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Epilepsy and Seizures
John Miller
Epilepsy
 Genetic, acquired or idiopathic (70%)
 4th most common neurological disorder in U.S.
 Over 75, 10% experience seizures, 3% have epilepsy
 Pathophysiology
o Impulses not controlled
o Seizure occurs when threshold is lowered.
 Triggers
 Music, flashing lights, odors
 Fatigue, hypoglycemia, fever, alcohol, constipation,
hyperventilation, menstruation
o Oxygen and glucose are rapidly used up.
 Hypoxemia
 Lactic acidosis
 Both cause brain tissue destruction.
Other causes of seizures
 Intracranial tumor
 Head injuries
 CVA and arteriosclerosis
 Arteriovenous malformations
 Meningitis
 Alcohol or barbiturate ingestion or withdrawal
Types of Seizures
 Partial (focal)
o Partial seizures with no loss of consciousness
o Complex partial seizure
 Generalized
o Absence (petit mal)
o Myoclonic
o Clonic
o Tonic
o Tonic-clonic (gran mal)
o Atonic
 Status epilepticus
 Pseudoseizures (not actually seizures but mimic them)
o Do not repeat same activity each time
o Mental health problems.
Epilepsy society: Seizure Types Videos
https://www.epilepsysociety.org.uk/seizure-types-videos#.VzfAr5ErJnJ
Epilepsy Foundation of Delaware: Types of Seizures
http://www.efde.org/types-of-seizures/
Epilepsy - Types of Seizures https://youtu.be/otuaPazecDo
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Partial (focal, local) seizures with no loss of consciousness
 Subtypes
o Motor
 Starts in upper arm.
 Involuntary movement spreads throughout arm and to same side face
and lower extremity.
 Known as Jacksonian march.
o Sensory
 Numbness or tingling in affected area (parietal focus)
 Bright or flashing lights (opposite side of focus in occipital area)
 Aphasia problems (temporal focus)
o Autonomic
 GI sensations, pallor, sweating flushing, piloerection, pupil dilation,
tachycardia, tachypnea
o Psychic (temporal lobe)
 Aura
 Sensation that localizes the seizure.
 Strange smell, noise, sensation, feeling of rising up or welling up in
epigastric region, visual, déjà vu.
Temporal Lobe Epilepsy Clinical Presentation
http://emedicine.medscape.com/article/1184509-clinical
Complex partial seizure
 Subtypes
o With automatisms
 Purposeless repetitive activity
 Lip smacking, chewing, patting part of body, picking at clothes
while in a dream-like state.
 Inappropriate or antisocial behavior
o Think client is mentally disturbed.
 Last 2-3 minutes usually.
 Client is unaware during, may be confused or drowsy postictally (after
seizure).
o Evolving into generalized seizure
 Starts in one part, then spreads, loses consciousness.
Complex Partial Seizures Clinical Presentation, Emedicine,
http://emedicine.medscape.com/article/1183962-clinical
Generalized seizures
 Lose consciousness
 Types
o Absence
 Childhood, brief loss of consciousness, may progress to tonic-clonic.
o Myoclonic
 Single or multiple muscle groups, causing fall.
o Tonic-clonic
o Atonic
 Loss of muscle tone
Absence Seizures, hummingbird678, http://youtu.be/9HiKwTm755o
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Tonic-clonic
 Formerly known as gran mal.
 Aura may be present.
 Sudden loss of consciousness
 Tonic phase
o Stiffening of all muscles
o Fall, cry
o Respirations cease, cyanosis
o Breathes deeply or sighs at end.
o Pupils fixed, dilated
Clonic phase
 Rhythmic (jerking) contraction and relaxation of all body muscles
 Incontinent, bite tongue and mouth area
 Entire seizure lasts 2-5 minutes
 Postictal (sleepy) period for 30 minutes to several hours
 Amnesia of seizure
 May be nauseated, stiff, sore.
