Seizures Seizures & Status Epilepticus Seizures are episodes of disturbed brain activity that cause changes in attention or behavior. Donna Lindsay, MN RN, CNS-BC, CCRN, CNRN Neuroscience Clinical Nurse Specialist Stroke Program Coordinator Hennepin County Medical Center Causes Cerebral Abnormalities or Injury Anoxic brain injury Traumatic brain injury (including birth trauma) Infectious disorders (meningitis, encephalitis, abscesses) Disorders of cerebral circulation (arteriovenous malformation) Hemorrhagic or ischemic stroke Brain Tumors (most likely to cause seizures when located in the temporal lobe) Causes Biochemical or Metabolic (often reversible) Electrolyte abnormalities hyponatremia, hypocalcemia, hypomagnesemia Hypoglycemia Drug overdose/alcohol Toxicity Vitamin Deficiency Metabolic Disorders Heavy Metal Poisoning Chemical/Substance Withdrawal Fever Sleep deprivation (especially in combination with stimulant abuse) Unknown/Ideopathic 70% of cases Types of Seizures Partial/Focal Seizures Simple Complex Tonic-Clonic Absence Non-convulsive (sub-clinical) Partial/Focal Seizures Simple Partial Continuous or repeated focal motor seizures, focal sensory symptoms or cognitive symptoms without impaired consciousness Examples: 1
Partial/Focal Seizures Complex Partial Continuous or repeated focal motor movements, focal sensory symptoms and cognitive symptoms with impaired consciousness. Automatisms common Partial Seizures Muscle contraction/relaxation (clonic activity) -- common Affects one side of the body (hand, arm, leg, part of the face, etc.) Abnormal head movements Forced turning of the head Partial Seizures Staring spells, with or without complex, repetitive movements (such as picking at clothes) -- these are called automatisms and include: Abnormal mouth movements Lip smacking Behaviors that seem to be a habit Chewing/swallowing without cause Tonic-clonic (aka grand mal ) seizures Tonic - characterized by rigidity and extension of arms and legs, jaw snaps shut, respirations may decrease or cease, lasts up to 1 minute Clonic - Begins suddenly and ends gradually, characterized by quick, bilateral jerking movements, autonomic symptoms, usually < 1 minute Other signs & symptoms Biting tongue and/or cheek Clenching of jaw Difficulty breathing or apnea leading to hypoxia Incontinence After seizure common to have post-ictal phase Sleepiness Drowsiness Headache At risk for impaired swallowing until fully awake Non-convulsive (sub-clinical) seizures fairly common and should be ruled out in patients with an unexplained alteration in consciousness 2
Absence (aka petit mal ) seizures Most common in children ages 6-12 40% end at adolescence 50% are supplanted by tonic-clonic seizures 10% persist into adulthood Sudden momentary loss of consciousness Less than 15 seconds Automatisms may be seen Treatments Medication - 75-80% controlled by Antiepileptic Drugs (AEDs) levetiracetam, phenytoin, fosphenytoin, valproic acid most commonly used in ED/ICU Typically administer loading dose initially Cardiac monitoring required for phenytoin/fosphenytoin load due to risk of arrhythmias. Severe hypotension also possible with rapid load. Scheduled maintenance doses Serum drug level monitoring required for all except levetiracetam Surgical Treatment For severe and uncontrolled seizures if seizure focus can be identified and removed without devastating functional loss Complications Respiratory Respiratory distress Hypoxia Aspiration Pneumonia Cardiovascular Hypertension Tachycardia or bradycardia Hyperthermia Complications Cerebral or Central Increased metabolic demand Glycolysis Anoxia Cerebral edema Metabolic Metabolic acidosis Rhabdomyolysis Assessment Note signs and symptoms what extremities One sided? Bilateral? Head movements, mouth movements, Autonomic signs (flushing, sweating etc) Incontinence? TIME the seizure Hemodynamics and SpO2 check Nursing Management Patient safety Do not restrain patient Pillow or blanket under head if on the ground and if available Notify MD and administer a benzodiazepine to stop seizure activity if prolonged Recovery position as seizure abates 3
