Management of Seizures in school-age Children

Maja Ilic, MDPediatric Neurologist and Epileptologist

Westchester HealthMarch 31, 2016

The nurse should have an understanding of seizures as well as antiepileptic medications (esp rescue medications), seizures first aid and precautions to minimize seizures negative impact on child's quality of life.

Clinical Stereotypical, usually unprovoked, disturbance of consciousness, behavior, emotion, motor function or sensation as a result of the cortical neuronal discharge

What is seizure?

At least 2 unprovoked seizures occurring >24 h apart

“First unprovoked seizure and a probability of further seizures similar to the general recurrence risk (at least 60%) after 2 unprovoked seizures, occurring over the next 10 years.”

WHAT IS EPILEPSY

R. Fisher et al: A practical clinical definition of epilepsy; Epilepsia, 55(4):475–482, 2014

Possible precipitation factors

OverexertionFever, infectionsMassive sleep deprivationRecent head trauma, concussionAnxiety, stressExcessive use of stimulants (ADHD)Electrolyte disturbance (dehydration, low Glc, Na, Ca, Mg)Flashing lights

EPILEPSY CLASSIFICATION:

Generalized Epilepsy

Focal Epilepsy

Secondary Generalized

Seizure onset characterized by electrical abnormality affecting both hemispheres of the brain

Generalized tonic clonic Tonic Myoclonic - Absence- Atonic

GENERALIZED SEIZURES

Most patients (>60%) will have excellent seizure control with medications

Some patients will continue to have seizures despite good medical therapy

Ketogenic dietVNS Epilepsy surgery

Impaired quality of lifePoor school performanceCognitive deficits (esp memory)Behavior problems

Social isolation

Increased morbidity and mortalityAccidentsDepression, CVA, CVDDeath-SUDEP

Driving restrictionsLoss of independence

Impact of Refractory Epilepsy

Seizure Safety

Important for to be aware/have available:

What type of seizure (medical alert bracelet)Rescue medications2 spare dose of maintenance medication

When is it (and isn’t) necessary to call for emergency help?

Documented nursing assessment notes:What occurred during ictal (active seizure) phase (progression, sequencing, symmetry of activity, clonic, tonic)Consult and obtain information from witnesses

Child should be monitored (RR, HR, temperature, color change, injuries,…)

Posticatal condition and activity should be documented

Any actions taken, including an medication given should be documented

ACTIVITIES THAT SHOULD BE AVOIDED/ CLOSELY SUPERVISED:

Swimming alone (life vest)Wear head protection when playing contact sports/risk of fallingWhen riding a bicycle, wear helmet, knee pads and elbow pads Avoid high traffic areas

Climbing chars or ladders and highs Climb only as high as you can fall without injuring yourself

Use of electrical appliances, sharp objectsLimit exposure to flashing lights (certain seizures types)

Stand well back from the road when waiting for the school bus and away from the platform edge

SEIZURE FIRST AID

Loosen clothing

DO NOT try to force an airway (injury)

Turn the person into a side-lying position as soon as convulsion has stopped

DO NOT restrain (will not stop the seizure)

PROVIDE AS MUCH PRIVACY AS POSSIBLE during and after the seizure activity

Continue to asses until child returns to baselineAllow child to sleep, reorient upon awakening

When to call 911:

Lasting > 5min or has 2 or more seizures

If first seizure

If seizure occurred in water

If has patient with DM

Breathing affected or not returning to baseline after seizure stopped

HELPFUL LINKS:

www.epilepsyfoundation.orgwww.epilepsyadvocate.comwww.epilepsy.com www.paceusa.org

Nursing Assessment and Treatment of Headaches in

School-age Children

• It is essential that school nurse is familiar with the various types and causes of headaches, and is able to recognize and respond to the warning sings of potentially serious headaches

• Appropriate assessment is imperative for accurate interpretation of the cause so that effective intervention can be implemented

•Headache is … a single or repetitive discomfort or pain about the head or face

• Common problem in adults as well in children

• Over 40% of 7-year-olds and 75% of 15-year-olds are reporting that they have had a headache

• Headaches do not originate from the brain tissue but arise from stimulation of nerve endings in larger arteries or veins or from the periosteum, skin of the head, face or neck, mucosal lining of the airways and sinuses, from the temporal mandibular joint or from the teeth and gums

Headaches categories:• Sinus • Migraine• Tension• Depression• Trauma• Other (Intracranial masses, BIH, Epilepsy, Aneurysms…)

Sinus headaches• Only 15% of patient with sinus pathology report headache• Pain in, around, above or behind the eyes, in the maxillary rea and in

face rather that head location• Dull or throbbing• Increased by changing to reclining position• Worse in the morning or during night• Can be associated with fever, cough, postnasal drip, sore throat

Migraine• 5% of elementary-age children are affected (boys

more) and 17% of adolescents (girls more)

• Many have a positive history of motion sickens or vertigo

• 70% of adolescent suffers have positive family history of migraine

MIGRAINE or VASCULAR TYPES:• CLASSIC (with aura): bilateral, unilateral, not always the same side

• COMMON: MOST COMMON IN CHILDREN/ADOLESCENTS: less well-defined

• COMPLICATED: neurological deficits may persist after the pain resolved- HEMIPLEGIC/HEMISENSORY-unilateral motor weakness/sensory disturbance (may last hours

after headache gone)- BASILAR- coming from basilar, posterior cerebral arteries, give rise to occipital headache often

with diplopia, tinnitus, or ataxia (older adolescent girls)- OPHTHALOPLEGIC- rise to same-side third cranial nerve palsy

• CLUSTER: vascular; nasal discharge, congestion, watery eye, but no nausea or vomiting

TENSION HEADACHES• Caused by muscular contractions and usually have an onset at 8-12 years of

age• Most common in overweight females

• Preceded by stress• No prodrome, no nausea, vomiting • Often lengthy lasting hours to days• Generalized or occipital and typically dull pain

HEADACHES ASSOCIATED WITH HEAD TRAUMA, CONCUSSIONS:• Acute or chronic

• Increasing witching the first hours

• Nausea, vomiting, lethargy or seizures in acute phase

• Dizziness, sleep disturbance, depression, learning difficulies later and can persist days or weeks

IMPORTAINT TO ASK:• Was student dieting? • Dehydration?• Is the child sleeping well?• DM or suffering from hypoglycemia?• Any change in appetite and weight?• What was the student just been doing?• Is it a post gym/exercise headache?• Sad, crying, depressed, getting along with peers, teachers, siblings?• Substances of abuse?• Vision, sensory, motor changes?

Important variables in NURSING ASSESMENT:• Location• Quality• Quantity• Chronological- how has the pain changes since it started• Prodrome

• Associated symptoms (nausea, vomiting, deficits)

• Aggravating and/or alleviant factors

When to refer to MD ?• Sudden onset• Increasing severity• Severe pain on awakening• Seizures• History of head trauma• Fever• Nuchal rigidity• Increasing BP• Lethargy • Slurred speech• Rash, petechiae, ecchymosis• Vomiting

Nursing Intervention:• Vary with assessment

• Reassurance, rest and carbohydrate snack, hydration, allow to relax• Acetaminophen, ibuprofen, naproxen (sooner)• Physician orders may include preventive medications (beta blockers, TCA,

anticonvulsants, calcium channel blockers)

• FOR FREQUENT SUFFERER: keep headache log• Sending child home is last resort

• REFER CHILD TO THE DOCTOR if headaches requires the child to be sent home more than once a semester