epilepsy.pptx

Management of patient with
Epilepsy

Introduction
Definition: seizure is a paroxysmal, uncontrolled
electrical discharge of neuron in the brain that interrupts
normal function
An epileptic seizure is electrophysiologically
characterized by abnormal transient and excessive
electrical discharge of cerebral neurons and clinically
characterized by paroxysmal episodes of loss or excess of
motor, sensory, autonomic or psychic functions with or
without alteration in consciousness.

Difference
seizure is a symptom and epilepsy is a syndrome. Though
epilepsy begins first with a seizure, not all first seizures
lead to epilepsy. Seizures may often occur in acute
systemic conditions such as metabolic disturbances
(hypoglycemia), drug toxicity (chloroquine) and drug
withdrawal (diazepam) but usually they do not constitute
epilepsy.

Classification of Seizures
ILAE Classification (1981)
I. Partial (Focal)seizures
A. Simple partial seizures
B. Complex Partial Seizures
C.Partial Seizures evolving to
secondary generalized seizures
(tonic-clonic, tonic or clonic)
II. Generalized seizures (Convulsive and
non-convulsive)
A. Absence seizures
i) Typical ii) Atypical
B. Myoclonic seizures
C. Clonic seizures
D. Tonic seizures
E. Tonic-Clonic seizures
F. Atonic seizures
(Combinations may occur: myoclonic and atonic or
myoclonic and tonic)
III. Unclassified epileptic seizures

Causes of Epilepsy
In 30% cases cause can be determined.
Rests (70%) are Idiopathic.
Determined causes:
●Inherited genetic
● Acquired : trauma, Neuro surgery, Inflammatory, Metabolic,
Infections, Tumor, Toxic disorders, drugs, etc.
●Congenital: inborn error of metabolism.
●Withdrawal of drugs
Alcohol,Benzodiazepine,
Barbiturates, Other Anti-Epileptics

Pathophysiology
 A seizure occurs when a portion of the brain becomes overly excited
or when nerves in the brain begin to fire together in an abnormal
fashion. Seizure activity can arise in areas of the brain that are
malformed from birth defects or genetic disorders or disrupted from
infection, injuries, tumors, strokes, or inadequate oxygenation.

The seizures results from an abrupt imbalance between
the forces that excite and inhibit the nerve cells such that
the excitatory forces take precedence. This electrical
signal then spreads to the surrounding normal brain cells,
which begin to fire in concert with the abnormal cells.

Pathophysiology of Epilepsy
 In normal brain inhibitory circuits limits synchronous
discharge.
GABA
is particularly play this role.
 When GABA receptors blocked ➔Rhythmic
and repetitive hypersynchronus discharge
of neurons ➔ seizures
 Excitatory NT ➔ Ach , Aspartate and Glutamate also
involved
to develop seizures
 Intracellular recording shows burst of rapid action

Pathophysiology of Epilepsy contd
Repeated subthreshhold of a neuron ➔generates an
action potentials ➔ seizures
It has been suggested that chronic epileptic
discharges may lead to secondary epileptogenesis.
Short, uncomplicated seizures cause no permanent/
progressive neorological dysfunctions in human
brain
BUT
uncontrolled generalized tonic-clonic seizures or
status epilepticus is associated with high
neurological morbidity and permanent brain
damage ( due to hypo perfusion, hypoxia, acidosis
and other metabolic disturbance).

Clinical
manifestations
Partial seizures or focal seizures are due to a small
epileptic focus in the brain.
They are divided into two main categories.
a. simple partial seizure in which the seizure starts as a
focal discharge and remains focal throughout without
alteration of consciousness
b. complex partial seizure when a seizure starts as a
focal discharge, but consciousness is also altered or lost

Clinical Presentations
Pupil size,
(Partial Seizures)
Simple Partial Seizures:
●Consciousness is fully preserved
● Motor disturbance may involve any body part
● Tingling , numbness, electrical shock like feelings
● Flashing light and colours, Simple hallucinations
● Changes in skin color, Blood pressure, Heart rate,
Piloerection.
● Psychic manifestation: Dysphasic- when cortical
area affected, Dysmnestic- disturbance of memory,
speech
Cognitive
symptoms- dreamy state, Affective symptoms- fear, depression, anger,
irritability, elation, erotic thoughts, Illusion of size, structured hallucination.

Definition
:
(Partial Seizures)

also
Frontal(30%).
(Partial Seizures)
Complex Partial Seizures
(Psychomotor Seizures/Temporal lobe Epelepsy)
● Always involved impairment of consciousness.
● Majority originate in Temporal lobe (60%); but
originate another lobe – particularly
● May start as simple partial seizures then progress.
● Aura may be present-short live (few seconds)
● Automatism: Oro-Alimentary, Mimicry, Gestural,
Ambulatory, Verbal, Responsive and Violent.
●Duration: < 3 minutes.

