Epilepsy

Epilepsy, GTCS, stages of gtcs, care of patient with gtcs

1. Epilepsy Evaluator: Presenter: Mr. L Anand Shruti Shirke Asso . Professor M.Sc nursing CON AIIMS BBSR Neurosciences nursing

2. Introduction Seizure: A single (finite) event of abnormal discharge in the brain that results in an abrupt and temporary altered state of cerebral function. Seizure disorder : a term adopted by some clinicians when referring to epilepsy . Although this has led to some confusion, the terms epilepsy and seizure disorder are used interchangeably. Epileptic syndrome: an epileptic disorder characterized by a cluster of signs and symptoms customarily occurring together.

3. The Indian Epilepsy Society (IES) The Indian Epilepsy Society (IES) was constituted and registered With the Registrar of Societies, Govt. of India, Delhi on May 13, 1997. The main objectives of the IES are to: Maintain the highest standard in the ethics and practice for the promoting of prevention, diagnosis, treatment and care of all persons with epilepsy. Promote and encourage research concerning the epilepsies. Improve education, and dissemination of knowledge concerning epilepsy. Maintain a good liaison with the organization of lay people.

4. Terminology Epilepsy: A chronic disorder of abnormal , recurrent , excessive , and self-terminating discharge from neurons. Periods between seizures can vary widely and can be measured in minutes, hours, days, weeks, months, or even years. Clinically , Epilepsy is characterized by recurring seizures accompanied by a disturbance in some type of behavior (i.e., motor, sensory, autonomic, consciousness, or mentation ).

5. Aura Aura is a premonitory sensation or warning experienced at the beginning of a seizure , which the patient remembers. An aura may be a gustatory, visual, auditory, or visceral experience, such as a metallic taste or flashing lights. If a patient has an aura, it usually is the same experience each time.

6. Automatisms Automatisms are more or less coordinated, involuntary motor activities that occur during a state of impaired consciousness either in the course of or after an epileptic seizure, for which the person is usually amnesic. Several different types of automatism have been recognized. Examples of automatisms are lip smacking, chewing, fidgeting, and pacing. Automatisms are often associated with temporal lobe seizures but can also occur with complex partial seizures as well as with other types.

7. Autonomic symptoms Autonomic symptoms are symptoms that occur as a result of stimulation of the autonomic nervous system (e.g., epigastric sensation, pallor, sweating, flushing, piloerection , pupillary dilation).

8. Clonus Clonus is a term used to describe spasms in which a continuous pattern of rigidity and relaxation is repeated . In the second phase of a generalized seizure, called the clonic phase, rhythmic movements are followed by muscle relaxation. In the clonic phase, the process repeats again and again.

9. Ictus & Postictal Ictus refers to an actual seizure ; a seizure may be referred to as an ictal event. Postictal refers to the period immediately after a seizure has occurred.

10. Prodromal & Tonus Prodromal refers to symptoms, such as a headache or feeling of depression, that precede a seizure by hours. Tonus is the degree of tone or contraction present in muscle when it is not undergoing shortening.

11. Todd’s paralysis Todd’s paralysis is a temporary, focal weakness or paralysis following a partial or generalized seizure that can last for up to 24 hours. The deficit can be correlated with an epileptic focus on the motor strip . Temporary neuronal exhaustion is probably the physiologic basis for the deficit.

12. Jacksonian march A  Jacksonian  seizure is a type of focal partial seizure, also known as a simple partial seizure. This  means  the seizure is caused by unusual electrical activity that affects only a small area of the brain. The person maintains awareness during the seizure.  Jacksonian  seizures are also known as a  Jacksonian march .

13. Reflex epilepsy In patients with epilepsy, seizures can be precipitated by various stimuli called triggers. Sometimes the trigger is very specific for a particular person. Common triggers include particular odors, flashing lights, and certain types of music. If a specific stimulus can be identified, then the pattern is called reflex epilepsy

14. Classification

15. Absence seizures Typical absence seizures: Common in children; characterized by brief interruption in consciousness without loss of postural control. Typically, there is an interruption of activity with a momentary lapse of consciousness lasting 3 to 30 sec. If talking, the speech stops or slows; if eating, the hand and mouth stop, and if patient is called, there is no response. During an attack, the eyes may appear vacant, stare, or roll upward; the eyelids may twitch.

16. Absence seizures Seizures occur a few times to hundreds of times per day; person may not be aware of them. Atypical absence seizures: The lapse of consciousness is usually of longer duration and less abrupt in onset; more obvious motor signs.

17. Myoclonic seizures Sporadic jerks that are sudden, brief; contractions that are usually symmetrical. When confined to one area, it may be the face and trunk; one or more extremities; an individual muscle; or a muscle group. Myoclonic jerks are rapidly repetitive or relatively isolated. Common around time of sleep or awakening; must be differentiated from myoclonic jerks of nonepileptic myoclonus.