AIRWAY Nursing Management Assure patient has patent airway and if respiratory distress evolves intubation may be necessary Jaw is usually clenched so paralytic often required Most common airway occlusion during seizure is the tongue, turn patient to side or prone to bring tongue forward if needed Do not insert anything into the mouth until required to achieve patent airway Have suction available Nursing Management Post Seizure Assess neuro status frequently Assess airway Ensure fully awake before allowing oral intake to avoid aspiration Collect labs to determine cause and/or check AED level if indicated Theurapeutic drug regimen AEDs Initiate ASAP if new medication Benzodiazapines Diagnostic Tests EEG Head CT Lumbar Puncture Treatment Goals Identify cause of seizure (if any) and treat if reversible Prevent further seizure activity Assess for complications and manage them appropriately Obtain and maintain therapeutic drug levels Status Epilepticus The occurrence of a single unremitting seizure with a duration longer than 5-10 minutes or frequent clinical seizures without an interictal return to the baseline state i.e if pt NPO receive order for IV Patient Education Status Epilepticus 100,000 to 200,000 episodes annually in the United States Estimated mortality rate of 20% Predisposing Factors AED noncompliance or discontinuation Withdrawal syndromes associated with alcohol, barbiturates, baclofen or benzodiazepines Brain tumor, head trauma, ICH, SAH, anoxia, hypoxia or infection Neurosurgery 4
Management ABC Neurological Exam Benzodiazepines AED load and scheduled maintenance doses Diagnostic Tests EEG Head CT MRI Lumbar Puncture Complications Rhabdo Lactic acidosis Aspiration pneumonia Neurogenic pulmonary edema Respiratory failure Neuronal death Can occur after 30 minutes of continuous seizure activity Continuous EEG Monitoring The incidence of seizure activity (convulsive and nonconvulsive) in Neuro Critical Care Units is approximately 20% Indications for continuous EEG Status Epilepticus Convulsive Non-convulsive Unexplained coma/altered LOC/confusion SAH/ICH with limited ability to assess patient Global cerebral anoxia/hypoxia Continuous EEG Monitoring In patients with convulsive status epilepticus who have stopped seizing, studies have shown that 14-20% are still experiencing non-convulsive seizures Continuous EEG is recommended for any patient whose convulsive seizure has stopped but he or she does not regain consciousness quickly Non-convulsive seizures are VERY COMMON during the re-warming phase following therapeutic hypothermia. Continuous EEG monitoring is now considered the standard of practice during rewarming for patients undergoing postcardiac arrest hypothermia Incidence of Non-Convulsive Status Epilepticus Etiology % of pts. with non-convulsive status epilepticus GTC Status Epilepticus 14-20% Confused/Comatose 8-37% SAH 8-13% ICH 13-14% Cerebral Hypoxia/Anoxia 12% Head Trauma 8% CNS Infection 17% Refractory Seizures Seizures that continue regardless of first line anticonvulsants Indicates a grave prognosis ICU management required 5
Refractory Seizures Questions????? Treatment Second AED load and scheduled maintenance doses Phenobarbital, pentobarbital, midazolam or propofol infusions (intubation if not already) Continuous EEG monitoring What type of seizure is commonly referred to as a grand mal seizure? A. Simple partial B. Generalized C. Complex Partial D. Absence All of the following EXCEPT are complications that can occur with seizures A. Aspiration Pneumonia B. Hyperthermia C. Increased Troponin D. Rhabdomylosis True or False? You should restrain your patient if seizure activity occurs? An EEG will provide diagnostic reasoning for why the patient is having seizures A. True B. False 6
Status Epiliepticus has what mortality rate? A. 20% B. 25% C. 35% D. 40% 7