(Complex Partial Seizures)
Definition:

Generalized
seizure
 These are seizures in which there is no evidence of an epileptic focus,
either clinically or on EEG, as opposed to secondary generalised seizures. The
epileptic discharge involves both cerebral hemispheres simultaneously from
the onset of the seizures. Hence, consciousness is almost invariably impaired
or lost at the onset of the attack

(Generalized Seizures)
Generalized Tonic-clonic (grand mal)
Convulsive seizures
No Aura but have prodormal phase- general malaise
Tonic phase- The tonic phase consists of rolling up of the eyes associated with
stiffening of the limbs followed by clenching of the jaws, often resulting in injury to
the tongue. Lasts 10 to 30 seconds
Clonic phase: intermittent clonic movements of musclesstrenuous breathing,
sweating, frothing of the mouth and excess salivation lasts for 1-2 minutes
This is followed by a deep comatose state, which lasts for about 5 minutes
Post ictal period: drowsiness, confusion, headache, deep sleep

Generalized Tonic-clonic (grand mal)
Definition:

(Generalized Seizures)
Typical Absence Seizures (Petit mal):
● Occur almost exclusively in childhood or early
adolescent.
●Sudden loss of consciousness and cease all motor
only for a brief period often < 10 seconds.
●Suddenly appears blank and stares, fluttering
of the
eyelids, swallowing, flopping of the head.
●Attacks last only a few seconds (<10 sec) and
often pass un-recognized. About 100-200 attacks
generalized
drowsiness,
may occur/day.
●Characteristic EEG : 3 per sec
spike and wave
●Attacks precipitate by fatigue,
relaxation , photic stimulation or
hyperventilation.

Typical Absence Seizures (Petit mal)

Myoclonic seizures
Abrupt , very brief, involuntery flexion movements.
Involve whole body or part of the body
Occur most commonly at morning, shortly after walking.
May occur in healthy people (physiological)
Atonic Seizures
Brief loss of muscle tone.
Heavy fall , with or without loss of consciousness.

Diagnosis of Epilepsy
LFT, RFT, CSF
Brain, MRS, PET,
Thorough History taking :
From patients
From reliable valid informants
From observer (who observed seizures)
Physical Examination:
Specially neurological system
Higher Psychic function
Laboratory Investigation:
S. Electrolytes, S. Prolactin, Blood sugar, CBC, TFT,
study
Imaging:
EEG, Video EEG telemetry, CT Scan of Brain, MRI of
SPECT.
Polysomnography

MANAGEMENT OF EPILEPSY
This consists of
(i) treatment of the acute convulsions,
The latter consists of :
1. Removal of precipitating or causative factors.
2. Antiepileptic medication.
3. Social rehabilitation

Management of Epilepsy
Medical treatment:
Immediate care of seizures
Move persons away from danger
Recovery position (semi prone)
Ensure clear airway
Do not insert anything into mouth
Urgent medical attention- (patent airway, O2 ,
anticonvulsant, investigate cause)
Should not be left alone after recovery
Consider about regular AED
Surgical treatment:
Indicated when seizures shown to be intractable to medical treatment.
Removal of epileptic focus (eg:mesial temporal sclerosis)
Anterior Temporal Lobectomy
Corpus callostomy
Subpial transection
Vagus Nerve stimulation
Ketogenic diet

Treatment of the acute
convulsions
Convulsion is a medical emergency especially if
prolonged, which should be arrested without delay
Ensure patent airway
Protect from injury (do not restrain)
Remove or loosen tight clothing
Establish IV line
Suction as needed

Removal of precipitating or causative
factors
Reversal of metabolic disturbance such as an abnormality
of serum electrolytes or glucose
sleep deprivation should obviously be advised to maintain
a normal sleep schedule
Avoidance of illicit drug use,alcoholism etc

slow intravenous injection of 5-10 mg of diazepam
An alternate anticonvulsant drug is lorazepam 4 mg IV
given slowly over 5-10 minutes.
Other drug that must be given parenterally is phenytoin
sodium 100-200 mg IV

ANTIEPILEPTIC DRUG THERAPY
(AED)
AEDs are not curative in epilepsy, they help to control
seizures and give symptomatic relief
INDICATIONS
When more than one unprovoked seizure has occurred in
the preceding one to two years or when the risk of
recurrent convulsionis high as in head injury or
intracranial infections. AED should be started