18. Tonic seizures & Clonic seizures Tonic seizures: Stiffening of the musculature, mostly of the body, but may also involve the arms. Clonic seizures : Repetitive rhythmic clonic movements that are bilateral and symmetric .

19. Atonic seizures Abrupt loss of postural muscle tone; last 1–2 sec. Consciousness is briefly impaired, but usually there is not postictal confusion. Common in children

20. Phases of GTCS Few hours or days less than 1 minute (average of 15 seconds) Last for 1-2 minutes 30 seconds, although it may be longer

21. Phases of GTCS Prodromal Phase : Irritability and tension may precede the seizure by several hours or days. people may or may not have warning signs like aura. Neuronal hyperexcitation spreads to the subcortex , thalamus, and upper brainstem, and consciousness is suddenly lost Tonic phase : There is a major tonic contraction (increased tonus) of the voluntary muscles, the body stiffens with legs and arms extended. If standing, the person falls to the ground. The jaw snaps shut and the tongue may be bitten in the process. The bladder and, less often, the bowel may empty. The pupils dilate and are unresponsive to light. Apnea occurs and lasts for only a few seconds.

22. Phases of GTCS Clonic phase : Inhibitory neurons of the cortex, anterior thalamus, and basal ganglion nuclei become active, intermittently interrupting the tonic seizure discharge with clonic activity. The clonic phase is characterized by violent, rhythmic, muscular contractions accompanied by hyperventilation. The face is contorted, the eyes roll, and there is excessive salivation with frothing from the mouth. Profuse sweating and a tachycardia are common. P ostictal phase : The clonic jerking gradually subsides in frequency and amplitude over a period of about 30 seconds, although it may be longer. The involved cells cease firing

23. Status Epilepticus Status Epilepticus defined as either continuous seizures lasting at least 5 minutes or two or more discrete seizures between which there is incomplete recovery of consciousness . The most common cause of status epilepticus is an abrupt discontinuation of antiepileptic drugs (AEDs). Other causes include withdrawal from alcohol, sedatives, or fever.

24. Status Epilepticus Status epilepticus constitutes a medical emergency associated with significant morbidity and mortality (20%). If not treated aggressively, cardiorespiratory dysfunction, hyperthermia, and metabolic imbalances can develop, leading to cerebral ischemia and neuronal death .

25. Epidemiology Approximately 30% of all epilepsies and about 60% of all childhood epilepsies may have a significant genetic susceptibility. The risk of epilepsy is about 1% from birth through 20 years and 3% for the 70-year and older age group. The prevalence and cumulative incidence of epilepsy and partial seizures increase in the elderly

26. Etiology

27. In adults

28. Pathophysiology of seizures

29. GLUTAMATE ExNT NMDA GABA InNT GABA Ca ++ Ca ++ Ca ++ Calcium influx Cl -- Cl -- Cl -- Chlorine influx Long lasting activation of NMDA, or dysfunctional GABA Receptors leads to too much excitation and too low inhibition.

30. Diagnosis Computed tomography (CT) scan Magnetic resonance imaging (MRI) (two to three times more sensitive than CT scan in identifying potential epileptogenic lesions) EEG • Video-EEG monitoring with either non-invasive scalp electrodes or deep invasive electrodes Possibly a positron emission tomography (PET) scan (limited availability due to high expense) Single proton emission computerized tomography (SPECT) scan (helpful for seizure localization and not diagnosis)

31. Treatment of Epilepsy

32. The approach to a patient with a seizure disorder is multidimensional and comprehensive. It includes:

33. Medical Management

34. Commonly Used AEDs

35. Protocol for the management of SE

36. The following are principles recommended for seizure management: Begin with a single drug, called monotherapy, which is the drug of choice for the particular seizure type. Increase the drug gradually over 3 to 4 weeks until seizure control is achieved, intolerable side effects occur, toxicity develops, or the maximum therapeutic range has been reached. Recognize that many AEDs are CNS depressants and that drowsiness, lethargy, and tiredness are common in the beginning of therapy; however, these symptoms will usually subside in 7 to 10 days.

37. Principles of Drug Therapy : cont.. Because of pharmacokinetics (cited later) and variations in requirements for specific seizure types with the same drug, expect to make individual adjustments in dosage . Some patients may need more or less than the recommended average therapeutic range for a particular drug.

38. Titrate a single drug until maximum benefit is achieved or intolerance or serious side effects occur. If a therapeutic blood concentration has been achieved and seizure control has not been achieved, a second drug may be added. A second drug may be used in combination with the first or replace the first. With replacement, the first drug should be gradually tapered after the second drug has been titrated to the desired dosage. This practice is necessary because the sudden withdrawal of a drug can cause status epilepticus, even though a new drug has been introduced in its place Principles of Drug Therapy: cont..

