Seizure disorders and its types, pathophysiology

ppt regarding seizure disorrders

1. Seizure disorders

2. Seizures Seizures are an abnormal, sudden, excessive discharge of electrical activity of the neurons within the brain. Epilepsy : a disorder characterized by chronic seizure activity and indicates brain irritation. Causes: genetic factors, trauma, tumors, circulatory or metabolic disorders, toxicity and infections. Status epilepticus is rapid succession of epileptic spasms without intervals of consciousness; can result in brain damage

3. Seizure Causes changes in : - consciousness, - behavior sensations and / or - muscular activities ( movements), - feelings beyond voluntary control.

4. Pathophysiology/ Etiology Altered Physiology Brain has metabolic needs for oxygen and glucose. Neurons have permeability gradients and voltage gradients affected by changes in the chemical and humoral environment. Changes in the permeability of the cell population (ischemia, hemorrhage) and ion concentration ( Na+, K+) can cause hyperexcitability of neurons. and demonstrate hypersynchrony, producing abnormal discharge of electrical activity.

5. Factors affecting cell permeability can make a person susceptible to seizure. medications, genetic factors, electrolyte imbalances, infections, brain inflammation, injury can lead a person to develop seizures

6. Cellular level Seizures starts with the excitation of susceptible cerebral neurons which leads to synchronous discharges of progressive larger group connected neurons.

7. Tumors, subdural hematoma Metabolic: hypoglycemia, hypocalcemia, hyponatremia Infection: meningitis, encephalitis Encephalopathy: lead poisoning, hepatic Congenital: hydrocephalus Vascular: intracranial hemorrhage Causes of seizures :

8. Neurotransmitters Glutamate – most common excitatory neurotransmitter Gamma – aminobutyric acid ( GABA)- important inhibitory neurotransmitter. An imbalance of excess excitation and decreased inhibition initiates electrical activity Increased activation or decreased inhibition of discharges = results in seizure

9. 4 STAGES OF SEIZURE 1. Prodromal : happens few days or hours prior to seizure S/s : mood changes, agitation, irritability, depression 2. AURA : change of activity few minutes or seconds prior to seizure S/s : olfactory ( smelling of burning wires) - optic ( photosensitivity) - déjà vu, migraine 3. ICTAL : seizure itself S/s : tonic ( stiffness ) , clonic (jerking movements of arms and legs) Priority: airway, suction secretions 4. POST ICTAL: Recovery phase S/s : generalized body weakness, recovery position

10. Types of seizures 1. Generalized Seizure Entire cerebral cortex is involved Initial onset in both hemisphere; affects both sides of the brain Involves loss of consciousness and bilateral motor activity (spasms, stiffening, shaking, muscle contraction or loss of muscle tone)

11. 1. Generalized Seizures 1. Tonic- Clonic ( Grand Mal seizures) Begin with an aura ( may experience abnormal sensations : smell, vertigo, nausea or anxiety). Tonic phase Involves the stiffening or rigidity of the muscles of the arms and legs and usually lasts 10 to 20 seconds followed by loss of consciousness. Clonic phase Consists of hyperventilation and jerking movements affecting the face, extremities and usually lasts about 30 seconds, then jerking movements slow down, body relaxes. May let out a deep sigh and return to normal breathing. Full recovery from the seizure may take several hours.

12. Tonic – clonic seizures After the seizure, person may remain unconscious for several minutes as the brain recovers from seizure activity. May appear to be sleeping or snoring. Gradually person regains awareness may feel confused, exhausted, sad, embarrassed for a few hours. May not remember having a seizure

13. Tonic – clonic

14. 4. Tonic- clonic (Grand mal) Maybe preceded by aura; tonic and clonic phases Tonic phase : Limbs contract and stiffen Pupils dilate and eyes roll up and to one side Glottis closes, causing noise on exhalation May be incontinent; occurs at same time as loss of consciousness Lasts for 20-40 seconds

15. 2. Absence ( Petitmal ) A brief seizure lasts for a few seconds individual may or may not lose consciousness. No loss or change in muscle tone occurs. Seizures may occur several times during a day. The victim appears to be daydreaming. Common in children.

