neuropsych testing Dr. Brandon Korman Dr. Reshma Naidoo
NM ext:4379 No glucose in fluids Limit sugar intake night before Dex stick before scan No seizure during exam Lasts about 20-30 minutes First part with EEG leads PET Scan
Spect scan Must be NPO Must be injected within seconds of onset of seizure
No prep- no NPO EEG off Magnet stimulation for language and motor mapping Done in the BI TMS
Discharged Friday After Discharge? 1-2 weeks after discharge (Wednesday 12pm BI conference room) Team meeting (Epilepsy Conference) https://www.hemr.org/hemr/notes/59587/show MD gets back to family Then scheduled to meet with neurosurgery
Surgical options:
Invasive 1 or 2 stage surgery Minimally Invasive Surgery
Laser Ablation
Surgery for Epilepsy Hemispherectomy Lobectomy Corpus Callosotomy
VNS
Reminders: Seizure logs Test patients during seizures- Oxygen is not always needed/ nor pupil checks Ask them questions Ask them to squeeze your hand Keep families up to date Be proactive Explain tests Keep kids on camera Keep cables out of the way Get child life and music therapy involved
Community Referrals Epilepsy Foundation http://www.efof.org/ Epilepsy.com http://www.epilepsy.com/ Camp Boggy Creek http://www.boggycreek.org/
Questions