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NEUROLOGY FOR NURSES

NEUROLOGY FOR NURSES. ANDREA VAN LIEROP RN BSN Arkansas Children’s Hospital. Children with Epilepsy School Issues. Children with poor seizure control are more likely to have trouble making friends.

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NEUROLOGY FOR NURSES

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  1. NEUROLOGY FOR NURSES ANDREA VAN LIEROP RN BSN Arkansas Children’s Hospital

  2. Children with EpilepsySchool Issues • Children with poor seizure control are more likely to have trouble making friends. • Taking medication at school may be associated with a significant decrease in social and peer relationships. Even in children with self reported good seizure control.

  3. DEFINITION • A seizure is a sudden and stereotyped alteration in motor activity, sensation, behavior or consciousness due to an abnormal electrical discharge of neurons • Epilepsy is a chronic neurological condition characterized by recurrent, unprovoked seizures.

  4. Epilepsy • Recurrent seizures produced by abnormal repetitive neuronal firing in the brain • Occurs in 1-2% of the population

  5. Seizure Classification Partial (Focal)Primary Generalized Simple ComplexAbsence Myoclonic Atonic Convulsive Tonic Clonic Tonic-clonic Tonic-clonic-tonic May secondarily generalize

  6. Evaluation of Epilepsy • EEG & Epilepsy • Awake only ( 30-40% abnormal) • Awake and asleep ( 60-70% abnormal) • Photic stimulation • may induce generalized spike and wave or occipital spikes • Hyperventilation • may induce 3/sec. spike and wave (absence)

  7. Evaluation of Epilepsy • Neuroimaging • Indicated with: • Abnormal neurological exam • Focal onset seizures • Uncertain if focal or primary generalized onset • Onset of seizures after adolescence • MRI is the gold standard (not CT) • CT is helpful in the acute setting • i.e. persistent alteration of consciousness or abnormal neurologic exam

  8. General Guidelines for Therapy: • Correct classification of seizures leads to correct AED selection • Treat when the benefit of therapy outweighs the risk • Avoid polypharmacy • Monotherapy usually results in better seizure control and less side effects

  9. General Guidelines for Therapy: • Maximize one medication before changing to the second • Treat the patient, not the EEG or the AED level • Use rational polypharmacy when indicated • IF IT’S NOT BROKEN, DON’T TRY TO FIX IT!!!!!!!!!!

  10. “Women” of Child Bearing Age on AED’s: • All should receive folic acid supplementation with a minimum of 1mg/day, or 4mg/day if they are pregnant or actively trying to become pregnant

  11. 1993 Phenobarbital Other barbiturates Primidone Phenytoin (Dilantin) Ethosuxmide (Zarontin) Carbamazepine(Tegretol) Valproate (Depakote, Depakene) 1993 Felbamate (Felbatol) Gabapentin (Neurontin) Lamotrigine (Lamictal) Tiagabine (Gabatril) Topiramate (Topamax) Oxcarbazepine (Trileptal) Levetiracetam (Keppra) Zonisamide (Zonegran) Development of AED’s

  12. Natalie • 3-week-old infant with no apparent perinatal complications • Hypotonia • Slow feeder, poor suck • Several spells per day of staring with slight jerking movements

  13. Neonatal Seizure

  14. Samuel • 7-month-old infant with cerebral injury from “shaken baby” syndrome • Now with episodes described as “startle reflexes” commonly occurring in clusters • Not responsive to maintenance phenobarbital

  15. Infantile Spasms

  16. Infantile Spasms • Flexion or extension spasms • Tend to occur in clusters • Cryptogenic vs. symptomatic • Many potential causes • Onset: Birth to 2 years • Peak onset: 5-6 months • 80% develop mental retardation • 60-70% have lifelong epilepsy • Hypsarrhythmia pattern on EEG

  17. Electrodecremental Seizure Hypsarrhythmia

  18. Charlie • 9-year-old boy with long-standing history of intractable epilepsy with tonic-clonic, tonic, myoclonic, atypical absence and atonic seizures • Moderate mental retardation • Frequent injuries from falls

  19. Head Drops

  20. Lennox-Gastaut Syndrome • Onset in early childhood • Multiple seizure types including • Atypical absence, generalized convulsive, atonic, myoclonic, partial • Negative neurodevelopmental impact • Mental retardation • Slow spike and wave (2 hertz)

  21. Atonic • No warning; abrupt onset • Loss of muscular tone results in sudden fall • Brief duration • Injuries common • Very difficult to treat

  22. Atonic

  23. Terry • 2-year-old boy with 3-week history of recurrent episodes of sudden fear or panic • Initial frequency of 2-3 per day, now increased to 1 per hour or more • Maintenance of consciousness • LMD felt these could not be seizures

