EPILEPSY

- Epilepsy is a brain disorder in which clusters of nerve cells, or neurons, in the brain sometimes signal abnormally.

- In epilepsy, the normal pattern of neuronal activity becomes disturbed, causing strange sensations, emotions, and behavior or sometimes convulsions, muscle spasms, and loss of consciousness.

- Only when a person has had two or more seizures is he or she considered to have epilepsy.

Etiology

-Idiopathic.
-Genetic factors
-Acquired: brain injury during prenatal, perinatal or postnatal periods or traumatic accident.
-Adverse Reactions to Drugs
-Infections which affect the brain such as meningitis

Classification of Epilepsy

1. Partial seizure
2. Generalized seizure
3. Absence Seizure

Partial seizures

Simple partial seizures.
- No loss of consciousness.
- May alter emotions or change the way things look, smell, feel, taste or sound.

Complex partial seizure

Observed more often in children from 3 years through adolescence.

Characterized by:
- Period of altered behaviors, amnesia for event
- Inability to respond to environment
- Impaired consciousness during event
- Drowsiness or sleep follows seizure
- Feeling of aura: Unpleasant odor or taste, complex auditory or visual hallucination.
- Strong feeling of fear and anxiety
- Small children may emit a cry or run for help.
- May be confused
- May perform purposeless, complicated repetitive running.

Generalized seizures

A. Tonic-clonic Tonic-clonic seizures (grand mal).
B. Atonic seizures. Also known as drop attacks, these seizures cause you to suddenly collapse or fall down.
C. Myoclonic seizures. These seizures usually appear as sudden jerks of your arms and legs.

A. Tonic clonic Seizure (Grand mal Seizure)

Most common and most dramatic, occur without warning .
phases
Tonic phase-(10-20 sec), The body becomes stiffs and breathing stops
Manifestation
- Eye roll upward,
- Immediate loss of consciousness,
- If standing, falls to ground,
- Generalized symmetric tonic contraction of entire body
- Arm flexed, head, leg and neck extended,
- may become cyanotic,
- increase salivation and
- loss of swallowing reflex.

Clonic phase: rhythmic shaking
Manifestations:
- Violent jerking movement
- may foam at mouth,
- may incontinent of urine and faeces,
- gradual decrease of rhythmic movement and cessation.

Postictal phase or Post seizure phase: depression, confusion, and disorientation
Manifestation;
- Appear relax,
- Difficulty to arouse,
- may awaken in few minutes,
- may remain confused for several hours,
- poor coordination
- Mild impairment of fine motor movement,
- visual, speech difficulties.
- May have vomit,
- sleeps for several hours, headache, no recollection of entire events.

B. Atonic and akinetic seizures (drop attacks)

Characterized by:
- Onset usually 2 to 5 years of age
- During an atonic seizure, the muscles in your body go floppy. If you have this type of seizure, you may fall forwards to the ground. or
- Sudden movementory losses of muscle tone and postural control, event occur frequently during the day

Manifestation:
- Child fall in the floor violently,
- Unable to break fall by putting out hands,
- May incur a serious injury to the face, head, or shoulder,
- movementary losses of consciousness.

C. Myoclonic seizure

- Your leg, arm, head or body will jerk in this type of seizure. This usually only happens in the morning
Characterized by:
- Sudden brief contracture of a muscle or group of muscle, repetitively,
- may or may not include loss of consciousness.

D. Absence seizure (petit mal seizure)

- Onset usually between 4 and 12 years of age , may continue to adulthood (common in girl).
- This kind of seizure doesn't involve falling down or experiencing involuntary jerking movements.
- This is also called petit mal epilepsy and isn't as obvious as a tonic-clonic seizure.

Manifestation
- Brief loss of consciousness or awareness
- Slight loss of muscle tone cause child to drop objects.
- Lip smacking, eyelid twitching, slight movement of hands.

Diagnostic investigation

1. Complete accurate and detailed history from reliable and knowledgeable informant
2. Complete physical and neurological examination including developmental assessment.
3. Laboratory studies
4. Scull radiographs, CT scan, MRI
5. EEG

Electroencephalography (EEG)

- wave activity EEG records a patient's brain. In patients with epilepsy, the electrical activity of the brain is disturbed. That disturbance may be detected by EEG.
- The pattern of brain wave activity may help physicians diagnose seizure type.
- In patients with partial epilepsy, EEG may also help physicians pinpoint the area of seizure onset.

- During EEG, a series of 32 electrodes are placed on the patient's scalp to record the brain's electrical activity.
- An EEG appointment takes one to two hours. The effectiveness of EEG in determining epilepsy is higher if the patient is asleep.
- Patients are encouraged to limit their sleep the night before testing to four to six hours, so that they are more likely to sleep during the study.

Magnetic Resonance Imaging (MRI)

- Magnetic resonance imaging provides details about the brain. MRI may detect certain lesions (diseased tissue) in the brain that cause seizures.

- MRI also helps specialists diagnose the causes of epilepsy and evaluate potential candidates for surgery.

