SEIZURE DISORDER
Overview
The majority of seizures are idiopathic. Seizures can present at any age and clinically can be described as convulsions, staring spells, muscle spasms, and odd sensations. Seizure types include febrile seizures, benign familial neonatal seizures, focal seizures, and generalized seizures, including absence epilepsy and juvenile myoclonic epilepsy (JME). Epilepsy has been defined by the International League Against Epilepsy (ILAE) as at least two unprovoked seizures occurring more than 24 hours apart, one unprovoked seizure, and the probability of further seizures similar to the general recurrence risk (at least 60%) after two unprovoked seizures occurring over the following 10 years and a diagnosis of an epilepsy syndrome (Fisher et al., 2014). Seizures that are provoked by changes in electrolytes, high fevers, or alcohol or drug withdrawal are not classified as epilepsy. Individuals can have a combination of provoked and unprovoked seizures. In children, brain malformations, intracranial lesions, or trauma can provoke seizures.
Background
Seizure disorders can be a chronic condition for many individuals, and chronic seizures can cause problems that impact social development and feelings that they are not like everyone else. This perceived feeling of social difference could also impact their psychological development. Furthermore, cognitive development can be impacted as a consequence of seizure frequency and medication side effects.
Clinical Aspects
ASSESSMENT
The evaluation of a patient with a seizure disorder consists of getting a detailed history of the event. This description includes what the child looked like before the event (if it was witnessed from the start), details of the event itself, whether the child lost consciousness and continence, how long the event lasted, and how long it took the individual to return to baseline. A thorough medical and developmental history is obtained. Labs, including a complete blood count (CBC), toxicology screen, and comprehensive metabolic panel (CMP), may be ordered depending on the circumstances surrounding the seizure. Neuroimaging studies, a head MRI, and an EEG are indicated.
Seizure disorders can be broken down into two main groups: focal and generalized. Generalized seizures involve both sides of the brain. They are associated with a loss of consciousness but not necessarily with shaking or convulsions. Generalized seizures are further delineated as absence (brief staring that may 97have associated automatisms) or tonic (stiffening), atonic (loss of tone), myoclonic (sudden, quick jerks), or clonic (jerking). The definition of status epilepticus has been revised to include seizure length as well as the time point that the seizure is now considered continuous seizure activity and the time after which there is a risk of long-term consequences (Trinka et al., 2015).
There are certain childhood epilepsies that are considered benign. These entities remit and require shortened or no medical intervention. Benign familial neonatal seizures affect otherwise healthy neonates. In general, seizures are brief and are associated with a period of apnea, causing cyanosis, and generalized tonic–clonic or focal–clonic movements (Park, Shahid, & Jammoul, 2015). The majority of infants with this seizure type have their seizures abate spontaneously. The infants can be started on phenobarbital with about 75% of infants responding to this treatment and continued for several weeks before weaning. Parents need to be aware of the increased risk of seizure recurrence later in life (Kaddurah, 2017).
Febrile seizures are a common occurrence in childhood affecting 2% to 5% of the pediatric population that is between 6 and 60 months of age. Febrile seizures occur in the presence of a fever not concomitant with an intracranial infection, a metabolic disorder, or in children who have a history of afebrile seizures (Shinnar & Shinnar, n.d.). Daily anticonvulsant therapy is not recommended for children with simple febrile seizures. Treatment options include the use of a benzodiazepine such as clonazepam orally disintegrating tablets, rectal diazepam gel, or buccal midazolam. These treatments can shorten the duration of the febrile seizure and are tolerated with less potential side effects than a daily anticonvulsant.
Sudden unexplained death in epilepsy (SUDEP) is defined as an unexpected, witnessed or unwitnessed, death in patients with epilepsy, with or without evidence of a seizure, an excluding documentation of status epilepticus, drowning, or trauma, with no toxicological or anatomic cause of death found on postmortem (Keddie et al., 2016). Individuals with epilepsy have a 24- to 28-fold increase of dying unexpectedly compared to the general population. Risk factors to SUDEP include poor seizure control, especially generalized tonic–clonic seizures, nighttime seizures, decreased supervision, polytherapy with antiepileptic medications, comorbid psychiatric conditions, and increased incidence of medication noncompliance (Tomson, Surges, Delamont, Haywood, & Hesdorffer, 2016).