 Fatigue, depression, confusion, headache may follow postictal period
 Associated injuries
My Tonic Clonic/Grand Mal Seizure, bigfrohead55, http://youtu.be/Nds2U4CzvC4
Tonic Clonic Seizure October 11/2014 5:30pm https://youtu.be/aZYgwLlAKAQ
Generalized Tonic-Clonic Seizure https://youtu.be/q4bIyIS0eT4
Diagnostic tests
 Often
o Electroencephalogram (EEG)
 Occasionally
o CT, MRI, PET, SPECT scanning
EEG
 Finds the focus and identify the specific type of seizure
 Used in OR during carotid surgery, brain death criteria.
 Ambulatory EEG with Holter monitor at home.
 May videotape seizure.
 Baseline taken at rest, then hyperventilation, sleeping, or flickering lights may be used.
 Preparation
o Wash hair.
o No stimulants (coffee, tea, alcohol, cola, cigarettes), sedatives, antidepressants,
anticonvulsants for 1-2 days prior.
o May want minimal sleep before test.
o Anxiety may interfere with results.
 Postprocedure care
o Resume diet, medications.
o Shampoo and acetone to remove gel from hair
Intro to EEG https://youtu.be/1ovv6lmPHSI
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Assessment During a seizure
 Level of consciousness (brain area of seizure focus)
 Activity before seizure (precipitating factors)
 Location of seizure starting on body (brain area of seizure focus)
 Epileptic cry at start (tonic phase of generalized tonic-clonic)
 Automatisms (examples: repetitive eye flutter, chewing, lip smacking, swallowing)
(complex, partial, and absence types)
 Length of time
 Changes in activities (example: tonic to clonic)
 Both sides or just one (brain area of seizure focus)
 Head turning or eyes looking (brain area of seizure focus, head turns away from focus)
 Pupillary reactions (autonomic nervous system)
 Fall and injuries (hit head: assess for head injury)
 Foaming or frothing at mouth; Urinary or bowel incontinence (usually tonic-clonic)
Management: Prevent injury
 Maintain airway
o Side lying position, tongue can obstruct (but will not swallow).
 Oxygen
 Pillow or folded blanket under head, without flexing the neck: Protect flailing arms and
legs with padding but do not forcibly restrain.
 Suction if needed, do not force oral airway in.
 Call ambulance if seizure longer than five minutes, a second seizure occurs rapidly,
respiratory difficulty, pregnant.
Management: Eliminate factors precipitating seizure
 Antiseizure (anticonvulsant) medications
o Block initiation or spread of seizures.
o First line drug choices
 Phenytoin or fosphenytoin
 Carbamazepine
 Lamotrigine
 Valproic acid
o Other drugs: diazepam, lorazepam, phenobarbital, gabapentin
General medication side effects
 Therapy is individualized for the patient.
 General side effects
o Fatigue, weight gain, dizziness
 General adverse effects
o Allergies, extreme fatigue, staggering, slurring of speech
o Monitor liver functions for toxicity.
 Suicidal behaviors
 Serum levels checked of the drug, particularly in elderly
 Discontinue medications, one at a time, after at least -3years of being seizure free.
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Phenytoin anticonvulsant drug therapy
 Sodium channel blocker, anticonvulsant
 Monitor serum level, 10-20 is normal.
o Phenytoin dose is adjusted for low serum albumin or chronic renal failure because
the active portion of the drug is unbound to protein, not the entire serum level.
 Phenytoin correction calculator,
http://clincalc.com/phenytoin/correction.aspx
 Use: Generalized tonic-clonic, partial seizures
 Enteral feedings protocol
o Enteral feedings interfere with absorption.
o Turn off pump hour before and hour after dose.
o Flush with 60 ml water prior to and after dose.
o If dose is more than 400 mg, divide into two doses per day.
