SEIZURES

1. SEIZURES Jean B. Fahey MSN, RN, ACNS-BC, CCRN, CNRN Neuroscience Clinical Nurse Specialist Massachusetts General Hospital Boston, MA JBFahey 3-2010

2. Nature of seizures & epilepsy • Incidence, risk factors • Brain anatomy and pathophysiology • Classification of seizure types • Signs and symptoms of seizures • Diagnosis & monitoring • Treatment, first aid, medications, surgery, other • Status epilepticus JBFahey 3-2010

3. PRINCIPLES OF STAFF EDUCATION • Fluent with seizure first aid and assessment • Awareness of what constitutes a neurological emergency, and the ensuing treatment / antiepileptic medication use • Documentation • Recognize the various manifestations of seizures JBFahey 3-2010

4. STARRY STARRY NIGHT JBFahey 3-2010

5. JAPAN, 1997, POKEMON JBFahey 3-2010

6. EPILEPSY FACTS • Prevalence of epilepsy in the United States is 0.5% to 1% (2.3 million). 1.4 million (15 to 64 years), 550,000 (>65), 300,000 (<14 years) • Approximately 2% to 5% of children have febrile seizures with an age range of 3 months to 5 years. • Most persons have one type of seizure • 80% Occur before age 20 From Epilepsy: A Report to the Nation. Published in 1999 by the Epilepsy Foundation JBFahey 3-2010

7. Seizure : Behavior change associated with an  electrical discharge in cortex. Neurons recruit other neurons to fire, thus clinical manifestations are related to the number of neurons affected & correlate with the focus & path of spread. Status epilepticus : recurring seizures with incomplete recovery between attacks. Epilepsy : Two or more unprovoked seizures. Convulsion : a seizure in which motor manifestations predominate. PATHOGENESIS JBFahey 3-2010

8. ETIOLOGY JBFahey 3-2010

9. Metabolic - drugs: amphetamines, cocaine, theophylline drug withdrawal: alcohol, sedatives, antiepileptic medications, electrolyte: hyponatremia, acidosis, Magnesium/Calcium /Amino acid disturbances • Genetic / birth or development abnormalities • Infections/poisoning • Lesions /trauma • Toxemia of pregnancy • Precipitating factors / triggers: alcohol, hyperventilation, menses, flashing lights, fever, exhaustion, nutrition, sounds, psych factors • Seizure Mimics /behavior disorders, breath holding, cardiac dysrhythmias, hyperventilation, migraine syndromes, movement disorders, psuedo seizures, sleep disturbances, syncope, transient ischemic attack, panic attack, psychogenic, toxic/metabolic abnormalities JBFahey 3-2010

10. CLASSIFICATION OF SEIZURES GENERALIZED (Bilateral hemisphere) PARTIAL (Local onset, aura) JBFahey 3-2010

11. GENERALIZED (Bilateral hemisphere) • Primary generalized seizures. Bilateral & symmetric without focal onset & usually idiopathic. Sign of “4” exception. • Absence (petit mal). 2 -10 second lapse of consciousness. Onset 4-12 y/o & decreased frequency in adolescence. Manifested by staring, eye blinking, lip smacking. • Myoclonic. Quick contractions of partial, whole, or groups of muscles. Single or intermittent jerk in the same or different body parts. Note: not all myoclonus is epileptic. • Clonic (flexion), tonic (extension), and tonic-clonic (grand mal). Abrupt loss of consciousness with tonic, clonic, or tonic-clonic convulsion, followed by postictal confusion. The most common, also the most dangerous • Atonic, loss of motor tone JBFahey 3-2010

12. PARTIAL (Local onset, aura) • Simple. Partial (focal) seizures. Consciousness is not impaired. Subjectively, patients are likely to experience déjà vu and sensory, motor, or autonomic symptoms. For example, patients may note vague abdominal or thoracic sensations. With motor involvement, patients are likely to exhibit hemifacial or hemibody twitching. • Complex: Consciousness is impaired. May have automatic behaviors such as lip smacking, fumbling with clothes, or even walking. Patients are amnesic for part or the entire episode. • Partial seizures that secondarily generalize JBFahey 3-2010

