Seizures

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A seizure (from the Latin sacire, "to take possession of") is a paroxysmal event due to abnormal, excessive, hypersynchronous discharges from an aggregate of central nervous system (CNS) neurons. Depending on the distribution of discharges, this abnormal CNS activity can have various manifestations, ranging from dramatic convulsive activity to experiential phenomena not readily discernible by an observer. Although a variety of factors influence the incidence and prevalence of seizures, ~5–10% of the population will have at least one seizure, with the highest incidence occurring in early childhood and late adulthood. The meaning of the term seizure needs to be carefully distinguished from that of epilepsy. Epilepsy describes a condition in which a person has recurrent seizures due to a chronic, underlying process. This definition implies that a person with a single seizure, or recurrent seizures due to correctable or avoidable circumstances, does not necessarily have epilepsy. Epilepsy refers to a clinical phenomenon rather than a single disease entity, since there are many forms and causes of epilepsy. However, among the many causes of epilepsy there are various epilepsy syndromes in which the clinical and pathologic characteristics are distinctive and suggest a specific underlying etiology. Using the definition of epilepsy as two or more unprovoked seizures, the incidence of epilepsy is ~0.3–0.5% in different populations throughout the world, and the prevalence of epilepsy has been estimated at 5–10 persons per 1000. "Seizure" is a general term that refers to a sudden release of abnormal electrical discharges from the brain or malfunction in the brain that causes someone to collapse, convulse, or have another temporary disturbance of normal brain function, often with a loss or change in consciousness. Epilepsy / Seizure Disorder: occurrence of at least two seizure not related to an underlyng disease condition. It is a chronic disorder of recurrent seizure Incidence About 10% of the population will have a seizure at some time their lives, but only 2% to 4 % will have recurrent seizure or epilepsy. • ETIOLODY/ RISK FACTORS

In about haft the cases of seizure disorder, the cause is unknown. However, some possible causes of seizure disorder included:  Birth Trauma

 Inadequate oxygen supply to the brain, blood incompatibility, or
hemorrhage.  Perinatal infection  Anoxia  After respiratory or cardiac Arrest  Infection Disease  Meningitis, encephalitis and brain abscess  Ingestion of toxins  Mercury, lead or carbon Dioxide.  Tumor of the brain  Inherited disorder or Degenerative Disease  Phenylketonuria or Tuberous Sclerosis    Head Injury or Trauma Metabolic disorder Hypoglycemia or Hypoparathyroidism

 Stroke( hemorrhage, thrombosis or embolism) • PATHOPHYSIOLOGY

Risk factors ↓ Alteration in the neural cell membrane integrity ↓ Increased frequency of neural cell firing ↓ Intensity reaches threshold ↓ Spread of neural firing to adjacent normal neurons ↓ Burst of electrical activity block normal inhibition and perpetuate a feedback loop ↓ Inhibitory neuron in the cortex, anterior thalamus and basal ganglia slow the neural firing ↓ Interruption of seizure ↓ Contraction- relaxation phase ↓

Exhaustion of epileptogenic neurons and building of inhibitory process ↓ Seizure stops ↓ CNS depression ↓ Impaired consciousness • SIGN AND SYMPTOMS

The Hallmark of seizure disorder is recurring seizures, which can be classified as partial or generalized.

I.

Partial Seizure arises from localized area of the brain, causing specific symptoms. In some patients, partial seizure activity may spread to the entire brain, causing generalized seizure. Partial seizure include the following:

o Simple Partial motor type of Seizure begins as a localized

motor seizure characterized by a spread of abnormal activity to adjacent areas of the brain. It typically produces stiffening or jerking in one extremity, accompanied by a tingling sensation in the same area. For example, it may start in the thumb and spread to the entire hand and arm. The patient seldom loses consciousness, although the seizure may progress to a generalized seizure. distortion, which can include hallucinations.

o Simple Partial sensory type of Seizure involves perception o Complex Partial Seizure the symptoms may vary but usually

include purposeless behavior. The patient experiences an aura immediately before the seizure. An aura represents the beginning of abnormal discharges within a focal area of the brain and may include a pungent smell, GI distress (Nausea and Indigestion), a rising or sinking feeling in the stomach, a dreamy feeling, an unusual taste, or a visual disturbance. Overt signs of complex partial seizure include a glassy stare , picking at one’s clothes, aimless wandering, lip smacking or chewing motion and unintelligible speech, these signs may last for jus few seconds or as long as 2o minutes.