Management of Drug-Nutrient Interaction Between Phenytoin Suspension and Continuous
Enteral Feedings, FHS Provider Orders
https://www.chifranciscan.org/uploadedFiles/For_Physicians/Provider_Orders/30400626_FHS_I
P_MANAGEMENT_IF_DRUG_NUTRIENT_INTERACTION_BETWEEN_PHENYTOIN_SUSPENSION_AND_
CONTINUOUS_ENTERAL_FEEDINGS_626_2014.pdf
Phenytoin adverse effects
 Respiratory depression
 CV: Heart block, heart failure, shock
 Skin
o Gingival hyperplasia
 Swollen, tender gums
 Reduced by brushing, massaging, and flossing 2-3 times daily.
o Purple glove syndrome
 CNS: Sedation, nystagmus, ataxia, diplopia, impaired cognition
 Osteoporosis
 Hirsutism
 Hyponatremia (SIADH effect)
 Avoid in pregnancy
Phenytoin interactions
o Phenytoin reduces these drug’s therapeutic effect: Warfarin, glucocorticoids,
oral contraceptives
o Increases therapeutic effect of phenytoin: Valproic acid, cimetidine, diazepam
o Decreases therapeutic effect of phenytoin: Carbamazepine, phenobarbital,
alcohol
o Increases CNS depression, additive effect: Barbiturates, alcohol, opioids
Drug-Induced Gingival Hyperplasia http://emedicine.medscape.com/article/1076264overview
Nursing considerations for phenytoin intravenous administration
 Incompatible with most solutions, use NS before and after, use filter.
 Never mix with dextrose solution which can cause crystals to precipitate. Use NS.
 Administer slowly, no more than 50 mg per minute.
 Monitor BP, HR, ECG.
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Intravenous Dilution Guidelines for Phenytoin
http://www.globalrph.com/phenytoin_dilution.htm
Fosphenytoin
 Form of phenytoin that is safer to give intravenously.
 Use status epilepticus and other short term situations.
 Administration time is less than phenytoin: 150 mg/min.
 Adverse effects are similar to phenytoin but reduced.
 Most common adverse effect is pruritus.
Phenobarbital
 Anticonvulsant
 Use: Generalized tonic-clonic, partial seizures
 Adverse effects
o CNS depression and excitement: Drowsiness, confusion, anxiety, irritability,
hyperactivity
o Avoid in pregnancy
 Interaction
o Phenobarbital reduces these drug’s therapeutic effect: Warfarin, digoxin, oral
contraceptives
o Increases therapeutic effect of phenobarbital: Valproic acid, disulfiram, opioids,
alcohol
Carbamazepine
 Anticonvulsant
 Use: Generalized tonic-clonic, partial seizures
 Adverse effects
o CNS: Nystagmus, diplopia, vertigo, staggering gait, headache
o Hem: Bone marrow depression (leukopenia, anemia, thrombocytopenia)
o CV: SIADH, CHF
o Skin: Stevens-Johnson syndrome
o Pregnancy risk D
 Interaction
o Carbamazepine decreases therapeutic effect of these drugs: Warfarin, oral
contraceptives.
o Increases therapeutic effect of carbamazepine: Grapefruit juice
o Decreases therapeutic effect of carbamazepine: Phenytoin, phenobarbital
Gabapentin
 Anticonvulsant
 Use: Partial seizures
 Adverse effects
o CNS: Somnolence, dizziness, ataxia, fatigue, nystagmus
o CV: Peripheral edema
 Interactions
o Do not take 1 hour before or 2 hours after antacids.
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Lamotrigine
 Anticonvulsant
 Use: Generalized tonic-clonic, partial, absence, myoclonic seizures
 Adverse effects
o CNS: Dizziness, somnolence, aphasia, diplopia, blurred vision, headache,
depression, suicidal
o GI: N&V
o Skin: Rash, Stevens-Johnson syndrome
o Pregnancy risk C
Valproic acid
 Use: Generalized tonic-clonic, partial, absence, myoclonic seizures
 Adverse effects
o CNS: Decreased LOC due to ammonia level
o GI: N&V, indigestion, pancreatitis
o Liver: Hepatitis
o Hem: Thrombocytopenia
o Pregnancy risk D
 Interactions
o Increases therapeutic levels of valproic acid: Phenytoin, phenobarbital
Diet therapy
 Ketogenic diet
o High fat, low carbohydrate diet mimics fasting.
o calories/kg weight, 1-2 grams protein/kg.