Triggering factors for epileptic fits

1. Sleep deprivation
2. Missing meals
3. Flashing or flickering lights - this is photosensitive epilepsy and affects less than one in 20 people with epilepsy
4. Stress
5. Hormonal changes, for example at certain times of the menstrual cycle in women - this is called catamenial epilepsy
6. sudden loud noise, specific voices, song etc
7. Starting sudden movement.
8. Extreme or drastic change in temperature.
9. Dehydration, fatigue, hypoglycemia, hyperventilation
10. Ingestion of caffeine, insufficient protein diet

Therapeutic management

Self Help: Some people can identify the triggers of their seizures
- If you know what triggers a seizure, you may be able to find ways of avoiding the trigger to help to control your seizures. For example, if stress is a trigger you may benefit from relaxation and anti-stress exercises such as yoga.
- Keeping a diary to record your seizures can help to identify triggers.

Drug therapy
- Phenytoin, phenobarbitone , sodium valporate and carbamazepine ( as prescribed)
- Duration of treatment varies from 2-3 years.
Surgical treatment
- If seizure activity is determined to be caused by a hematoma, tumor, or other progressive cerebral lesion, surgical removal is the treatment.

Nursing management

During seizure
1. Remain calm.
2. watch time, duration of the event
3. keep comfortable, harm free position
4. loosen restrictive clothing , remove eye glasses
5. clear any hazard or hard object from surroundings.
6. Allow seizure to end without interference.
7. If vomiting turn child to one side.
8. stay with them until they feel well again
9. Do not
- Attempt to restrain child or use force.
- Put anything to child’s mouth.
- Don't try to move or restrain the person

After seizure
1. Check breathing, keep in lateral position
2. If no breathing, give rescue breathing, call emergency service.
3. Remain with Patient
4. Don’t give food or liquid until fully alert and swallowing reflex has returned.
5. Check head and body for possible injuries.
6. Check either tongue or lips have been bitten.
Call emergency medical service in following condition
- Stopped breathing.
- Seizure more than 5 minutes.
- Child vomits continuously after seizure.
- Child can’t awaken and is unresponsive of painful stimuli.
- Seizure in water.
- Evidence of injury.

GENERAL GUIDELINES

Before a seizure occurs:
1. Safety measures should be taken if there is an indication that the person is experiencing an aura before the onset of a seizure, (e.g., have the individual lie down).
2. Determine if changes can be made in activities or situations that may trigger seizures.
3. Keep the bed in a low position with siderails up, and use padded side rails as needed. (These precautions help prevent injury from fall or trauma.)
4. Individuals with mental retardation or other developmental disabilities may have altered bowel habits, slowed activity, and /or decreased motor skills before a seizure.1

During a seizure: (Ictal stage)

When a seizure occurs, observe and document the following:
a. Date, time of onset, duration
b. Activity at time of onset
c. Level of consciousness (confused, shocked, excited, unconscious)
d. Presence of aura (if known)

f. Respirations (impaired/absent; rhythm and rate)
g. Heart (rate and rhythm)
h. Skin changes
- color/temperature;
- pale/cyanotic, (also check lips, earlobes, nailbeds) cool/warm; perspiration/clammy)
i. Gastrointestinal
- belching
- flatulence
- vomiting
j. Pupillary size, symmetry, and reaction to light
k. Changes in sensory awareness (auditory, gustatory, olfactory, vertiginous, visual)
l. Presence of other unusual and/or inappropriate behaviors

Movements

1. Body part involved
- progression and sequencing of activity (site of onset of first movement is very important as well as pattern, order of progression, or spreading involvement)
- symmetry of activity
- unilateral or bilateral

2. Type of motor activity
- clonic (jerking)
- myoclonic (single jerk of muscle or limb)
- tonic (stiffening)
- abnormal posturing movements, dystonia,
- eyes: eye deviation, open, rolling or closed, eyelids flickering
- head turning,
- twitching

Ensure adequate ventilation.
a. Loosen clothing, postural support devices and/or restraints.
b. DO NOT try to force an airway or tongue blade through clenched teeth. (Forced airway insertion can cause injury.)
c. Turn the person into a side-lying position as soon as convulsing has stopped. (This will help the tongue return to its normal front-forward position and will also allow accumulated saliva to drain from the mouth.)
3. Protect the person from injury (e.g., help break fall, clear the area of furniture).
4. DO NOT restrain movement. (Trying to hold down the person's arms or legs will not stop the seizure. Restraining movement may result in musculoskeletal injury.)
5. Remain with the person and give verbal reassurance. (The person may not be able to hear you during unconsciousness but verbal assurances help as a person is regaining consciousness.)
6. Provide as much privacy as possible for the individual during and after seizure activity.
7. Provide other supportive therapy as ordered by primary care prescriber or according to facility protocol.

