Seizure Disorders

Definition/Etiology:

A seizure is an episode of abnormal electrical activity in the brain. A misfiring of neurons if you will.

Seizures can have a few causes. Many are idiopathic or genetic. They can also be caused by trauma, strokes, or a disease process like cancer or meningitis. Of course, we all know about febrile seizures in pediatrics, but we are not going to cover that too much here. The increased temp from some sort of infection triggers seizure activity. There ya go, we just covered febrile seizures. Moving on.

Pathophysiology:

I have good news for you guys. Everyone has some propensity to have a seizure. Stay with me. Everyone lives on a seizure threshold susceptibility continuum. In simpler terms, everyone’s brain has the capacity to misfire. Most of the time, and in most individuals, the body is able to protect the brain from these situations.

On a cellular level, those that suffer a seizure have some excited cerebral neurons which are discharging their electrical impulses more than is expected and this overaction of these neurons can result in seizures.

Clinical Presentation:

OK, we all know the typical Tonic-Clonic seizure. Also known as grand-mal seizure (yes these are the same thing!!! I have seen many medics, emts, and nurses who think they are 2 different types of seizure and trying to get them to explain the difference has been both frustrating and hilarious). So, this is characterized by the extensor muscle spasms, bilateral clonic movements, and probably most important, apnea or irregular respirations. These are also followed by the postictal phase.

Another side note….this is spelled postictal. One word. There is no D in this word. It’s not Post Dictal. Its postictal. From the latin post, meaning after, and ictal, meaning a physiologic attack like a stroke or seizure. Postictal….after the seizure. Thank you for coming to my word origin lecture, now back to your regularly scheduled seizure.

You can also have partial or focal seizures. The seizure activity here is usually unilateral, does not produce a loss of consciousness, and is generally not life threatening.

Collaborative Management:

Management of seizures is focused on a few key things:

• ABCs
• Control of the seizure
• Identification of a possible cause.

Interventions will be based on that. Get these patients on O2 as best we can. Maintain their airway. Turn them to the side, why??????? That’s right, to prevent aspiration. Protect their head and pad the side rails.

While many seizures resolve on their own, some will require meds. Ativan and valium are the go-to to get the seizures to stop. Once the seizure is stopped, we are most likely going to infuse Phenytoin (aka dilantin) which is an anticonvulsant. OK…..dilantin….very VERY important point here. DO NOT SLAM IN DILANTIN. This is hung, usually over 20 minutes. Why….well, push it fast and you can kill your patient. Seeing as how their day is going pretty bad so far, it’s best not to make it worse. “But Mike, how would we kill them”. I’ll tell ya. Dilantin is a myocardial depressant. Pushing rapidly can actually cause 3rd degree heart block and cardiac arrest. So, yea, slow infusion here.

Evaluation | Patient Monitoring | Education:

Once the seizure is controlled, we want to keep a close eye on these patients as the possibility for recurrence is real. I suppose I should mention a condition I have left out…status epilepticus. The textbook definition of status epilepticus… a series of consecutive seizures without normal mentation between them, or a continuous seizure lasting more than 5 minutes that is unresponsive to traditional treatment. I’ll say it again: a series of consecutive seizures without normal mentation between them, or a continuous seizure lasting more than 5 minutes that is unresponsive to traditional treatment. Did we all get that? If not, just hit that rewind button.

OK, so we want to watch for recurrence. We also want to get as much info about the seizure as we can. One way we can do that is with the COLD mnemonic:
C – Character – what type of seizure
O – Onset – when, what were they doing
L – Location – where did it start
D – Duration – how long did it last.

If and when we are ready to discharge, we are going to need to provide some education. This can be about proper use of meds, avoiding triggers, and the like. I would check with your facility about contacting the DMV as people with epilepsy do have restrictions on driving. I am not sure, but the law may vary from state to state and your facility policy on contact could be different from mine.

Linchpins: (Key Points)

• AIRWAY!
• Safety
• Medications
• Identify the cause