39. If the patient is seizure free, check drug concentration in blood after 5 to 8 half-lives or a period of 3 to 4 weeks. The drug’s half-life is important because drugs of long duration (phenytoin, phenobarbital) may be taken once daily in some circumstances. Have the patient keep a daily drug diary routinely, but especially when a new drug is introduced. The diary should include dosage and side effects. The diary is helpful in evaluating the effectiveness of the drug therapy Principles of Drug Therapy : cont..

40. Summary of drug therapy Any patient receiving long-term drug therapy should be monitored carefully for the development of side effects or toxicity. Most drugs are metabolized by the liver and excreted by the kidneys. Periodic drug blood levels should be monitored. If anemia or blood dyscrasias are common side effects, a CBC should be done routinely. Folic acid deficiency has also been reported with some AEDs; therefore, folic acid levels should be monitored.

41. Refractory Epilepsy About 1/3 rd of patients with epilepsy do not respond well to treatment with monotherapy. It then becomes necessary to try a combination of drugs to control seizures. Although there are no guidelines for combining drugs, a combination of two first-line drugs (i.e., carbamazepine, phenytoin, valproic acid, lamotrigine) is tried. If this is not effective, adding one of the newer drugs (i.e., gabapentin or topiramate ) is suggested. When seizures cannot be controlled by drug therapy, the condition is called refractory epilepsy and surgery becomes a consideration.

42. Surgical Management M esial temporal lobectomy Lesionectomy Corpus callosotomy Hemispherectomy Vagus nerve stimulation

43. MANAGEMENT OF SEIZURES AND STATUS EPILEPTICUS IN AN ACUTE CARE SETTING

44. Before and During a Seizure If the patient is seated when a major seizure occurs, ease him or her to the floor, if possible. Provide for privacy by pulling the bed curtains or screen or closing the door. If the patient experiences an aura, have him or her lie down to prevent injury that might occur from falling to the floor. Remove patient’s eyeglasses and loosen any constricting clothing. Do not try to force anything into the mouth. Guide the movements to prevent injuries; do not try to restrain the patient. Stay with the patient throughout the seizure to ensure safety.

45. After a Seizure Position the patient on the side to facilitate drainage of secretions. Provide for adequate ventilation by maintaining a patent airway; suctioning may be necessary to prevent aspiration. Allow the patient to sleep after the seizure. On awakening, orient the patient (he or she will probably be amnesic about the event).

46. Nursing Assessment and Documentation The following are several points to consider when organizing information about a seizure: Was the seizure witnessed or not witnessed? Were there any warning signs or was there an aura? Where did the seizure begin and how did it proceed? What type of movement was noted and what parts of the body were involved? Were there any changes in the size of the pupils or was there conjugate gaze deviation? What was the duration of the entire attack and of each phase? Was the patient unconscious throughout the seizure? Was there urinary or bowel incontinence? What was the person’s behavior after the seizure? Was there any weakness or paralysis of the extremities after the seizure? Were there any injuries noted? Did the patient sleep after the seizure? How long?

47. Nursing Management of Status Epilepticus The nurse works as part of a collaborative team in addressing the medical emergency. Goals and responsibilities include: Maintaining a patent airway to ensure adequate ventilation. Suctioning as necessary to prevent obstruction of the airway and possible aspiration Providing oxygen by nasal cannula as ordered Protecting the IV site to allow for continuous access for medication Protecting the patient from injury Providing information to the family

48. Teaching Plan for Persons With Epilepsy or a Seizure Disorder

49. Patient Education

50. Conclusion Seizures are a problem of many. This not only cause physical damage but may also cause emotional problem and social stigma. Mood swings and depression from antiepileptic drugs is also a common issue. Better understanding of epilepsy its pathophysiology, symptoms, phases and its management it essential to bring change and to provide quality comprehensive care.

51. THANKYOU

52. References Browne, T. R., & Holmes, G. L. (2000). Handbook of epilepsy (2nd ed., pp. 1–18). Philadelphia: Lippincott Williams & Wilkins. Lowenstein , D. H. (2005). Seizures and epilepsy. In D. L. Kasper, E. Braunwald , A. S. Fauci , S. L. Hauser, D. L. Longo, & J. L. Jameson (Eds.). Harrison’s principles of internal medicine (16th ed., pp. 2357–2372). New York: McGraw-Hill. Ropper , A. H., & Brown, R. H. (2005). Adams and Victor’s principles of neurology (8th ed., pp. 271–301). New York: McGrawHill . Ropper , A. H., & Brown, R. H. (2005). Adams and Victor’s principles of neurology (8th ed., p. 281). New York: McGraw-Hill. Kotagel , P. (1997). Complex partial seizures with automatisms. In F. Wylie (Ed.). The treatment of epilepsy: Principles and practice (2nd ed., pp. 385–400). Baltimore: Williams & Wilkins. Commission of Classification and Terminology of the International League Against Epilepsy. (1981). Proposal for revised clinical and electroencephalographic classification of epileptic seizures. Epilepsia , 22, 489–501.