Focal seizures arise from the temporal lobe and can be termed “temporal lobe epilepsy.” Children can demonstrate automatisms and motor manifestations as part of their seizure pattern. These motor behaviors can change depending on the age of the child. In the 0- to 3-year-old age group, the child’s motor manifestations may be difficult to differentiate from generalized seizures as the behaviors seen may be bilateral and symmetric, appearing more consistent with seizures arising from the frontal lobe. Children in the 3- to 6-year age range may have automatisms that are easier to disseminate, such as dystonic posturing, eye/mouth or head deviation, as well as having an awareness of an aura. Children older than 6 years and into adolescence may report similar automatisms and auras as adults. Auras may include a confusion state before seizure 98onset, a feeling of déjà vu, an olfactory aura, lip smacking, dystonic posturing of an extremity, or aimless movements (Nickels, Wong-Kisiel, Moseley, & Wirrell, 2012).
Treatment options for focal seizures include, but are not limited to, the following medications: carbamazepine, oxcarbazepine, phenytoin, levetiracetam, zonisamide, and perampanel. Multiple factors influence medication choice. Children often require a medication that either comes in a liquid preparation or one that can easily be chewed or crushed. In general, medications that are administered daily or twice a day (BID) have a greater likelihood of compliance compared to three times a day (TID) or four times a day (QID) regimens. Any seizure medication has the potential to cause lethargy, so it is often advantageous to start with a bedtime dose and titrate up slowly to improve tolerability.
Childhood absence epilepsy is the most common of all childhood epilepsies with females having a higher rate of occurrence than males. Absence seizures are brief staring spells that may or may not have associated automatisms. The associated automatisms may include a repetitive eye blink, lip movement, finger picking/rubbing, trunk arching, or eyelid twitching (Park et al., 2015). This type of seizure manifests between 4 and 10 years of age with the highest prevalence between 5 and 6 years of age (Park et al., 2015). The prognosis for this type of seizure is good as the majority of children with just absence seizures have their seizures abate after 6 to 7 years (Vrielynck, 2013). Studies have shown about 40% of individuals with absence seizures develop a generalized tonic–clonic seizure. It may initially be thought to be inattentiveness or attention deficit hypertensive disorder (ADHD) with the child. Parents need to monitor the child for accidental injuries, such as falling when they experience a seizure, as well as comorbid conditions including ADHD, anxiety, self-esteem issues, and depression (Tenney & Glauser, 2013). Treatment options include ethosuximide, valproate, and lamotrigine. Ethosuximide is often the first choice as it has a high rate of treatment success with minimal side effects. When ethosuximide has tolerability issues, it is usually with the gastrointestinal (GI) system. Most often, dosing BID or TID and taking with food can minimize GI upset. A valproate is an option especially if the individual has also had a generalized convulsion.
JME consists of bilateral myoclonic jerks, usually most prevalent in the early morning after waking, generalized convulsions, and absence seizures. JME syndrome occurs most frequently in individuals aged 13 to 15 years (Park et al., 2015). Long-term seizure control by medication has been seen in as many as 75% to 90% of patients with a diagnosis of JME (Rossi, 2013). Individuals with JME should adopt lifestyle changes to maximize seizure control. This includes maintaining a regular eating and sleeping schedule, minimizing alcohol consumption, and maintaining a high percentage of medication compliance (Mantoan & Walker, 2011).
NURSING INTERVENTIONS, MANAGEMENT, AND IMPLICATIONS
There are several medication choices for the treatment of seizure disorders. Medication choice depends on seizure type, patient age, functional level, and 99comorbid conditions. Nursing intervention starts with the identification of the seizure. It is important to document how the patient looked at the start of the seizure, duration of the seizure, and duration until the child was back to baseline. Parental education is a crucial nursing function. There are several elements to seizure first aid and safety to be discussed with families. In addition to timing and noting the description of the event, parents should be instructed to lay the child down on a flat surface once the seizure starts. The child should be turned on his or her side to maintain a patent airway and prevent aspiration as the child may vomit during or immediately after the seizure. Keep the airway open and clear, and instruct the parents never to place anything, including their fingers, in the child’s mouth. The child’s glasses and nearby safety hazards should be removed. Safety issues for the child in the wheelchair are a bit different. These children are safer as they remain in the wheelchair. Make sure that the brakes of the wheelchair are engaged and that the seat belt is secured. Hold the wheelchair in place and upright while the child is seizing.
