Typical Tonic

 

I. Landover, M. (2011). Generalized TonicTonic - Clonic C lonic Seizure Disorder. Epilepsy Foundation. http://www.epilep syfoundation.org/aboutepilepsy/firstaid/generalized-tonic-clonic-seizures.cfm II. Content The vast majority of generalized seizures are idiopathic. However, some generalized seizures start as a smaller seizure such as a simple partial seizure or a complex partial seizure and then spread to both hemispheres of the brain. This is called a secondary generalization. However, factors could include chemical and neurotransmitter  imbalances and a genetically determined seizure threshold, threshold,   both of which havehypertension, been implicated. The  seizure threshold can be altered by or fatigue, lack of sleep or rest, hypertension,    stress,  stress, diabetes, the presence of  neon xenonmalnutrition, strobe-flashes, fluorescent lighting, rapid motion or flight, blood sugar  imbalances, anxiety, antihistamines and other  factors. In the case of symptomatic epilepsy, it is often determined by MRI or other neuroimaging techniques that there is some degree of damage to a large number of neurons. The lesions (i.e., scar  tissue) caused by the loss of these neurons can result in groups of neurons episodically firing abnormally, creating a seizure. Typical tonic –  –clonic clonic seizures (formerly termed grand mal seizures) are generalized seizures consisting of four stages. There may be a prodromal period of hours or days; an aura, or warning, immediately before the seizure; the tonic –clonic stage; and, finally, a postictal stage. Not all four  stages occur with every seizure. The p r o d r o m a l p e rrii o d   may consist of drowsiness, dizziness, malaise, lack of coordination, or tension. Parents may observe simply that their child is acting differently than usual. As a child reaches school age, the child may be able to predict from these vague preliminary feelings when a seizure is about to occur. The a u r a ,  or second phase, may reflect the portion of the brain in which the seizure originates. Smelling unpleasant odors (often reported as feces) denotes activity in the medial portion of the temporal lobe. Seeing flashing lights suggests the occipital area; repeated hallucinations arise from the temporal lobe; numbness of an extremity relates to the opposite parietal lobe; and a ―Cheshire―Cheshire -cat grin‖ relates to the frontal lobe. Young children, unable to describe or understand an aura, may scream in fright or run to their parent with its onset. Noting exactly what symptoms the child experiences during this time helps to localize the involved brain portion. The third phase is the t o n i c s t a g e . All muscles of the body contract, and the child falls to the ground. Extremities stiffen; the face distorts. Although this phase lasts only about 20 seconds, the respiratory muscles are contracted, so the child may experience hypoxia and turn cyanotic. Contraction of the throat prevents swallowing, so saliva collects in the mouth. The child may bite the tongue when the jaws contract. As the chest muscles contract initially, air  is pushed through the glottis, producing a guttural cry. The seizure then enters a c l o n i c s t a g e ,  in which muscles of the body rapidly contract and relax, producing quick, jerky motions. The child may blow bubbles or foamy saliva and, if the tongue was bitten when the jaw shut with a spasm, saliva will be bloody. A child will be incontinent of stool and urine. This phase usually lasts 20 to 30 seconds.  After the tonic –  –clonic clonic period, the child falls into a sound sleep, called the postictal period. He will sleep soundly for 1 to 4 hours and will rouse only to painful stimuli during this time. When he awakens, he often experiences a severe headache. He has no memory of the seizure. Seizures may occur only at night. The child wakes in the morning with a bitten tongue, blood on the pillow, or a bed wet with urine. In a child with persistent bedwetting, the possibility of nocturnal seizures must be considered. Children with this type of seizure usually, although not al- ways, have an abnormal EEG pattern. Other family members may have similarly abnormal EEG patterns although they do not have symptoms. Therapy includes the daily administration of an anti- convulsant such as valproic acid (Depakene) and carbamazepine (Tegretol). Phenobarbital has the advantage of being an inexpensive anticonvulsant. However, drowsiness and sleepiness from this may interfere with a child’s ability to perform in school. Phenobarbital dosages should be tapered, never stopped suddenly, because the body becomes dependent on it. Rapid withdrawal may precipitate a seizure. Children with tonic –  –clonic clonic seizures also may be given phenytoin sodium (Dilantin) for control. One nontoxic side effect of phenytoin is painless hypertrophy of the gums. Unless the gum hypertr ophy ophy is extensive, it is not sufficient reason to discontinue the drug. Medications a ketogenic diet is monotonous for children and difficult for parents to prepare, however, it is hard to maintain for very long. A thorough pregnancy history must be obtained for any child with seizures. Events that occurred immediately before the seizure and an accurate description of the seizure itself also should be recorded. Investigate the child’s overall

 

behavior in the last few weeks. Is the child an A student who has been getting Ds lately? Has the parent noticed bedwetting? These might be signs of absence or nocturnal seizures that have occurred but gone unnoticed. A complete physical and neurologic examination and blood studies are necessary to rule out metabolic or infectious processes. Prepare a child for a lumbar puncture to rule out meningitis or bleeding into the CSF. A CT scan, MRI, skull radiograph, or EEG may be obtained if  indicated. During the EEG, the child may be stimulated with rhythm patterns or flashing l ights or asked to hyperventilate to see whether a seizure can be provoked. When providing seizure first aid for generalized tonic-clonic seizures, these are the key things to remember:  Keep calm and reassure other people who may be nearby.  Don't hold the person down or try to stop his movements.  Time the seizure with your watch.  Clear the area around the person of anything hard or sharp.  Loosen ties or anything around the neck that may make breathing difficult.  Put something flat and soft, like a folded jacket, under the head.  Turn him or her gently onto one side. This will help keep the airway clear. Do not try to force the mouth open with any hard implement or with fingers. It is not true that a person having a seizure can swallow his tongue. Efforts to hold the tongue down can cause injury.  Don't attempt artificial respiration except in the unlikely event that a person does not start breathing again after the seizure has stopped.  Stay with the person until the seizure ends naturally.  Be friendly and reassuring as consciousness returns. Phenobarbital Classification:  Classification:  Phenobarbital is a central nervous system (CNS) depressant.  Action: Acts as an anticonvulsant by lowering the seizure threshold (Karch, 2009). Pregnancy Risk Category: D Dosage: 3 to 6 mg/kg/day orally, or 4 to 6 mg/kg/day parenterally, for 7 to 10 days until a blood level of 10 to 15 mg/mL is achieved, or 10 to 15 mg/kg/day IV or IM. In status epilepticus, 15 to 20 mg/kg IV administered over 10 to 15 min. Possible Adverse Effects: Somnolence, sedation, confusion, ataxia, lethargy, hangover, paradoxic excitement, nausea, vomiting, constipation, diarrhea, epigastric pain, bradycardia, hypotension, syncope, hypoventilation, respiratory depression, pain or tis- sue necrosis at the injection site. Nursing Implications closely—especially pulse, blood pres- sure, and respiratory rate Assess vital signs closely— Administer the oral form of the drug with food to minimize gastrointestinal upset. Instruct parents to do the same. Caution the parents and child that the drug will make the person drowsy. Advise the person to change positions slowly and to sit at the edge of the bed for a few minutes before arising. Assist parents with safety measures to protect the child from injury. Monitor laboratory tests for liver and renal function and blood counts if the child is on long-term therapy. Inform parents about the possible need for follow-up laboratory tests. Instruct parents and child to avoid alcohol and sleep- inducing or over-the-counter drugs, which could cause increased CNS depression. Warn parents not to discontinue the drug abruptly or change the dose unless ordered by the health care provider.