13. SEIZURE OBSERVATION • Motor movement observation predominate seizure documentation, but emphasis should be placed on key observational details such as responsiveness. • Videotaped seizures & periodic retraining retain quality of assessment skills. JBFahey 3-2010

14. FOCAL SYMPTOMS • Lateralizing signs assist to classify partial seizures with secondary generalization: head turning, neck extension, mouth or eye deviation. • The same type of seizure may manifest in different symptoms between patients • Seizures are unpredictable, they may startle the observer and the observer may not see the actual beginning of the seizure until it progresses, the details may be incomplete. • The need to provide first aid may shift attention away from the observation task. JBFahey 3-2010

15. POSSIBLE ICTAL MANIFSTATIONS • Emotions: disassociated affects, negative affects, panic attacks, rage, transient psychosis • Gustatory affects: metallic or foul taste, burning, decaying, ammonia, overpowering perfume • Visual: patterns, shaped, flashing lights, fully formed complex images, sudden distortions (metmorphosia), micropsia, macropsia • Auditory: ringing or buzzing, repetitive stereotyped phrases, music, distortion, illusions of echo, alteration of volume • Somatosensory: headache, discomfort, pain, tingling, numbness, vertigo JBFahey 3-2010

16. POSSIBLE ICTAL MANIFSTATIONS • Motor: automatisms (simple or complex), abnormal eye movements, nystagmus, jerking, staring, twitching, repetative speech, lurring of speech, speech arrest • Autonomic: flushing, piloerection, perspiration, shortness of breath, chest pain, palpitations, sinus tachycardia, nausea, epigastric rising or sinking, incontinence, salivation, belching, coughing • Experiential Phenomena: Intrusive memory flashbacks, illusions of familiarity (déjà vu), or unfamiliarity (jamais vu), feeling of clairvoyance or of an observing presence, mind body disassociation, derealization, depersonalization, confusion, disorientation, sense of profundity, illusion of possession JBFahey 3-2010

17. SPECIALIZED LOBULAR FUNCTION AND ASSOCIATED SYMPTOMS Frontal: primary motor, expressive language, executive functions, attention, social & sexual behaviors, olfactory Parietal: primary somatosensory cortex, integration of sensory output, spatial location of sensory input, guidance of proximal limb movement, body image, graphic construction Temporal / Limbic: primary auditory cortex, language comprehension, memory, emotion Occipital: primary visual, perception of form, color, depth, & mvmt. Right hemisphere: visuospatial functions, construction, spatial attention, affective speech Left hemisphere: language, fine motor control, manipulation of numbers., linear thinking, detail oriented JBFahey 3-2010

18. EEG RECORDING Temporal Lobe Partial Seizures JBFahey 3-2010

19. PARTIAL COMPLEX SEIZURES • Hippocampus JBFahey 3-2010

20. JBFahey 3-2010

21. DIAGNOSTIC EVALUATION • History & Examination • Laboratory investigation • Computerized tomography & Magnetic resonance imaging • Electro encephalographic tests - Surface electrodes, Nasopharyngeal or sphenoid leads, Cortical strip electrodes or depth electrodes JBFahey 3-2010

22. INTRACRANIAL DEPTH ELECTRODES JBFahey 3-2010

23. SUBDURAL GRID JBFahey 3-2010

24. TREATMENT • Management of a convulsion • Idiopathic (Seizure control) Symptomatic (Treat cause) • Anticonvulsants • Surgical resection, disconnection, or augmentation • Other DRUG THERAPY Anticonvulsants JBFahey 3-2010

25. INTRAVENOUS PHENYTOIN • Vesicant, (pH- 14), necrosis at site if infiltration occurs. Do not use in hand, wrist, or foot lines. Forearm suggested. Always affirm vein patency. • Rate per institution, 25mg/minute suggested. Possible 50mg/ minute maximum. • Only compatible with normal saline –precipitates with glucose contaminated line. • Cardiovascular side effects, hypotension, bradycardia. • Limited stability once placed in solution. JBFahey 3-2010

