The Acute Management of an Individual with Epilepsy
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Transcript of The Acute Management of an Individual with Epilepsy
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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
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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
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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)
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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
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Classification of Seizures
• Partial seizures: Simple Partial & Complex Partial
• General seizures
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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
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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
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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
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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
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Atonic seizures
• Sudden often brief loss of body tone which may result in a fall
• Also known as ‘drop attacks’
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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
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Common AED’s
• Phenytoin
• Tegretol (Carbamazepine)
• Gabapentin
• Lamotrigine
• Epilim (Sodium Valporate)
• Phenobarbitone
• Aim for Monotherapy
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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
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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
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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
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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
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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
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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?
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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
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Causes of Status
• AED non-compliance
• Head injury/surgery
• Raised ICP
• Stress
• Metabolic imbalance i.e. Diabetes, low Sod.
• Drug/alcohol toxicity
• Pyrexia
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Carol Forde-Johnston
• Lecturer Practitioner in Neurosciences
• The Radcliffe Infirmary, Oxford