Seizure Disorders and Meningitis

1. Seizure Disorders and Meningitis

2. Differentiating Meningitis • Aseptic meningitis—NONbacterial • Most commonly viral in etiology. • Associated with mumps, measles, herpes, other viral syndromes • Signs and Sx—generally gradual in onset, but may be sudden. • Headache • Fever—low-grade, usually • GI sx—nausea and vomiting may be R/T  ICP • General malaise • Maculopapular rash • Symptoms usually disappear in 3-10 days

3. Bacterial Meningitis • Acute inflammation of meninges & CSF caused by bacterial infection • Haemophilus influenzae type B (vaccine) • Streptococcus pneumoniae • Neisseria meningitidis • Risk factors: immunosuppression, preexisting CNS anomalies, chronic diseases • Organisms may come from infections in teeth, sinuses, tonsils, lungs, skull fracture

4. Etiology by age of incidence: • Neonate-3 months: Group B Beta Strep and E.Coli • 3 months-3 years: • Haemophilus Influenzae Type B • Streptococcus pneumonieae • Neisseria meningitidis (meningococcal) • Staphylococcus aureus • School-age and beyond: Meningococcal due to high transmissibility through droplet form.

5. Meningitis Symptoms • Hx of URI or ear infection • Irritabilitiy, restlessness • Severe HA, fever, chills, vomiting • Stiff neck (nuchal rigidity) can progress to point of opisthotonos • Alterations in sensorium • High pitched cry in infants; bulging fontanel • May begin w/seizure or develop later • Photophobia • Kernig’s and Brudzinski’s sign

6. Meningitis • Dx: Hx/physical and lumbar puncture • CSF cloudy; culture done **KNOW CSF FLUID RESULTS!! • Management: • Droplet isolation till on meds for 24hrs if bacterial, longer if viral • Begin IV antibiotics IMMEDIATELY AFTER Lumbar Puncture • IV fluids • NPO • Freq VS & neuro checks • I&O • Assess for ↑ICP; Keep HOB elevated • Assess for SIADH – may need to restrict fluids • Keep room/environment quiet, darkened; ↓stimuli • Pain meds as ordered; uninterrupted rest periods • Seizure precautions • Reportable to local Health Dept.

7. Other management issues • Complications of meningitis: • epilepsy • neuro damage (brain damage to learning disabilities) • hearing or vision loss – hearing most common • hydrocephalus • 10-15% mortality

8. Reyes Syndrome • Acute toxic encephalopathy w/other organ involvement; fatty changes in liver • Sudden change in LOC, fever, vomiting • Progresses rapidly; ↑ICP; death • Risk factors: triggered by a mild viral illness like chickenpox or flu and use of salicylates especially Aspirin • Children <18; most between 4 – 14 yrs • Liver Biopsy is final clinical Dx

9. 5 Clinical Stages • Quiet, lethargic, vomiting • Confusion, combativeness, hyper-reflexia • Obtunded, seizures, decorticate rigidity • Deepening coma, fixed pupils • Coma, loss of deep tenden reflexes, flaccid, respiratory arrest

10. Nursing Management • ICU – monitor for cerebral edema; ICP • Assess resp status, CVP, arterial pressure • Oxygen; intubation if needed • Accurate and frequent I & O • Tx: shock (fluids, electrolytes, vasopressors) • Tx: for ↑ICP –keep ↑HOB, airway support, administer mannitol as ordered) • Treat hyperthermia(cooling & meds) • Supportive care & ongoing info for family

11. Seizure Disorders • Malfunction in the electrical system of the brain; alterations in the firing of the neurons by group of hyper-excitable cells • Epilepsy: chronic disorder w/recurrent seizures • Partial – begins local in one hemisphere • Simple partial or partial complex • Generalized – both hemispheres • Immed loss of consciousness • Tonic clonic and Absence seizures (petit mal)

12. Partial Seizure Types • Simple partial: No loss of consciousness; alterations in motor function, autonomic signs, sensory symptoms (numbness tingling) • May experience sudden feelings of joy, anger or sadness • Complex partial: consciousness impaired; • Automatisms-staring, lip smacking, chewing, unusual hand movements • Most common type of seizure-harder to diagnose • Can begin with an aura-feeling of dejavu

13. Generalized Seizures • Petit mal or Absence: lack of awareness, unresponsive; lasts less than 15 secs; abrupt onset and cessation • Tonic clonic: most dramatic with on warning • Postictal period after seizure: relaxation, confusion, amnesia, unresponsiveness • Tonic: sudden loss of consciousness, cry out & muscles get rigid; jaw clenched • Clonic: loss of conciousness alternate contraction and relaxation of extremities

14. Status Epilepticus • Prolonged seizures: > 20 min or recurrent • OR postictal period > 30 min • Medical emergency → resp failure, hypotension, hypoxic brain damage, hypoglycemia • ICU – need IV benzodiazepine • Diazepam or Lorazepam • If IV access is difficult, EBP has shown that anti-convulsants administered rectally via a 5-8 French feeding tube with syringe is very effective.

15. Nursing Management • When to call 911 • If no history of previous seizure • Not breathing • Seizure lasting > 5minutes • Turn child to side; put NOTHING in mouth • Do not restrict movement • Protect head – maintain safe environment • Observe, record, and report seizure activity • Provide information/teaching to family

16. Meds • Anticonvulsants: • Phenobarbital • Phenytoin (Dilantin): gum hyperplasia SE • Carbamazepine (Tegretol) • Valproic acid (Depakene) • Primidone (Mysoline) • Ethosuximide (Zarontin) • Clonazepam (Klonopin) • Ketogenic diet • High-fat, low carb and adequate protein. (body shifts from using glucose to fat as energy source) Tx for epilepsy 30-40% reduction in seizures