16. 3. Myoclonic May present as a brief generalized jerking or stiffening of extremities . Victim may fall to the ground from the seizure. 4. Atonic or Akinetic (Drop Attacks) Is a sudden momentary loss of muscle tone . Victim may fall to the ground as result of the seizure .

17. 2. Partial sezures Begins in focal / locally ( specific) area of the brain 1. Simple Partial Produces sensory symptoms accompanied by motor symptoms that are localized or confined to a specific area. Does not lose consciousness , client remains conscious, may report an aura. Symptoms confined to one hemisphere 2. Complex Partial ( originate in one are of the brain, affecting consciousness) Is a psychomotor seizure. Temporal lobe most usually involved. Characterized by periods of altered behavior of which client is not aware. Patient losses consciousness for a few seconds.

18. Status epilepticus

19. Status epilepticus generalized grand mal seizures Seizure is prolonged( repetitive without regaining consciousness between attacks) Unresponsive to treatment Brain damage may occur secondary to prolonged hypoxia and exhaustion which can lead to death. CAN RESULT IN DECREASED OXYGEN SUPPLY AND POSSIBLE CARDIAC ARREST.

20. Other type of seizures 1. Febrile seizure Common in 5% under 5 population Nonprogressive Does not result in brain damage Occurs only when fever is rising EEG : normal 2 weeks after seizure

21. 2. Jacksonian Seizure( Focal seizure)- common among clients with brain lesion Aura is present Commonly occur during sleep Begin with tonic contractions of the fingers in the hand that progress into tonic- clonic movements that proceed up the muscles of the left side of the body Grand mal seizure).

22. 3. Psychomotor Seizure- has a psychiatric component (hallucinations and illusions) Aura is present Manifested by confusion, amnesia Patient may commit violent social acts like: going naked in public, running amok. May loss consciousness

23. Medical management ANTICONVULSANTS A. Hydantoin 1. Phenytoin (Dilantin) Often used with phenobarbital for its potentiating effect Inhibits spread of electrical discharge S/E Gum hyperplasia , hirsutism, ataxia, gastric distress, nystagmus, anemia, sedation, bone marrow depression Causes pinkish red to brown discoloration of urine (harmless side effect). Drug is withdrawn gradually to prevent status epilepticus.

24. Clinical manifestations of seizures Related to area of brain involved in the seizure activity Single abnormal sensations Aberrant/ deviating motor activity Altered consciousness/ personality to loss of consciousness Convulsive movements Confusion

25. Diagnostic tests Blood studies : rule out lead poisoning , hypoglycemia, infection, electrolyte imbalances LP: rule out infection Skull X- rays, CT scan & MRI : detects pathologic defects EEG : abnormal wave patterns characteristic of different type of seizures. Npo ( 6- 8 hours) Consent Shampoo head ( to remove grease) No stimulants 24-48 hours before procedure Avoid 3 C’s: caffeine, cola, chocolate

26. Nursing Intervention on Phenytoin Therapy Monitor CBC Monitor Serum drug levels to prevent toxicity (can cause neurologic symptoms from nystagmus to ataxia to coma) . Instruct the client to take anticonvulsant everyday with food or milk ( prevents GI bleeding). Avoid driving or strenuous activity Withdraw the drug gradually Contraindicated in pregnancy : causes fetal anomalies ( cardiac defects, cleft lip and palate)

27. Nursing Intervention on Phenytoin Therapy Maintain serum drug levels Therapeutic serum level: 10-20 mcg/ml More than 20mcq/ ml = toxicity Less than 10mcq/ ml – prone to seizure Ensure adequate nutrition Avoid driving and performing hazardous activities Avoid alcohol and CNS depressant Prevent gum hyperplasia ( overgrowth of gums, too much gum tissue)

28. Anticonvulsant: Phenytoin - IM injection causes tissue irritations - IV infusion causes hypotension and cardiac dysrhythmias injected slowly and directly into a large vein through a large – gauge needle or Intravenous catheter. IV administration should not exceed 50 mg/min in adults. Oral dosage – at first 100mg 3X a day or 300 mg OD

29. Note : if PHENYTOIN is used, it is administered ONLY with NORMAL SALINE and administer it slowly Rationale ; BECAUSE IT PRECIPITATES WHEN MIXED WITH GLUCOSE.

