Seizure Disorders

  1. General information
    1. Seizures: recurrent sudden changes in consciousness, behavior, sensations, and/or muscular activities beyond voluntary control that are produced by excess neuronal discharge
    2. Epilepsy: chronic recurrent seizures
    3. Incidence higher in those with family history of idiopathic seizures
    4. Cause unknown in 75% of epilepsy cases
    5. Seizures may be symptomatic or acquired, caused by
      1. Structural or space-occupying lesion (tumors, subdural hematomas)
      2. Metabolic abnormalities (hypoglycemia, hypocalcemia, hyponatremia)
      3. Infection (meningitis, encephalitis)
      4. Encephalopathy (lead poisoning, pertussis, Reye's syndrome)
      5. Degenerative diseases (Tay-Sachs)
      6. Congenital CNS defects (hydrocephalus)
      7. Vascular problems (intracranial hemorrhage)
    6. Pathophysiology
      1. Normally neurons send out messages in electrical impulses periodically, and the firing of individual neurons is regulated by an inhibitory feedback loop mechanism
      2. With seizures, many more neurons than normal fire in a synchronous fashion in a particular area of the brain; the energy generated overcomes the inhibitory feedback mechanism
    7. Classification (see Table 5.3 below)
      1. Generalized: initial onset in both hemispheres, usually involves loss of consciousness and bilateral motor activity
      2. Partial: begins in focal area of brain and symptoms are appropriate to a dysfunction of that area; may progress into a generalized seizure, further subdivided into simple partial or complex partial
  2. Medical management
    1. Drug therapy (refer to Anticonvulsants, in Unit 2)
      1. Phenytoin (Dilantin)
        1. often used with phenobarbital for its potentiating effect
        2. inhibits spread of electrical discharge
        3. side effects include gum hyperplasia, hirsutism, ataxia, gastric distress, nystagmus, anemia, sedation
      2. Phenobarbital: elevates the seizure threshold and inhibits the spread of electrical discharge
    2. Surgery: to remove the tumor, hematoma, or epileptic focus
  3. Assessment findings
    1. Clinical picture varies with type of seizure (see Table 5.3 below)
    2. Diagnostic tests
      1. Blood studies to rule out lead poisoning, hypoglycemia, infection, or electrolyte imbalances
      2. Lumbar puncture to rule out infection or trauma
      3. Skull x-rays, CT scan, or ultrasound of the head, brain scan, arteriogram, or pneumoencephalogram to detect any pathologic defects
      4. EEG may detect abnormal wave patterns characteristic of different types of seizures
        1. child may be awake or asleep; sedation is ordered and child may be sleep deprived the night before the test
        2. evocative stimulation: flashing strobe light, clicking sounds, hyperventilation
  4. Nursing interventions
    1. During seizure activity
      1. Protect from injury.
        1. prevent falling, gently support head.
        2. decrease external stimuli; do not restrain.
        3. do not use tongue blades (they add additional stimuli).
        4. loosen tight clothing.
      2. Keep airway open.
        1. place in side-lying position.
        2. suction excess mucous.
      3. Observe and record seizure.
        1. note any preictal aura.
          1. affective signs: fear, anxiety
          2. psychosensory signs: hallucinations
          3. cognitive signs: "déjà-vu" symptoms
        2. note nature of the ictal phase.
          1. symmetry of movement
          2. response to stimuli; LOC
          3. respiratory pattern
        3. note postictal response: amount of time it takes child to orient to time and place; sleepiness.
    2. Provide client teaching and discharge planning concerning
      1. Care during a seizure
      2. Need to continue drug therapy
      3. Safety precautions/activity limitations
      4. Need to wear Medic-Alert identification bracelet or carry identification card
      5. Potential behavioral changes and school problems
      6. Availability of support groups/community agencies
      7. How to assist the child in explaining disorder to peers

TABLE 5.3 Types of Seizures

Type of Seizure

Clinical Findings

Generalized seizures

Major motor seizure (grand mal)

May be preceded by aura; tonic and clonic phases.
Tonic phase: limbs contract or stiffen; pupils dilate and eyes roll up and to one side; glottis closes, causing noise on exhalation; may be incontinent; occurs at same time as loss of consciousness; lasts 20–40 seconds.
Clonic phase: repetitive movements, increased mucus production; slowly tapers.
Seizure ends with postictal period of confusion, drowsiness.

Absence seizure (petit mal)

Usually nonorganic brain damage present; must be differentiated from daydreaming.
Sudden onset, with twitching or rolling of eyes; lasts a few seconds.

Myoclonic seizure

Associated with brain damage, may be precipitated by tactile or visual sensations.
May be generalized or local.
Brief flexor muscle spasm; may have arm extension, trunk flexion.
Single group of muscles affected; involuntary muscle contractions; myoclonic jerks.

Akinetic seizure (tonic)

Related to organic brain damage.
Sudden brief loss of postural tone, and temporary loss of consciousness.

Febrile seizure

Common in 5% of population under 5, familial, nonprogressive; does not generally result in brain damage.
Seizure occurs only when fever is rising.
EEG is normal 2 weeks after seizure.

Partial seizures

Psychomotor seizure

May follow trauma, hypoxia, drug use.
Purposeful but inappropriate, repetitive motor acts.
Aura present; dreamlike state.

Simple partial seizure

Seizure confined to one hemisphere of brain.
No loss of consciousness.
May be motor, sensory, or autonomic symptoms.

Complex partial seizure

Begins in focal area but spreads to both hemispheres.
Impares consciousness.
May be preceded by aura.

Status epilepticus

Usually refers to generalized grand mal seizures.
Seizure is prolonged (or there are repeated seizures without regaining consciousness) and unresponsive to treatment.
Can result in decreased oxygen supply and possible cardiac arrest.