Download Seizure Management - Hatzalah of Miami-Dade

Managing Seizures
Tracy Evans, RN, MS, MPH, EMT-P
February 2000
Tracy Evans. Copyright, 2000. All
rights reserved.
Shake, Rattle and Roll
Tracy Evans, RN, MS, MPH, EMT-P
Tracy Evans. Copyright, 2000. All
rights reserved.
February
2000
Seizure
Paroxysmal discharge of neurons that
results in prolonged electrical activity of the
brain
 Abnormal neuron firing
 Interferes with normal brain function

Tracy Evans. Copyright, 2000. All
rights reserved.
Incidence

No statistics on total number of Americans
having seizures annually

4 million Americans have epilepsy
+ males
 + African-Americans

Tracy Evans. Copyright, 2000. All
rights reserved.
Epilepsy

A chronic seizure disorder
Tracy Evans. Copyright, 2000. All
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Anatomy
Tracy Evans. Copyright, 2000. All
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Tracy Evans. Copyright, 2000. All
rights reserved.
Tracy Evans. Copyright, 2000. All
rights reserved.
Causes


Ionic Changes
– pH
– Electrolyte Imbalances
– Hyperventilation

Metabolic Changes
–
–
–
–
Nerve Cell Structural
Changes
–
–
–
–
Hypoxia
Trauma
Tumors
Vascular Insufficiency
Hypoglycemia
Fever
Stress
Fatigue
Tracy Evans. Copyright, 2000. All
rights reserved.
Classification
Partial
 Generalized (Grand Mal)

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Partial
Portion of the brain is effected
 Possible change in mental status
 Classified as Simple or Complex

Tracy Evans. Copyright, 2000. All
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Simple


vs
No change in mental
status
Affect brain activity in
temporal lobe or
limbic system
Complex


Change in mental
status
Affect any area of the
brain
Tracy Evans. Copyright, 2000. All
rights reserved.
Generalized
Change in mental status
 Clinical evidence can range from Absence
to Tonic Clonic

Tracy Evans. Copyright, 2000. All
rights reserved.
Stages of Seizure Activity
Aura
 Prodrome
 Tonic Phase
 Clonic Phase
 Postictal State

Tracy Evans. Copyright, 2000. All
rights reserved.
Caution

Assessment for seizure activity and changes
in activity are crucial

Cessation of tonic clonic activity does not
always indicate cessation of seizure
activity!
– The muscles may be unable to meet metabolic
demands.
Tracy Evans. Copyright, 2000. All
rights reserved.
Status Epilepticus

A seizure lasting more than twice its normal
duration, or

Two or more seizures without a lucid
interval
Tracy Evans. Copyright, 2000. All
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Critical Point

Status Epilepticus is DYNAMIC
Tracy Evans. Copyright, 2000. All
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Incidence of Status Epilepticus

50,000 - 60,000 cases per year
3% pediatric mortality
 10% adult mortality

Tracy Evans. Copyright, 2000. All
rights reserved.
Management of Status
Epilepticus
Recognize this life threatening emergency!
 Protect the patient from injury
 Airway management, O2, Monitor
 IV access, Normal Saline KVO
 Check blood sugar level
 IV Benzodiazepine, per protocol
**This patient may require BVM ventilation.
**Be prepared for cardiac arrest.

Tracy Evans. Copyright, 2000. All
rights reserved.
Febrile Seizures
2-5% of previously healthy children will
have a febrile seizure
 Ages 6 months to 5 years
 Generally self-limiting
 Cool patient with tepid water. Never use
alcohol baths or ice water!