o Partial with Secondary Generalization, seizures start from a

II.

focus, then the electrical discharges spread throughout the brain → Focal sign maybe observed first such as twitching of the face then later involving all other body parts. Generalized Seizure

As the term suggest, cause a generalized electrical abnormality within the brain and included several distinct type:

o Absence( petit mal) seizure occur most commonly in children,

although they may affect adults as well. They usually begin with brief change in level of consciousness, indicated by blinking or rolling of the eyes, a blank stare, and slight mouth movements. There’s little or no tonic clonic movement. The patient retains his posture and continues preseizure activity without difficulty. Typically, each seizure last from 1 to 10 seconds. If not properly treated, seizure can recur as often as 100 times per day. An Absence seizure may progress to generalized tonic- clonic seizure. o A Myoclonic ( bilateral massive epileptic myoclonus) seizure is characterized by brief, involuntary muscular jerk of the body extremities, which may occur in a rhythmic fashion and precede generalized tonic-clonic seizure by months or years. o Generalized tonic clonic (grand- mal) seizure typically begin with a loud cry, precipitated bay air rushing from the lungs through the vocal cord. This comprises only 10% of all seizure types. Phases • Pre-ictal phase(may last from 2 to 5 minutes)  Aura which may or may not be present  Sudden loss of consciousness Ictal phase  •



Tonic phase (30-60 seconds)



• • • extension • • • • • bladder •

Rigidity Respiration is altered Rising of arms Opening of the eyes and mouth 10-15 seconds of pronounced Extremities are extended Generally high muscle tension Jaws close sharply Air is rapidly expelled Evacuation of the urinary Pupils are unresponsive to light

Clonic phase • Initial muscle relaxation






• Post- ictal phase     seizure

Violent spasm of contraction and relaxation (elbow flexion, leg extension and torso hyperextension) Pronounced perspiration Alternating constriction and dilation of the pupils Heavy salivation secretion

Victims become limp and quiet Restoration of normal breathing restored. An hour of deep sleep Amnesia of immediate events preceding

III. Unclassified Seizure o West Syndrome (Infantile spasm)

Infant present with diffusely abnormal EEGs, tonoc clonic convulsion, myoclonic jerks and mental retardation. Mortality or severe disability is high o Lennox-gestaut Syndrome

Present between 1-7 years of age Associated with large number f disorder including hypoxia, intracranial hemorrhage, toxoplasmosis, cytomegalovirus infection and tuberous sclerosis.

 Status epilepticus is the most serious seizure disorder and a medical
emergency because the seizure does not stop. Electrical discharges occur throughout the brain, causing a generalized tonic-clonic seizure. Status epilepticus is diagnosed when a seizure lasts more than 5 minutes or when people do not completely regain consciousness between seizures. People have convulsions with intense muscle contractions and cannot breathe adequately. Body temperature increases. Without rapid treatment, the heart and brain can become overtaxed and permanently damaged, sometimes resulting in death.



DIAGNOSTICS

Various blood tests and other tests looking for temporary and reversible causes of seizures, may include:
• • • • • • •

Blood chemistry Blood sugarBlood sugar CBCCBC (complete blood count) CSF (cerebrospinal fluid) analysis CSF (cerebrospinal fluid) Kidney function tests Liver function tests Tests for infectious diseases

The following tests may be done:


Blood tests is done to measure the levels of substances such as sugar, calcium, sodium, and magnesium and to determine whether the liver and kidneys are functioning normally. A sample of urine may be analyzed to check for recreational drugs that may not be reported. Such drugs can trigger a seizure CT scan of the head or MRI of the head is usually done promptly to check for bleeding, tumors, and other structural damage to brain tissue (for example, by a stroke). If results are negative, magnetic resonance imaging (MRI) is usually done later. It provides detailed images of abnormalities and can detect most neurologic disorders. Electroencephalography (EEG) (usually not in the emergency room) is a recording of the brain's electrical activity. The procedure is simple and painless. About 20 small adhesive electrodes are placed on the scalp, and the brain's activity is recorded under normal conditions. Then the person is exposed to various stimuli, such as bright or flashing lights, to try to provoke a seizure. During a seizure, electrical activity in the brain accelerates, producing a jagged wave pattern. Such recordings of brain waves help identify a seizure disorder. Different types of seizures have different wave patterns. Lumbar puncture Lumbar puncture (also called a spinal tap) if doctors suspect a brain infection such as meningitis or encephalitis







The need for further tests or treatment depends on a number of factors.
• • •

A single seizure due to an obvious trigger (such as fever or a drug) is treated by eliminating or avoiding that trigger. A new seizure without an obvious trigger will require further testing and possible treatment. A seizure in a person with known epilepsy will require tests to make sure the patient is taking the correct dose of their medicines. A possible change in medicines may be needed.

MANAGEMENT Goals: Maintain the airway and promote cerebral perfusion Prevention of injury during seizure Determine type of seizure Administer anti-epileptic drug Home Care If someone who has never had a seizure before has one, call your local emergency number immediately. *Persons with epilepsy should always wear a medical alert tag. Most seizures stop by themselves. However, a person having a generalized seizure may be injured; breathe food, fluid, or vomit into the lungs; or not get enough oxygen. During a generalized seizure, it is important to protect the person from injury. Turn the person on the side, so that any vomit leaves the body and does not enter the lungs. After a generalized seizure, most people go into a deep sleep. Do not prevent the person from sleeping. The person will probably be disoriented, or possibly agitated for awhile after awakening. Treatment If the cause can be identified and eliminated, no additional treatment is necessary. For example, if a low blood sugar (glucose) level (hypoglycemia— see Hypoglycemia) caused the seizure, glucose is given, and the disorder causing the low level is treated. Other treatable causes include an infection, certain tumors, and an abnormal sodium level. If people have a seizure disorder, general measures plus drugs are usually sufficient. If drugs are ineffective, surgery may be recommended. General Measures: Exercise is recommended and social activities are encouraged. However, people who have a seizure disorder may have to make some adjustments. For example, they should eliminate or limit their consumption of alcoholic beverages and should not use recreational drugs. They should refrain from activities in which a sudden loss of consciousness could result in serious injury. For example, they should not bathe in a bathtub, climb, swim, or operate power tools. After seizures are controlled (typically for at least 6 months), they can do these activities if adequate precautions are taken. For example, they should swim only when lifeguards are present. In most states, laws prohibit people with a seizure disorder from driving until they have been free of seizures for at least 6 months to 1 year. A family member or close friend should be trained to help if a seizure occurs. Attempting to put an object (such as a spoon) in the person's mouth to

protect the person's tongue should not be tried. Such efforts can do more harm than good. The teeth may be damaged, or the person may bite the helper unintentionally as the jaw muscles contract. However, helpers should do the following during a seizure:
• • •

Protect the person from falling Loosen clothing around the neck Place a pillow under the head

If a pillow is unavailable, helpers can put their foot or place an item of clothing under the person's head. People who lose consciousness should be rolled onto one side to ease breathing. People who have had a seizure should not be left alone until they have awakened completely, are no longer confused, and can move about normally. Usually, their doctor should be notified. Anticonvulsants: These drugs reduce the risk of having another seizure. Usually, they are prescribed only for people who have had more than one seizure, unless the cause has been identified and completely eliminated. They are usually not prescribed when people have had only one generalized seizure. Most anticonvulsants are taken by mouth. Anticonvulsants can completely prevent generalized seizures in about one third of people who have them and greatly reduce the frequency of seizures in another third. Almost two thirds of people who respond to anticonvulsants can eventually stop taking them without having a relapse. However, anticonvulsants are ineffective in about 10 to 20% of people with a seizure disorder. These people are referred to a seizure center and evaluated for surgery. There are many different types of anticonvulsants. Which one is effective depends on the type of seizure and the response to it. For most people, taking one anticonvulsant, usually the first or second one tried, controls seizures. If seizures recur, different anticonvulsants are tried. Determining which anticonvulsant is effective may take several months. Some people have to take several drugs, which increases the risk of side effects. Some anticonvulsants are not used alone but only with other anticonvulsants. Doctors take care to determine the appropriate dose of an anticonvulsant for each person. The best dose is the smallest dose that stops all seizures while having the fewest side effects. Doctors ask people about side effects, then adjust the dose if needed. Sometimes doctors also measure the level of anticonvulsant in the blood. Anticonvulsants should be taken just as prescribed. People who take anticonvulsants to control seizures should see a doctor regularly for dose adjustment and should always wear a Medic Alert bracelet inscribed with the type of seizure disorder and the drug being taken.

