The Acute Management of an Individual with Epilepsy

• Classification & Different types of Seizure

• The Facts

• Diagnosis

• Nursing/Medical Management

• Status Epilepticus

• Psycho-social implications: more next term

Epilepsy : The Facts

• Epilepsy is the 2nd most common neurological disorder what is first?

• The incidence is 1 in 200 a prevalence that is very close to Diabetes

• Approx 70% of people with epilepsy are controlled on drugs

• Epilepsy still carries huge stigma• Prejudice in job market: others anxieites

More FACTS

• 2/3rds of people at time of their marriage had not informed their partners of their epilepsy

• Only 28% of those in full time jobs informed employers

• 33% of those who disclosed to partner experienced broken realtionship

• Scrambler & Hopkins (1997)

Definition of Epilepsy

• A seizure is the synchronous & excessive discharge of a group of neurones

• Epilepsy is the repetitive occurance of these discharges

• Seizures are a symptom, not a cause or syndrome

Classification of Seizures

• Partial seizures: Simple Partial & Complex Partial

• General seizures

Partial Seizures

• Simple Partial: consciousness is not impaired & manifestations depend on which group of neurones is involved i.e. seizures with focal motor signs

• Autonomic symptoms, pallor, flushing

• Somatosensory symptoms, flashing lights, unpleasant odours, taste

• Psychic symptoms, dejavu, fear

Complex Partial

• Consciousness is impaired

• they may evolve from simple partial seizures or occur with impairment of awareness at onset

• Automatisms may be involved e.g. chewing, swallowing, fumbling, smaking of lips

Generalised Seizures

• Absence seizures: brief blank episodes for few seconds ‘petit mal’

• Myoclonic seizures: sudden muscle jerks

• Clonic seizures: without the stiffness

• Tonic seizures: sudden increase in muscle tone- person may fall like a board

Tonic-Clonic Seizures

• Grand Mal

• Tonic phase may start with an expulsion of air resulting in a high pitched cry. Falls, legs extended, arms flexed may be cyanosed

• Clonic phase: rhythmic movements of arms & legs, tongue biting

Atonic seizures

• Sudden often brief loss of body tone which may result in a fall

• Also known as ‘drop attacks’

Diagnosis

• History: witness account very useful, type aura, how long, post-seizure period

• EEG: Electroencephalography not always useful particularly if N.A.D. between seizures

• Videotelmetry: EEG & Video

• MRI scan to exclude structural cause

Common AED’s

• Phenytoin

• Tegretol (Carbamazepine)

• Gabapentin

• Lamotrigine

• Epilim (Sodium Valporate)

• Phenobarbitone

• Aim for Monotherapy

Goals of Treatment

• Seizure freedom: Overall prognosis is good. 20 years after onset 70-80% in remission for 5 years, 50% in remission for at least 5 years and no longer take AED’s

• To decrease seizure severity. More likely with partial seizures, reduce to simple partial

Intractable Seizures

• Trick is to try to achieve some sort of balance between side effects of AED’s & seizure control: part of Epilepsy Nurses role

Status Epilepticus

• Any type of seizure which occurs so frequently that the patient is unable to recover to a normal level of functioning between seizures

• Most common form is Tonic/Clonic

• Mortality rate is 3-27%

• Classed as a medical emergency

Safety Issues

• Tonic/Clonic seizures classed as medical emergency ?ITU/HDU

• Aim to stop seizures, IV access, Oxygen Sats

• Diazepam rectally, IV Lorazepam, IV Phenytoin

• Airway: Tongue biting, hypoxia, ventilation

Other safety issues

• Location on ward/unit, near nurses, oxygen & suction

• Use of cotsides, pillows, safe positioning on side

• Location of seizure: bathing, hard floor, call bell

• Oedema, resp arrest, ventilation & ITU

What do I need to know about someones epilepsy??

• What types of seizure?

• Do they have an aura?

• How long do they last & how frequent?

• How long does it take to recover?

• Do they need to sleep after? Are they confused before, during or after?

• Is there a history of status?

Self Management

• Keep a diary

• Managing drug therapy - non-compliance

• Identifying triggers I.e. stress, alcohol

• Safety at home, work, medic alert bracelet

• Voluntary organisations

• Emphasis on what they can do

Causes of Status

• AED non-compliance

• Head injury/surgery

• Raised ICP

• Stress

• Metabolic imbalance i.e. Diabetes, low Sod.

• Drug/alcohol toxicity

• Pyrexia

Carol Forde-Johnston

• Lecturer Practitioner in Neurosciences

• The Radcliffe Infirmary, Oxford