TREATMENT OF TYPES OF epilepsy AND SEIZURES.ppt

EPILEPSY MANAGEMENT

1. Epilepsy School Nurses’
Presentation
Lucyna Zawadzki, MD
Meghan Furstenberg-Knauff, BSN, RN, MSN,
FNP-BC, APNP
Kamilee Hobbs BSN, RN

2. Part 2: Treatment Options

3. What are they?
•Medications
–Anti Epileptic Drugs (AEDs)
–IVIG
•Epilepsy Surgery
•Ketogenic Therapy
•VNS

4. Medications
•Making the choice as to what medication to
use for seizure treatment is a difficult
decision.
•Seizures are the result of abnormal electrical
activity. This is the results of an imbalance
between the excitation and inhibition.
•Anti-seizure medications impact the key
players to prevent seizure activity.

5. History of Antiepileptic
Drug Therapy in the U.S.
•1857 –bromides
•1912 –phenobarbital (PB)
•1937 –phenytoin (PHT)
•1944 –trimethadione
•1954 –primidone
•1958 –ACTH
•1960 –ethosuximide (ESM)
•1963 –diazepam
•1974 –carbamazepine (CBZ)
•1975 –clonazepam (CZP)
•1978 –valproate (VPA)
•1993 –felbamate (FBM),
gabapentin (GBP)
•1995 –lamotrigine (LTG)
•1997 –topiramate (TPM), tiagabine
(TGB)
•1999 –levetiracetam (LEV)
•2000 –oxcarbazepine (OXC),
zonisamide (ZNS)
•2005 -pregabalin (PGB)
•2008 –lacosamide (LCM),
rufinamide (RUF)
•2009 –vigabatrin (VGB)
American Epilepsy Society
2011

6. AEDs: Molecular and
Cellular Mechanisms
•Phenytoin (Dilantin, Phenytek),
carbamazepine (Tegretol, Carbatrol)
–Block voltage-dependent sodium
channels
American Epilepsy Society
2011

7. AEDs: Molecular and
Cellular Mechanisms
•barbiturates
–Prolong GABA-mediated
chloride channel openings
–Phenobarbital
•benzodiazepines
–Increase frequency of GABA-
mediated chloride channel
openings
–Clobazepam
–Clobazam (Onfi)
American Epilepsy Society
2011

8. AEDs: Molecular and
Cellular Mechanisms
•felbamate(Felbatol)
–Blocks voltage-dependent
sodium channels
–Modulates NMDA receptor and
GABA receptors
•gabapentin (Neurontin)
–Blocks calcium channels
–Suppressed presynaptic vesicle
release
American Epilepsy Society
2011

9. AEDs: Molecular and
Cellular Mechanisms
•lamotrigine (Lamictal, Lamictal
XR)
–Blocks voltage-dependent sodium
channels
American Epilepsy Society
2011

10. AEDs: Molecular and
Cellular Mechanisms
•Ethosuximide
(Zarontin)
–Blocks low threshold,
“transient” (T-type) calcium
channels in thalamic neurons
•Valproate,
Divalproex Sodium
–May enhance GABA
transmission in specific
circuits
–Blocks voltage-dependent
sodium channels
–Modulates T-type calcium
channels
American Epilepsy Society
2011

11. AEDs: Molecular and
Cellular Mechanisms
•Topiramate (Topamax)
–Blocks voltage-dependent Na
+
channels
–Increases frequency at which
GABA opens Cl
-
channels
–Antagonizes glutamate action
•zonisamide (Zonegran)
–Blocks voltage-dependent sodium
channels and
T-type calcium channels
American Epilepsy Society
2011

12. AEDs: Molecular and
Cellular Mechanisms
•Levetiracetam (Keppra,
Keppra XR)
–Action is unknown, suspect it acts on
GABA
•Oxcarbazepine
(Trileptal, Oxtellar XR)
–Blocks voltage-dependent sodium
channels
–Exerts effect on K
+
channels
American Epilepsy Society
2011

13. AEDs: Molecular and
Cellular Mechanisms
•Lacosamide (Vimpat)
–Enhances slow inactivation of voltage
gated sodium channels
American Epilepsy Society
2011

14. AEDs: Molecular and
Cellular Mechanisms
•rufinamide
–Unclear: Possibly
stabilization of the sodium
channel inactive state
•vigabatrin
–Irreversibly inhibits GABA-
transaminase
American Epilepsy Society
2011

15. •For Generalized seizures:
–Levetiracetam (Keppra)
–Lamotrigine
–Topiramate
–Zonegran
–Valproic Acid
–Ethosuximidate –specifically used for absence seizures
•For Partial seizures:
–Oxcarbazepine

16. IVIG Therapy
•Inflammation is known to cause several
neurological disorders.
•Recently, it is being acknowledged to have a
role in Epilepsy.
•IVIG –Intravenous immunoglobulin –contains
pooled, polyvalent, IgG antibodies that work to
suppress inflammation.
•It’s on the horizon as an effective treatment
for Epilepsy.

17. Medication Alternatives

18. Epilepsy Surgery
Seizure
Epilepsy diagnosis
Medication trials
Imaging for pathology
Medical intractability
Surgical Consideration
Surgical workup
Surgery
American Epilepsy Society
2011

19. Ketogenic Therapy
•This is a rigid, mathematically calculated, doctor-
supervised diet. It can only be attempted under close
medical and dietary supervision.
•Who is a candidate?
–In general, individuals with uncontrolled seizures that have failed
at least two medications for seizure control can be considered
for this therapy.
–Research shows that it is more effective for certain seizures
types. These include infantile spasms, Doose Syndrome, Rett
Syndrome, and tuberous sclerosis complex.