Anticonvulsants can interfere with the effectiveness of other drugs, and vice versa. Consequently, people should make sure their doctor knows all the drugs they are taking before they start taking anticonvulsants. They should also talk to their doctor and possibly their pharmacist before they start taking any other drugs, including over-the-counter drugs. Example of Anticonvulsant Drugs that help to terminate the seizure and to prevent exhaustion  Diazepam at doses 5-10 mg is given to 10-20 minutes WOF the occurrence of respiratory depression after repeated injection. The maximum dose is 30 mg in an 8 hour period.  Lorazepam and Phenytoin can be given. In case phenytoin is used, it is advised that cardiac monitoring be done.  If diazepam and lozepam remains ineffective, Phenobarbital can be used to induce barbiturate coma and suppress the brain activity. In such case, the client is admitted at the ICU where he is put in ventilation.

 If in any cases, all medications are ineffective, use of general
anesthesia is the last result. Vecuronium bromide which is a neuromuscular blocker is used. The patient is admitted at the ICU where he is put on mechanical ventilator, continuous cardiac monitoring and hemodynamic monitoring.

After seizures are controlled, people take the anticonvulsant until they have been seizure-free for at least 2 years. Then, the dose of the drug may be decreased gradually, and the drug eventually stopped. If a seizure recurs after the anticonvulsant is stopped, people may have to take an anticonvulsant indefinitely. Seizures usually recur within 2 years if they are going to. A recurrence is more likely in people who have had any of the following:
• • • • •

A seizure disorder since childhood The need to take more than one anticonvulsant to be seizure-free Seizures while taking an anticonvulsant Partial or myoclonic seizures Abnormal EEG results within the previous year

Anticonvulsants, although very effective, may have side effects. Many cause drowsiness, but some may make children hyperactive. Blood tests are done periodically to determine whether an anticonvulsant is impairing kidney or liver function or reducing the number of blood cells. People taking anticonvulsants should be aware of possible side effects and should consult their doctor at the first sign of side effects. For women who have a seizure disorder and are pregnant, taking an anticonvulsant increases the risk of miscarrying or of having a baby with a birth defect (see Drug Use During Pregnancy: Categories of Risk for Drugs During Pregnancy ). However, stopping the anticonvulsant may be more harmful to the woman and the baby. Having a generalized seizure during pregnancy can injure or kill the fetus. All women who are of childbearing age and take an anticonvulsant should take folate supplements to reduce the risk of having a baby with a birth defect. Emergency Treatment: Emergency treatment is required for status epilepticus and seizures that last more than 5 minutes. Large doses of one or more anticonvulsants are given intravenously as quickly as possible. Measures to prevent injuries are taken during the prolonged seizure. People are monitored closely to make sure breathing is adequate. If it is not, a tube is inserted to help with breathing—a procedure called intubation. If seizures persist, a general anesthetic is given to stop them.

•     

SURGICAL MANAGEMENT Cortal Resection/ Corpus Callostomy Temporal Lobectomy Hemispherectomy Vagal Nerve Stimulator Implantation Selective Amygdalo- hippocampectomy

Angeles University Foundation
College of Nursing
Angeles City

In partial fulfillment of the requirements in Nursing Care Management 104 Related Learning Experience AUFMC Special Area

SEIZURES
A Written Report
Submitted by: Santos, Gian Carla D. Santos, Rustia Rica L. BSN IV-6 Group 24

Submitted to: Kristoffer Alexis D. Serrano Clinical Instructor Special Area

July 29, 2010

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