26. Vesicant Infiltration, Purple Glove JBFahey 3-2010

27. MANAGEMENT OF A CONVULSION: (preictal state) • Note time of onset and duration • Note any precipitating factors • Note presence of an aura • Stay in attendance, remain calm • Guide person to a safe place and remove harmful objects from surroundings JBFahey 3-2010

28. MANAGEMENT OF A CONVULSION:(ictal state) • Note seizure activity: body parts, sequence, character of movement • Autonomic signs • Level of consciousness • Protect from secondary injury, do not place anything in the mouth during a seizure • Do not restrain JBFahey 3-2010

29. MANAGEMENT OF A CONVULSION: (postictal state) • Assess level of consciousness & maintain airway protection • Suction and oral airway as required, remove pillows • Nothing by mouth until fully awake, position patient on side to prevent silent aspiration • Remain in attendance with patient until stable • Reassure & reorient: assess for Todd’s Paralysis. • Note associated injuries • Consider need for oxygen face mask • Continue neurological assessment • Maintain bed rest until back to baseline JBFahey 3-2010

30. STATUS EPILEPTICUS • Recurring seizures with incomplete recovery between attacks • Etiology: -known seizure disorder: withdrawal or subtherapuetic antiepileptic medications, superimposed illness. -without seizure history: encephalitis, intracranial bleed, hypoglycemia, alcohol withdrawal, cerebral trauma JBFahey 3-2010

31. MANAGEMENT: STATUS EPILEPTICUS- (initial 10-12 minutes) (MGH 2007, Status Epilepticus Protocol, Epilepsy Service) • Initial rapid assessment: airway, vital signs • Monitor: oxygen saturation, electrocardiogram • Establish intravenous access & obtain laboratory tests: Complete blood count, electrolytes, Blood urea nitrogen/Creatinine, Glucose, Calcium, Magnesium, Phosphorous, liver function tests, antiepileptic medication levels, Toxicology screen, arterial blood gas • Administer intravenous Thiamine -100mg & 50% Dextrose - 50 cc • Lorazepam, 0.1 mg/kg IV (<2 mg/min) JBFahey 3-2010

32. MANAGEMENT : STATUS EPILEPTICUS (within 40 minutes) • Phenytoin, 20mg/kg IV @ 50 mg/min. or Fosphenytoin 20mg/kg IV @ 150mg/min. monitor electrocardiogram, assess for hypotension- blood pressures every 2 minutes • Phenytoin 10mg/kg IV @ 50/min. or Fosphenytoin 10mg/kg IV @ 150/min. Send repeat Dilantin level 20 minutes after load. JBFahey 3-2010

33. MANAGEMENT : STATUS EPILEPTICUS (within 40 minutes) • As alternative: Valproic Acid 30mg/kg IV @150mcg/min. or Levetiracetam 50mg/kg IV @ 100mg/min JBFahey 3-2010

34. MANAGEMENT : STATUS EPILEPTICUS (within 60 minutes) • Phenobarbital 20mg/kg @ 75 mg/min • Intubate, if not already done • Initiate electroencephalographic monitoring • Contact Neurologist/ Epilepsy specialists JBFahey 3-2010

35. MANAGEMENT : STATUS EPILEPTICUS Load and titrate to stop clinical and electroencephalographic seizures, or maintain burst suppression on electroencephalogam. Use fluid to support blood pressure, add vasopressors if fluids fail. • Pentobarbital 5mg/kg IV load, then titrate (0.3-9 mg/kg/hr, avg..= 4mg/kg/hr), or • Midazolam 0.2 mg/kg IV, load preferred if BP is unstable, then titrate 0.1-0.4mg/kg/hr, or • Propofol 1-2 mg/kg IV load/hr, then titrate 2-10mg/kg/hr JBFahey 3-2010

36. MANAGEMENT : STATUS EPILEPTICUS (ideally within 48 hours) • Obtain CT scan (if clinically indicated) • Correct underlying cause of status epilepticus • Adjust the principal anticonvulsants to therapeutic effect • Taper Midazolam, PentobarbitaL, or Propofol after above is complete JBFahey 3-2010