20. Ketogenic Therapy
•The Basics:
–The ketogenic diet is a medical treatment for controlling seizures
by switching the body's primary energy source to fat-based
(ketones) verses sugar-based (glucose).
–We are not sure why this diet is successful.
–The diet can be adapted using table foods or given formula based.
–There are potential side effects associated with the diet, however,
all are treatable and reversible without having to stop the diet.
•They include, lack of weight gain, slightly decreased growth, somewhat high
cholesterol, constipation, kidney stones, and acidosis.
•There are a number of common misunderstandings about
this therapy.
•Additional Resources:
–On the Web -The Charlie Foundation -
www.charliefoundation.org

21. Vagus Nerve Stimulation
•The Basics
–The vagus nerve is one of the primary communication
pathways between the body and the brain.
–This is not drug therapy! VNS Therapy is delivered by a
surgically implanted generator and lead. It's best to think of
it as similar to a pacemaker.
•Side Effects:
–Cough*
–Hoarseness*
–Paraesthesia
–Shortness of Breath
–Vocal Cord Paralysis/weakness
–Infection
–Increased/Improved Mood
–Increased Alertness
–Improved Memory

22. Part 3: Safety

23. During a Seizure
Caring for a child during a seizure is all about safety. The following is
needed of you:
•Keep calm.
•Time the seizure.
•Don't hold the child down or try to stop any movements.
•Clear the area of any hard or sharp objects and loosen ties or anything around the
neck that may make breathing difficult.
•Place something flat and soft under the head.
•Turn the child gently onto one side. This will help keep the airway clear.
•Do not try to force the mouth open with any hard objects or with fingers. A person
having a seizure CANNOT swallow their tongue. Efforts to hold the tongue down can
injure teeth or the jaw.
•Remain with child the entire time.
•The child may be disoriented and confused as they wake from the seizure, be
reassuring during this time.
•Assess for injury and respiratory status.
•If the child is sleepy following the seizure, allow them to rest.
•Nothing to eat or drink until able to swallow.

24. When to Call 911
•When seizures approach 5 minutes in duration or
per patient's seizure action plan (administering
rescue med for the first time).
•If the child has seizures back to back
•If it's the child's first seizure
•If injury is suspected
•If child is pregnant or diabetic
•If child does not return to baseline in an expected
amount of time post seizure activity
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25. Potential Injuries from Seizures
•Immediate: lacerations, bruises, burns, head
trauma, fractures, and drowning/near
drowning.
•Delayed: fever, aspiration pneumonia,
subdural hematomas, and fractures.
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26. Tips for Seizure Observation and
Documentation
•What happened before,
during, and after the
event
•Be detailed
•Include lots of
information from the
start to the end
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27. Seizure Safety
•There are some restrictions that must be in place for a period of time
following a seizure in order to keep the child safe. These restrictions are
in place for 90 days, they include:
–No driving a motor vehicle or operating heavy machinery (this is mandated
by the State of Wisconsin Department of Transportation).
–No high climbing, this means nothing higher then 2 steps off the ground or
the child’s height.
–No swimming in lakes or rivers due to concerns with currents and the worry
that if a seizure occurred the child could be swept away or under.
–If swimming in a pool or soaking in a hot tub, must have an adult in the
water at all times within an arms reach.
–No tub baths. Children should only shower during this period.
•Any individual who is being treated for seizures should avoid sports
where a moment’s inattention could lead to injury these include such
activities as skydiving, bungee-jumping, scuba-diving, or motor racing.
•We strongly encourage Medical Alert use.

28. Home “Rescue” Medications
•We typically prescribe a specific medication to be used when a
child has a prolonged seizure or a cluster of seizure activity (a
series of seizures in a short amount of time) that can be used at
home. This medication is a rescue medication.
•These medications can be administered in a variety of ways.
We typically used two routes, buccal or rectal.
•The medication that is prescribed depends on the type of
seizure a child has and the age of the child.
We prescribed either rectal Diastat or buccal Midazolam.

29. Diastat
•Diastat is a rectal form of diazepam that is used to stop
a seizure.
•It is effective, well tolerated, and side effects such as
changes in breathing are not common.
•Dosing of this medication is dependent on a child’s age
and weight.
•The biggest advantage of giving a medication rectally
during a seizure is that it can be given and absorbed
quickly.
•Education on Diastat administration should be
preformed while inpatient. The drug company provides
a DVD as well as teaching sheets.

30. Midazolam
•Midazolam is a short acting benzodiazepine.
•It can be administered in two ways for rescue with a
single prolonged seizure or cluster, buccal or intranasal.
•The most common side effects are drowsiness,
tiredness, weakness, and nausea. There is a chance
that a child may experience breathing problems
following this medication. We advise families that the
first time they use this, they call 911 to ensure it is well
tolerated.
•To administer buccally, simply divide the prescribed
dose in half, giving on each side between the cheek and
gum.

31. Communication and Collaboration with Healthcare Providers
•Medication Administration Forms
•Any concerns about medication compliance or
safety risks.
•Any letters for special privileges (water bottles,
activity restrictions, etc.)
•Any general questions about medications
•Any general questions about plan of care
•We encourage you to fax us updates or
concerns. This is recommended as we know we
will likely recieve this correspondence.