Nursing education of anticonvulsants includes more than discussing potential side effects. Compliance issues can be addressed by determining the route and frequency of medication administration that will work best for each patient. When checking anticonvulsant levels, instruct families to obtain levels first thing in the morning or late in the day as a trough level. A trough level may be more beneficial than obtaining a peak level. It is important for the nurse to know the reference range and parameters so that the lab value is interpreted correctly. A thorough medication history, including over-the-counter medications and herbal supplements, is done to determine any potential drug interactions.
Individuals with seizure disorders should be encouraged to take showers rather than baths, so the drain is always open, and standing water cannot accumulate. Nonskid strips on the tub or shower floor are often helpful in preventing falls, and bathroom doors should never be locked in the event an emergency occurs. Swimming needs to be supervised with an adult present who can remove the child from the water if a seizure occurs. Schools often require a seizure action plan for students with epilepsy. In addition to the student and parent’s name, it should include several contact numbers for the family as well as for the treating provider. Medications, including routine and as needed (pro re nata [PRN]) rescue medications, as well as instruction for use are imperative. The plan needs to dictate when 911 is to be called as well as how to manage the child in the postictal period until able to return to the classroom.
The last restriction that should be discussed with the family is driving privileges. Each state has its protocol regarding getting and maintaining a license when there is a history of seizure disorders. The individual needs to demonstrate that he or she has been seizure free for at least 6 months. The individual needs to have a measurable blood level of his or her anticonvulsant(s). It is recommended that this level be checked randomly as a trough rather than at a scheduled or predetermined visit. The random check will give the provider a better sense of patient compliance rather than giving the patient the opportunity to take an oral load to catch up for missed doses. The state bureau of motor vehicle forms is completed every 6 to 12 months.
100OUTCOMES
There are several medication choices for the treatment of seizure disorders. Medication choice depends on seizure type, patient age, functional level, and comorbid conditions. The outcome of medication treatment is to balance the therapeutic levels with toxic side effects. The patients’ and families’ quality of life will depend upon their perceived feeling of social difference and the cognitive, physical, and social development of the child.
Summary
Seizure disorders can affect individuals throughout their life spans, and the diagnosis can be challenging for both the patient and his or her family. It is imperative to provide support for the patient and all concerned. There are several community-based resources that can and should be made available to the family. The local Epilepsy Foundation (www.epilepsy.com) will provide additional educational materials as well as in-services for schools, day cares, and employers. The American Epilepsy Society (www.aesnet.org) can also provide helpful information. Prescription medication can be costly to families, and programs such as www.Rxassist.org should be discussed with the family. Finally, additional resources for insurance/coverage such as state health departments should be made available to families.
Fisher, R. S., Acevedo, C., Arzimanoglou, A., Bogacz, A., Cross, J. H., Elger, C. E., . . . Wiebe, S. (2014). ILAE official report: A practical clinical definition of epilepsy. Epilepsia, 55(4), 475–482. doi:10.1111/epi.12550
Kaddurah, A. (2017). Benign childhood epilepsy. In A. Kao (Ed.), Medscape. Retrieved from http://emedicine.medscape.com/article/1181649-overview#a1
Keddie, S., Angus-Leppan, H., Parker, T., Toescu, S., Nash, A., Adewunmi, O., & Liu, R. (2016). Discussing sudden unexpected death in epilepsy: Are we empowering our patients? A questionnaire survey. Journal of the Royal Society of Medicine Open, 7(9). doi:10.1177/2054270416654358
Mantoan, L., & Walker, M. (2011). Treatment options in juvenile myoclonic epilepsy. Current Treatment Options in Neurology, 13(4), 355–370. doi:10.1007/s11940-011-0131-z
Nickels, K. C., Wong-Kisiel, L. C., Moseley, B. D., & Wirrell, E. C. (2012). Temporal lobe epilepsy in children. Epilepsy Research and Treatment, 2012, 1–16. doi:10.1155/2012/849540
Park, J. T., Shahid, A. M., & Jammoul, A. (2015). Common pediatric epilepsy syndromes. Pediatric Annals, 44(2), e30–e35. doi:10.3928/00904481-20150203-09
Rossi, M. A. (2013). Juvenile myoclonic epilepsy: When will it end. Epilepsy Currents, 13(3), 148–149. doi:10.5698/1535-7511-13.3.148
Shinnar, R. C., & Shinnar, S. (n.d.). Febrile seizures. Retrieved from http://www.child neurologyfoundation.org/disorders/febrile-seizures
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