37. Care of the patient on paralytics, or in barbiturate coma. Associated hazards of immobility - pulmonary, skin, GI, positioning & splinting, eye care, hemodynamic support & assessment Consider antibiotics, antiviral agents, or lumbar puncture, cool patient if febrile, frequent lab assessments Family support & education MANAGEMENT : STATUS EPILEPTICUS JBFahey 3-2010

38. PRINCIPLES OF LONG TERM MONITORING • Wean from antiepileptic medications • Capture and collect electric, visual, & auditory data on seizure events in a controlled situation. • Maintain safety at all times JBFahey 3-2010

39. DOCUMENTATION Inherent in good seizure observation is good documentation. Accurate documentation can lead to a more definitive and expedited diagnosis. Note time of onset and duration, precipitating factors, presence of an aura, note seizure activity- body parts involved, sequence and character of movement, autonomic signs, level of consciousness and content of consciousness, neurological exam and presence of postictal deficits, or secondary injury related to seizure activity JBFahey 3-2010

40. DOCUMENTATION • Describe the beginning • Describe responsiveness • Describe movement, mobility, and tone • Describe sensation and perception • Describe post ictal responses JBFahey 3-2010

41. DOCUMENTATION-1 Describe the beginning • Describe circumstances. • Describe precipitating factors. • Was the seizure onset observed? • Was there an aura? • Did the person continue, stop, or slow down their activity? • What happened first and how did it proceed? JBFahey 3-2010

42. DOCUMENTATION-2Describe responsiveness • Describe responses to you, self & environment. • Describe responses, automatic or complex? • Assess response to touch. • Assess response to auditory stimuli. • Assess response to visual stimuli, check pupils. JBFahey 3-2010

43. DOCUMENTATION-3 Describe movement, mobility, and tone • Was there movement or posture change? • Was there movement of the head or eyes? • Was it unilateral or bilateral, was it symmetrical if bilateral? • Assess whether tone is increased (rigid) or decreased (limp)? • Were there any automatisms (repetitive purposeless movements), or purposeful movements? JBFahey 3-2010

44. DOCUMENTATION-4Describe sensation and perception • What does the person describe or say? Ask them for a description. • Are there any automatic signs (skin temperature change, change in color, sweating)? • Did they say or do anything unusual (cursing, swearing, mumbling, wandering, combative)? JBFahey 3-2010

45. DOCUMENTATION-5 Describe post ictal responses • What were they like after the seizure? • How long before they were back to baseline? • Could thy recall the event or what happened at the beginning of the seizure? • Were there any temporary deficits? • Was there any confusion or disorientation? • Was there any bowel or bladder incontinence? JBFahey 3-2010

46. Non-epileptic seizures (NES) • Events that may present similar to epileptic seizures, however there is no electrographic correlate on EEG • May be unable to determine type of seizures based on clinical presentation alone • Of patients admitted to inpatient epilepsy monitoring units, up to 40% are diagnosed with NES • More common in females in their 30’s • Can also have concurrent epilepsy JBFahey 3-2010

47. NES – Clinical features • Most episodes occur with a witness present • NES tend NOT to occur during sleep • Episodes are often frequent • Most report at least daily episodes • Often have an incomplete loss of consciousness • Are rarely less than 1 minute, usually much longer • May have forced eye closure • During true ictal events, eyes are usually open JBFahey 3-2010

48. Criteria to distinguish epileptic versus psuedo seizures JBFahey 3-2010

49. Psychiatric conditions with NES - Depression • Anxiety • Somatoform/conversion disorder • Post Traumatic Stress Disorder • Dissociative disorder • Personality disorders (borderline personality, Obsessive Compulsive Disorder, narcissistic, histrionic and antisocial personalities) JBFahey 3-2010

50. Diagnosis of NES • Routine Electroencephalogram • Often not very useful • Video Electroencephalogram • Gold standard for diagnosis • Serum testing • Neuropsychological testing • Neuroimaging • Magnetic resonance imaging – often normal in true epileptics JBFahey 3-2010