o Fats at 3 or 4 grams per gram of carbs and protein,90% of calories from fat
 Modified Atkins diet (MAD)
o No fluid, protein, or calorie restriction
o Fats encouraged
o Less carbohydrate (15-20 grams/day)
 Low glycemic index treatment (LGIT)
o -60 gm carbohydrate/day, with low glycemic index (focusing on how fast
glucose is raised)
o % of calories from fat
Dietary therapies http://www.epilepsy.com/learn/treating-seizures-and-epilepsy/dietarytherapies
Surgical management
 Removal of corpus callosum, temporal or parietal lobe, or cortex of a hemisphere.
 Vagal nerve stimulator implantation
o Pacemaker like device implanted in neck and attached to vagus nerve and
causes interference with the seizure electrical activity.
 Responsive neuro stimulation
Vagus Nerve Stimulation (VNS), EpilepsyFoundation, http://youtu.be/PdlqfdlSoT4
VAGAL NERVE STIMULATION
https://youtu.be/T_W5WNgyR6M?list=PLdVvae0BQcKwOcvbYG2FcLr7rVWuLt9Bo
Neuropace http://www.neuropace.com/the-rns-system/
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Electrical Stimulation of the Brain to Treat Epilepsy
https://youtu.be/43ExCfh4onQ?list=PLdVvae0BQcKwOcvbYG2FcLr7rVWuLt9Bo
Other interventions
 Risk for injury
o Seizure precautions
 Padded bed rails
 Falls risk precautions
 IV line, suction, oxygen ready
 Risk for impaired adjustment
o Activities
 Driving
 Driving permitted after seizure free for 3-6 months, depending on
the state residing in.
 Swimming
 Heights
 Fire
 Power tools
o Poor eating and sleeping can decrease seizure threshold.
o Flickering lights or images can precipitate seizures.
o Employment difficulties, prejudices
o Embarrassment, poor self image, anger, depression to deal with.
DRIVING AND THE LAW, http://www.epilepsy.com/driving-laws/2008876
Ineffective health maintenance
 Medications
o Consult with MD before using OTC medications.
o Avoid alcohol
 Reduces seizure threshold.
 Seizure medications also metabolized by liver.
Epilepsy is much more than seizures https://youtu.be/6dLCSn86UTI
Medical Marijuana and Epilepsy
http://www.epilepsy.com/learn/treating-seizures-and-epilepsy/other-treatmentapproaches/medical-marijuana-and-epilepsy
Seizure First Aid
 Stay with person.
 Time the seizure and remember characteristics.
 Prevent injury by moving objects out of the way.
 Make the person as comfortable as possible. Help them to the floor. Support head to
prevent injury. Do not forcibly hold person down.
 Keep onlookers away.
 Make sure breathing is okay. Do not give water, pills or food unless person is fully awake.
 Call for emergency help
o If seizure is 5 minutes or longer or one right after another without awakening
o Breathing is difficult
o Is in water or if injured
o If person requests
 Stay with person until they recover and reassure.
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Seizure First Aid
http://www.epilepsy.com/learn/treating-seizures-and-epilepsy/seizure-first-aid
Status epilepticus
 Medical emergency
o Continuous seizures or seizures in rapid succession without regaining
consciousness
o Seizures more than 5 minutes.
 Assessment
o Labs: electrolytes, CBC, tox screen, anticonvulsant drug levels, ABG
o Chest x-ray, CT/MRI, blood cultures, LP
Interventions for Status Epilepticus
 Establish and maintain airway, intubation and ventilator.
 Large vein IV access
 ml of 50% dextrose; 100 mg thiamine
 IV diazepam or lorazepam (4 mg/10 minutes)
 IV fosphenytoin, may want higher therapeutic levels, such as 22-25 (phenytoin) .
 IV phenobarbital if seizures continue.
 General anesthesia (induced coma) if above drugs not successful.
 ECG, EEG monitoring; Urinary catheter and NG
 Otherwise similar to seizure treatment.
Status Epilepticus, Emedicine, http://emedicine.medscape.com/article/1164462-overview