After the Seizure: (Postictal Stage)

1. After the seizure activity has ceased, record the presence of the following conditions and their duration in the individual’s record. Continue to assess until person returns to baseline.
a. gag reflex, decreased
b. headache (character, duration, location, severity)
c. incontinence (bladder and bowel)
d. injury (bruises, burns, fractures, lacerations, mouth trauma)
e. residual deficit
- behavior change
- confusion
-language disturbance
- poor coordination weakness/paralysis of body part(s)
- sleep pattern disturbance
2. Allow the individual to sleep; reorient upon awakening. (The individual may experience amnesia; reorientation can help regain a sense of control and help reduce anxiety.)
3. Conduct a post seizure evaluation
a. What was the person doing prior to the seizure?
b. Was this the first seizure?
c. Review current medications including recent changes in medicine and/or dose.
d. Other illnesses?
e. Possible precipitating factors (See Table 1)

Complications of epilepsy

Status epilepticus
- Any seizure or group of seizures that lasts longer than 30 minutes, without recovery in between is called status epilepticus. If this occurs during a tonic-clonic seizure, it's a medical emergency.

SUDEP
- Sudden unexpected death in epilepsy (SUDEP) is rare and can occur in a small number of individuals.

Status Epilepticus (SE)

Status epilepticus is defined as continues seizure that last more than thirty minutes or recurrent seizure without regain of pre morbid level of consciousness.

Note:
- Convulsive SE is the most important as it is associated with significant morbidity and mortality.
- The chance of complication is higher if seizure for more than 60 minutes.
- Status epilepticus is a medical emergency requiring immediate intervention to prevent permanent injury to the brain, respiratory failure and death.

Management

1. Secure airway: lateral position, maintain airway, insert airway, may need suctioning.
2. Administer O2.
3. Intubation with bag- valve- mask may be needed or mechanical ventilation may be needed.
4. Immediate open the IV line for stat medicines and IV fluids
5. Immediate determination of blood sugar. If hypoglycemia; administer 25% dextrose IV bolus.
6. Administer medicines accurately and promptly as prescribed.
7. Maintain systolic BP within range.
8. Hyperthermia is common which can cause CNS injury so management of fever related to seizure.
9. Other nursing care as mentioned above.( nsg care of general epilepsy)

Health education

Teach the patient or family the followings:
1. Avoid activities that need concentration such as driving, machinery work, and dangerous work like swimming, fire work etc.
2. If you have a seizure or suspected seizure at any time you must stop driving.
3. It's a good idea for you to carry a card or wear a bracelet which says that you have epilepsy.
- The bracelet should state who to contact in an emergency and what medications you use. Any allergies to medications also can be noted.

4. Be sure to take your medication correctly.

5. Don't take it upon yourself to adjust your dosage levels. Instead, talk to your doctor if you feel something should be changed.

6. It's also important to keep a detailed seizure record. Each time a seizure occurs, write down the time, the type of seizure it was and how long it lasted.

7. Also make note of any unusual circumstances, such as changes in medication, increased stress or other events that might trigger seizure activity.
8. Seek input from people who may observe your seizures — including family, friends and co-workers — so that you can record information you may not know.
9. Sleep deprivation is a powerful trigger of seizures. Be sure to get adequate rest every night, and make a conscious effort to eat a balanced diet, exercise and manage stress effectively.
10. Excessive alcohol consumption may trigger seizures. If you have difficulty avoiding alcohol and cigarettes, ask your doctor for help.
11Wear a medical bracelet to help emergency personnel.

Social Aspect of Epilepsy

1. Marriage: Less likely to marry if seizures started before 10yrs in women and before 20yrs in men. However if seizures well controlled by 12yrs, marriage rate the same as general population.
2. Separation and Divorce
- Men with poorly controlled seizures since childhood have high rates of separation or divorce.
3. Sexuality:
Hypo sexuality –
- surveys suggest 22-67% reduction in sexual interest
Erectile Dysfunction –
- occurs in 57%[ Toone et al 1989], up to 83% .

4. Occupational – Unemployment, poor job-seeking skills, Non competitive, unskilled manual employment are common.
5. Social isolation .

Considerations for Planning Daily Care

General Health
1. Avoid constipation, excessive fatigue, hyperventilation and stress because they may trigger
seizures.
2. Seizures may increase around the time of menses.
3. Fever may trigger seizures, therefore, the fever and underlying cause must be treated. If antibiotics are ordered, interactions with AEDs should be evaluated.
4. Environmental and recreational risk factors that should be avoided or minimized:
a. Electric shocks
b. Noisy environments
c. Bright, flashing lights
d. Poorly adjusted televisions or computer screens
5. Showers, rather than tubs baths, should be taken, when possible.
6. Good oral hygiene and regular visits to the dentist are important to minimize effects of gingival hyperplasia that can occur from some AEDs.

Diet

1. A well balanced diet should be eaten at regular times.
2. Coffee and other caffeinated beverages should be limited to a moderate amount.
3. Fluid intake should be between 1,000 to 1,500 ml per day (depending on the weather).
4. Alcoholic beverages should be avoided.

Physical Activity

1. Regular activity and exercise should be encouraged. Activity tends to inhibit rather than increase seizures. However, over-fatigue and hyperventilation should be avoided. When possible, exercise should take place in climate-controlled settings.
2. Activities that could harm the patient should be avoided. The person may swim if accompanied by someone who knows what to do if a seizure occurs. The person should wear a life jacket and stay in relatively shallow water to facilitate seizure management should a seizure occur.
3. Regular sleep patterns are important.