9.2 Seizure disorders and epilepsy

Seizures are sudden, abnormal electrical discharges in the brain that can cause various symptoms. Understanding the pathophysiology and types of seizures is crucial for nurses to provide effective care. This knowledge helps in recognizing different seizure presentations and implementing appropriate interventions.

Proper diagnosis and management of epilepsy involve a multidisciplinary approach. Nurses play a vital role in patient safety, medication administration, and education. They also collaborate with other healthcare professionals to ensure comprehensive care for individuals with epilepsy.

Pathophysiology and Types of Seizures

Pathophysiology of seizure types

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• Abnormal, excessive, synchronous neuronal activity in the brain causes seizures
• Imbalance between excitatory neurotransmitters (glutamate) and inhibitory neurotransmitters (GABA) leads to seizure activity
• Factors affecting seizure threshold include genetics (channelopathies), brain injury (trauma, stroke), infections (meningitis, encephalitis), and metabolic disturbances (hypoglycemia, electrolyte imbalances)
• Generalized seizures involve both cerebral hemispheres from the onset and include:
  • Tonic-clonic (grand mal): characterized by loss of consciousness, muscle rigidity (tonic phase), and rhythmic jerking (clonic phase)
  • Absence (petit mal): brief lapses in consciousness accompanied by staring and eye fluttering, more common in children
  • Myoclonic: sudden, brief muscle jerks involving one or more muscle groups
  • Atonic: sudden loss of muscle tone, causing falls or head drops
• Focal seizures originate in a specific area of the brain and are classified as:
  • Simple focal: no alteration in consciousness, may involve motor (jerking, stiffening), sensory (tingling, visual disturbances), or autonomic (sweating, heart rate changes) symptoms
  • Complex focal: altered consciousness accompanied by automatisms (repetitive, purposeless movements such as lip-smacking or hand rubbing)
  • Focal seizures with secondary generalization: begin focally and spread to involve both hemispheres, resulting in a generalized tonic-clonic seizure

Diagnostic criteria for epilepsy

• At least two unprovoked seizures occurring more than 24 hours apart confirms epilepsy diagnosis
• One unprovoked seizure with a high probability of recurrence (>60%) based on EEG findings (epileptiform discharges) or structural lesions on neuroimaging (MRI, CT) also meets diagnostic criteria
• Diagnostic tests for epilepsy include:
  • Electroencephalogram (EEG): records electrical activity in the brain, identifies abnormal patterns and seizure foci, sleep-deprived or prolonged EEG may increase diagnostic yield
  • Neuroimaging: MRI or CT scan to identify structural abnormalities (tumors, malformations, scars)
  • Video-EEG monitoring: simultaneous video and EEG recording to correlate seizure activity with clinical manifestations, helpful in differentiating epileptic from non-epileptic events
• Differentiating epilepsy from other neurological conditions is crucial:
  • Syncope: brief loss of consciousness due to decreased cerebral blood flow, often preceded by lightheadedness or visual changes
  • Transient ischemic attack (TIA): temporary neurological deficits (weakness, numbness, speech difficulties) due to focal cerebral ischemia, resolving within 24 hours
  • Migraine: recurrent headaches with associated neurological symptoms (visual aura, sensory disturbances), may mimic focal seizures
  • Psychogenic non-epileptic seizures (PNES): seizure-like episodes without corresponding EEG abnormalities, often associated with psychological factors (stress, trauma)

Nursing interventions for seizure management

• Ensure patient safety during seizures by maintaining a clear, safe environment (remove hazards, pad bed rails)
• Protect the patient's head and turn them on their side to prevent aspiration of secretions or vomit
• Avoid restraining the patient or placing objects in their mouth, as this can cause injury
• Monitor vital signs (blood pressure, heart rate, respiratory rate) and oxygen saturation during and after the seizure
• Administer rescue medications as prescribed for acute seizure management:
  • Benzodiazepines (lorazepam, diazepam) are first-line treatments, can be given intravenously (IV), rectally, buccally, or intranasally when IV access is unavailable
• Monitor for and manage complications related to seizures:
  • Aspiration pneumonia: monitor for signs of respiratory distress, fever, and abnormal lung sounds
  • Injuries related to falls or muscle contractions: assess for fractures, dislocations, or soft tissue injuries
  • Status epilepticus: continuous seizure activity lasting more than 5 minutes or multiple seizures without regaining consciousness, requires prompt treatment to prevent neurological damage
• Provide patient and family education on seizure first aid, safety precautions (avoiding triggers, water safety), medication adherence, side effects, and the importance of maintaining a seizure diary to track frequency and characteristics of seizures
• Encourage lifestyle modifications such as maintaining good sleep hygiene, managing stress, and avoiding known seizure triggers (alcohol, sleep deprivation, flashing lights)

Interdisciplinary epilepsy treatment planning

• Pharmacological treatment with antiepileptic drugs (AEDs) is the mainstay of long-term seizure management:
  • Monotherapy (using a single AED) is preferred to minimize side effects and drug interactions
  • Common AEDs include levetiracetam, valproic acid, carbamazepine, lamotrigine, and phenytoin
  • Monitor therapeutic drug levels and adjust dosages as needed to optimize seizure control and minimize adverse effects
  • Assess for drug interactions (with other AEDs, antibiotics, oral contraceptives) and adverse effects (drowsiness, dizziness, cognitive impairment)
• Non-pharmacological approaches may be considered for patients with refractory epilepsy:
  • Ketogenic diet: high-fat, low-carbohydrate diet that can reduce seizure frequency, requires close monitoring by a dietitian
  • Vagus nerve stimulation (VNS): implanted device that delivers electrical stimulation to the vagus nerve, can reduce seizure frequency and severity
  • Responsive neurostimulation (RNS): implanted device that detects and disrupts seizure activity in real-time, targeting specific brain regions
  • Surgical options for refractory cases include resection of the seizure focus (temporal lobectomy) or corpus callosotomy to prevent the spread of seizures between hemispheres
• Interdisciplinary collaboration is essential for comprehensive epilepsy care:
  1. Neurologists: diagnose epilepsy, prescribe medications, and oversee long-term management
  2. Neurosurgeons: perform surgical interventions when indicated (resection, VNS, RNS placement)
  3. Nurses: provide patient education, monitor treatment response, ensure medication adherence, and assess for complications
  4. Dietitians: assist with the implementation and monitoring of the ketogenic diet, ensuring nutritional adequacy
  5. Social workers: address psychosocial concerns (stigma, employment, driving restrictions) and connect patients with community resources (support groups, transportation services)
  6. Occupational and physical therapists: help patients maintain independence in activities of daily living and prevent injuries related to seizures