  24. Simple Partial Seizure

  25. Gabrielle • 12 y/o hispanic girl with 1-year history of frequent spells with several daily • Diagnosed with “pseudoseizures” • Maintenance of consciousness • Events are stereotypical with extension of the right arm and turning to the left, followed by agitated movements and vocalization with an abrupt recovery

  26. Frontal Lobe Seizure

  27. Simple Partial • Focal onset • Aura is common • No alteration of consciousness • May secondarily generalize

  28. William • 12-year-old boy with intractable seizures with episodes of confusion and disorientation • Ash leaf spots noted on Wood’s lamp exam • Intractable seizures despite numerous AED’s

  29. Complex Partial Seizure

  30. Complex Partial • Focal onset • Aura is common • Alteration of consciousness • Automatisms • Postictal confusion • May secondarily generalize

  31. Chelsea • 9-year-old girl with 2 seizures during the last 4 months • First episode occurred during sleep consisting of a brief generalized convulsion • Second seizure occurred during wakefulness and involved the right face and arm with subsequent secondary generalization

  32. Bilateral Centrotemporal Spikes

  33. Benign Focal Epilepsy of Childhood • Rolandic (centrotemporal) or occipital spikes • Nocturnal seizures are common • Seizures are usually infrequent • Remits by 15-16 years of age or earlier

  34. Benign Focal Epilepsy of Childhood: Treatment *Treatment may not be warranted for uncomplicated, infrequent seizures. If seizures are frequent or tend to secondarily generalize, treatment should be considered.

  35. Tina • 13 y/o girl with frequent staring episodes described as a blank stare with unresponsiveness, noted daily at school • Decreasing school performance • Key question: Is there an acute arrest of activity?

  36. Absence

  37. Absence • Brief staring episodes with unresponsiveness • Sudden onset with an arrest of activity • No aura or postictal confusion • May have associated eye flutter or simple automatisms • Generalized 3 per second spike and wave • 80% will have resolution with age • 20% also have convulsive seizures.

  38. 1st Choice AED’s Ethosuximide (Zarontin) Valproate (Depakote, Depakene) Absence: Treatment Phenytoin, Phenobarbital, Carbamazepine, Gabapentin, Topiramate May even exacerbate seizures

  39. Absence Followed by Clonic-Tonic-Clonic

  40. Primary Generalized Convulsive • No warning; abrupt onset • Tonic, clonic, tonic-clonic or clonic-tonic-clonic activity • Bowel and bladder incontinence common • Postictal unresponsiveness or confusion • Generalized spike and wave

  41. 1st Choice AED’s Valproate (Depakote, Depakene) Primary Generalized Convulsive: Treatment

  42. 1st Choice AED’s Valproate (Depakote, Depakene) Lamotrigine (Lamictal) 2nd Choice AED’s Topiramate (Topamax) Ethosuximide + Valproate Zonisamide Levetiracetam (Keppra) Felbamate (Felbatol) Primary Generalized Convulsive & Absence: Treatment

  43. Bubba • 13-year-old boy who had a single generalized convulsion 3 weeks ago • No previous history of seizures • Key question: Do you ever have small jerks of your arms, especially early in the morning? • Answer: “Oh yeah, I’ve been doing that for a couple of years”

  44. Myoclonic Seizure

  45. Myoclonic • Sudden single jerks of the arms and head • May occur in clusters • No alteration in consciousness • May progress to a clonic-tonic-clonic seizure • Generalized multispike wave • Valproate, Clonazepam, Zonisamide

  46. 1st Choice AED’s Valproate (Depakote, Depakene) Juvenile Myoclonic Epilepsy: Treatment

  47. Juvenile Myoclonic Epilepsy • Autosomal dominant inheritance • Chromosome 6 • Myoclonic seizures with onsetin late childhood or adolescence • May develop generalized convulsive or absence seizures

  48. The Rescue Drug • Diastat Acudial is a diazapam rectal gel intended for the management of seizure patients who require intermittent use of Diazepam for seizure activity greater than 5 min. • 10mg diastat Acudial can be dialed to 5mg 7.5mg or 10mg • 20mg Diastat Acudial can be dialed to 12.5mg 15mg 17.5mg and 20mg • 2.5mg diastat is still available

  49. MAD • Nasal Drug Delivery System • Fast and Effective • Controlled Delivery • No Needles • Midazolam/ Versed • Dosage .2mg/Kg up to max of 10mg • 50kg = 10mg/2ml • Deliver slowly in one side of nostril, hold other side closed

  50. WHEN DO YOU CALL 911 • If a patient has been given Diastat or versed and is not recovering after 3 min. • If the patient has turned cyanotic and is not breathing • If the patient is having cycles of seizures even after receiving rescue medication.

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