AED: Indications and Dosage
Absence, Myoclonus
Myoclonus
AED Seizure type Dose range
(mg/day)
Doses
per day
Therapeutic
range
(μmol/L)
Carbamazepine Partial,Secondary GTCS, 250-2000 2-3 30-50
Sodium
Valporate
Primary & Secondary GTCS, 400-2500 1-2 NA
Phenytoin Partial, Secondary GTCS 150-350 1 40-80
Lamotrigine Partial, secondary GTCS 25-500 1-2 NA
Lorazepam Status Epilepticus 4 i.v. -- NA
Clonazepum Partial (adjunctive), 1-8 2-4 NA
Ethosuximide Childhood Absence 500-1500 2 200-700
Topiramate Partial, secondary GTCS 200-600 1-2 NA
Phenobarbital Partial, secondary GTCS 60-100 1 50-150

Guidelines for Anticonvulsant Therapy
until side
Start with one first line drugs
Start with low dose: Gradually increase to effective dose or
effects.
Check compliance
If first drug fails due to side effects or continue seizures, start second line
drugs whilst gradually withdrawing first.
Try Three AED singly before using combinations
Beware about drug interactions
Do not use more than two drugs in combination at any one time
If above fails consider occult structural or metabolic lesion and whether
seizures are truly epileptic.

Withdrawal of AED
After complete control of seizures for 2-4 years, withdrawal of Anti
Epileptic drugs may be considered. But in case of special professional
group (car driver, machine man etc) withdraw the AED after keen
follow-up.
AED should be tapered during the stopping of medications.
Slow reduction by increments over at least 6 months.
If the patient is taking two AEDs one drug should be slowly
withdrawn before the second is tapered.

Surgical Management of Epilepsy
 Lobe resection:Temporal lobe epilepsy, in which the seizure focus is
located within the temporal lobe, is the most common type of epilepsy
in teens and adults
 Lesionectomy: This is surgery to remove isolated brain lesions -- areas of
injury or defect such as a tumor or malformed blood vessel -- that are
responsible for seizure activity

Corpus callosotomy: The corpus callosum is a band of
nerve fibers connecting the two halves (hemispheres) of
the brain. A corpus callosotomy is an operation in which
all or part of this structure is cut, disabling communication
between the hemispheres and preventing the spread of
seizures from one side of the brain to the other.

Functional hemispherectomy: This is a variation of a
hemispherectomy, a radical procedure in which one entire
hemisphere, or one half of the brain, is removed. With a
functional hemispherectomy, one hemisphere is
disconnected from the rest of the brain, but only a limited
area of brain tissue is removed.

Vagus nerve stimulation (VNS): This is a device that
electronically stimulates the vagus nerve (which
controls activity between the brain and major
internal organs) is implanted under the skin

Responsive neurostimulation device (RNS): This device
consists of a small neurostimulator implanted within the
skull under the scalp. The neurostimulator is connected to
one or two wires (called electrodes) that are placed where
the seizures are suspected to originate within the brain or
on the surface of the brain. The device detects abnormal
electrical activity in the area and delivers electrical
stimulation to normalize brain activity before seizure
symptoms begin.

Complicatio
n
 When recurrent seizures occur at a frequency which does not allow
consciousness to be regained in the interval between seizures, it is called
status epilepticus
 prolonged or frequent seizures also lead to permanent damage to
the brain (hippocampus, Purkinje cells of cerebellum and
extrapyramidal system

Management
Time is a critical factor in the management of status
epilepticus
Benzodiazepines such as diazepam, lorazepam,
midazolam and clonazepam are all potent fast-acting
antiepileptic drugs, preferred for terminating the attack
immediately.

10 mg diazepam (0.3-0.5 mg/kg bw) should be given
slowly intravenously over a period of 2-5 minutes..
Lorazepam -0.1 mg/kg at 2 mg/minute is preferable to IV
Diazepam as it has longer duration of action (> 4 hrs) and
lesser respiratory depression

NURSING MANAGEMENT
Assessment
Physical examination
Emergency Management of seizure

Nursing
diagnosis
1.Ineffective breathing pattern related to neuromuscular
impairment secondary to prolonged tonic phase of seizure
or during post ictal period as evidenced by abnormal
respiratory rate, rhythm and depth
2.Risk for injury related to seizure activity and
subsequent impaired physical mobility secondary to
postictal weakness

3.Ineffective coping related to perceived loss of control
and denial of diagnosis as evidenced by verbalization bout
not having epilepsy ,lack of truth telling regarding seizure
frequency ,non compliant behavior.
4.Ineffective therapeutic regimen management related to
lack of knowledge about management of seizure disorder
as evidenced by verbalization of lack of knowledge
,inaccurate perception of health status.

Famous Persons with Epilepsy
Aristotle
Socrates
Julius Caesar
Fyodor Dostoyevsky
Lord Byron
Vincent Van Gogh
Alfred Nobel
Vlaldimir Illyich Lenin
Naepoleon Bonaparte
Tony Greig

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epilepsy.pptx