Download Understand why continuous EEG is being requested in certain

4/12/2016
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.
Kathleen Rieke, MD
Chari Ahrenholz
Curt Devos
Seizure description
Basic EEG
ICU monitoring
Inpatient Monitoring
Elective admission for continuous EEG
monitoring
Nursing’s Role
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
•
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)
•
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
Cryptogenic- cause is not known but it is not generalized
▪ Temporal lobe epilepsy, frontal lobe epilepsy, Benign Rolandic Epilepsy
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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
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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
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
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
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
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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
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
25-30 % of hypothermia protocol patients have
nonconvulsive seizures
• cEEG became 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
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
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
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
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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
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
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
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
▪ Eyes closed is a red flag for a NES
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
cEEG is 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 cEEG is
critical to accurate diagnosis
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