30. 2. Barbiturates Phenobarbital Causes depression of CNS, by acting on GABA-A receptor subunits. Elevates the seizure threshold and inhibits the spread of electrical discharge Grand mal, petit mal, status epilepticus

31. OTHER DRUGS: ( anticonvulsants) Barbiturates ( Barbital) Amobarbital (Amytal)-status epilepticus Mephobarbital (Mebaral)-grand mal, petit mal Phenobarbital (Luminal)-grand mal, petit mal, status epilepticus Primidone (Mysoline)-grand mal, psychomotor seizure WOF : Respiratory depression, barbiturates are CNS depressants.

32. Anticonvulsants : Iminostilbenes : Antiseizure agent Carbamazepine (Tegretol) Adverse effect : agranulocytosis Use for tonic- clonic , bipolar disease, partial seizure, grandma seizures. Benzodiazepines : Sedative medications Diazepam (Valium) administered IV status epilepticus Lorazepam (Ativan) status epilepticus Infusion rate should not exceed 2mg / min.

33. surgery a. Resective surgery: removal of a small portion of the brain. Surgeon cuts out brain tissue from the area where seizures occur ( site of tumor, brain injury/ malformation). To remove the tumor, hematoma, or epileptic focus Temporal lobectomy (removal front part of temporal lobe to treat drug related epilepsy) Extratemporal resection( removes part of the lobe where seizures start. Corpus callosotomy: cutting a band of fibers( corpus callosum) in the brain Hemispherectomy ( removal of diseased half of the brain)

34. COLLABORATIVE MANAGEMENT 1 . Stay with the patient 2. Protect the patient/person from INJURY - PROMOTE SAFETY put up padded side rails if client is STANDING/SITTING - ease him onto the floor with a pillow under the head do not apply restraints Do not insert tongue blade during tonic- clonic movements.

35. 3. Promote patent AIRWAY Turn the client on the side Loosen constricting clothing especially around neck. 4. Note the time and duration of the seizure. 5. Provide privacy

36. Please be reminded! NOTE: Nothing should be force into the mouth because this may occlude the airway. do not insert tongue blade Contrary to popular belief, it is not true that a person having a seizure can swallow his tongue. Do not put anything in the person’s mouth. Efforts to hold the tongue down can injure the teeth or jaw.

37. 6. Note the type , character and progression of the movements during a seizure. Document the characteristics of seizure. Monitor for incontinence . Administer intravenous medications as prescribed to stop the seizure. Monitor behavior following the seizure: State of consciousness Motor ability Speech ability

38. 10. Instruct about client importance of lifelong medications, and need for follow- up determination of medication blood levels. 11. Instruct client to avoid alcohol, excessive stress (can increase susceptibility to seizure),fatigue, and strobe lights . 12. Encourage the client to wear a Medic- Alert bracelet.

39. Seizure management Floor Bed Anticonvulsants

40. Seizure management FlOOR Face on the side Loosen clothing Observe head protection Over pillow/ rolled towel Remove nearby objects Discharge instructions: wear helmet

41. Nursing interventions Maintaining cerebral perfusion Maintain patent airway Provide oxygen inhalation Stress importance of taking medications regularly Monitor therapeutic levels of medications Monitor toxic/ side effects of medications Monitor platelet/ liver function test for drug toxicity

42. Nursing interventions B. Preventing injury Provide safe environment by padding side rails. Place bed in low position Do not restrain during a seizure Do not put anything in patient’s mouth during a seizure to prevent aspiration. Protect patient’s head during a seizure Manage the patient in status epilepticus.

43. Nursing interventions C. Strengthening coping Consult social worker for community resources for vocational rehabilitation, counselors, support groups. Teach stress reduction techniques Initiate appropriate consultation of behaviors related to personality disorders .

44. Evaluation Taking medications as ordered, drug level within normal range No injuries observed Uses stress management techniques.

45. WHEN DO SEIZURES USUALLY OCCUR? Anything that interrupts the normal connections bet nerve cells in the brain. Includes high fever, high or low blood sugar, alcohol, drug withdrawal, brain concussion.