Tracy Evans. Copyright, 2000. All
rights reserved.
Assessment of Seizure Patients
Airway
 Respiratory Effort
 Hemodynamics
 Neurologic Status


Re-evaluate continuously
Tracy Evans. Copyright, 2000. All
rights reserved.
Neurologic Status
AVPU
 Glascow Coma Scale


Neurological Status is a on a continuum
from Awake to Unresponsive
Tracy Evans. Copyright, 2000. All
rights reserved.
EEG

Recording of electric potentials based on
the distributions of waveforms with
different frequencies and amplitudes that
are generated by the cerebral cortex of the
brain
Tracy Evans. Copyright, 2000. All
rights reserved.
Common Antiepileptics
Dilantin ®
 Cerebyx ®
 Tegretol ®
 Depakote ®
 Barbita ®
 Zarontin ®
 Neurontin ®
 Lamictal ®

Tracy Evans. Copyright, 2000. All
rights reserved.
Dilantin® - Phenytoin

Action: Unknown
– Phenytoin is thought to stabilize neuronal membranes
and limit seizure activity by modulation of voltagedependent sodium channels of neurons, inhibition of
calcium flux across neurons, and enhancement of
sodium-potassium ATPase activity in neurons and glial
cells.

Monitor blood levels
Tracy Evans. Copyright, 2000. All
rights reserved.
Cerebyx® - Fosphenytoin

Action: Unknown
–
–
–
–
–


A prodrug of phenytoin
Immediately converts to phenytoin
100% Bioavailability
Less Alkaline
IM/IV
Monitor blood levels
Expensive
Tracy Evans. Copyright, 2000. All
rights reserved.
Tegretol® - Carbamazepine

Action: Unknown
– Thought to stabilize neuronal membranes and
limit seizure activity by either increasing efflux
or decreasing influx of sodium ions across cell
membranes in the motor cortex during
generation of nerve impulses

Monitor blood levels
Tracy Evans. Copyright, 2000. All
rights reserved.
Depakote® - Valproic Acid

Action: Unknown
– Probably inhibits brain levels of gammaaminobutyric acid, which transmits inhibitory
nerve impulses in the CNS

Monitor blood levels
Tracy Evans. Copyright, 2000. All
rights reserved.
Barbita® - Phenobarbital

Action: Unknown
– Probably depresses mono and polysynaptic
transmission in CNS and increases threshold
for seizure activity in the motor cortex

Monitor blood levels
Tracy Evans. Copyright, 2000. All
rights reserved.
Zarontin® - Ethosuxamide

Action: Not clearly defined
– A succinimide derivative that probably
increases seizure threshold.

Monitor blood levels
Tracy Evans. Copyright, 2000. All
rights reserved.
Neurontin® - Gabapentin

Action: Unknown
– Structurally related to gamma-aminobutyric
acid (GABA)
– Does not interact with GABA and isn’t
converted to GABA or a GABA agonist

Monitoring of blood levels is not necessary
Tracy Evans. Copyright, 2000. All
rights reserved.
Lamictal® - Iamotrigine

Action: Unknown
– May cause inhibited release of glutamate and
aspartate (excitatory neurotransmitters) in the
brain. This may occur by way of action at
voltage-sensitive sodium channels

Monitor blood levels
Tracy Evans. Copyright, 2000. All
rights reserved.
Use of Benzodiazepines

In some settings, this is controversial in the
prehospital setting
– Prolonged seizures caused hypoxia and cellular
and neuronal damage and death
– Benzodiazepines can cause respiratory
depression
Tracy Evans. Copyright, 2000. All
rights reserved.
Benzodiazepines
Potentiates the effects of gammaaminobutyric acid (GABA) an inhibitory
neurotransmitter, and depresses the CNS at
the limbic and subcortical levels of the
brain.
 Used for 30 years
 Controls status in 79% of patients
 Can cause respiratory and CNS depression

Tracy Evans. Copyright, 2000. All
rights reserved.
Diazepam




More Lipid soluble
Highly protein bound
Duration 20-30
minutes
Rectal administration
vs
Lorazepam
Less highly protein
bound
 Lower volume of
distribution
 Longer duration of
action 12-24 hours
 Requires cooler
environment but may
be stable for 60 days
 Less respiratory
Tracy Evans. Copyright, 2000. All
rights reserved.depression

Management
Assessment
 Re-Assessment
 Airway
 Respiratory Effort
 Hemodynamics
 Control Seizures

Tracy Evans. Copyright, 2000. All
rights reserved.
Airway Management
Supplemental oxygenation
 BVM assistance
 Prepare for intubation and RSI
 Monitor oxygenation

Tracy Evans. Copyright, 2000. All
rights reserved.