Chapter 26 Seizures
INTRODUCTION
Anyone can have an isolated seizure at some point in their life (NSE 2002a). They can happen for a variety of different reasons. Seizures are periods of sudden disturbance in neurological function that cause involuntary muscle activity, change in level of consciousness, or altered behavioural and sensory manifestations (Cameron et al 2005). Seizures can be frightening and disturbing to observe, both for the professional and the family. A number of dangers can occur during a seizure, i.e. apnoea, airway obstruction, aspiration and injury. The nurse’s role is to provide a safe environment for the duration of the seizure and respond appropriately to the situation.
RATIONALE
At least 20% of children admitted to hospital have a neurological problem, either as the sole or an associated complaint. Seizures are the most frequently observed neurological dysfunction in children (Slota 2006). Although seizures are the main characteristic of epilepsy, a chronic disorder with recurrent and unprovoked seizures, a single seizure event should not be classified as epilepsy. Seizures are a symptom of an underlying disease process and they can occur with a variety of conditions involving the central nervous system (CNS) (Wong 2007). Approximately 20% of children will experience a seizure in the first 5 years of life, often associated not with epilepsy, but with a febrile illness (Rudolf & Levene 1999). In children who have experienced a seizure associated with a febrile illness, about 15% of cases will have a further seizure within the same illness; 60% of these children are at risk of at least one more febrile seizure before they are 6 years old, with a further third of these at risk of three or more seizures (Crisp & Rainbow 2007). The risk is even higher if the onset is before the age of 1 year and if there is a positive family history (Lissauer & Clayden 2001). It is therefore important for the paediatric nurse to know how to care for a child during a seizure. Education of parents is also important as to the cause, and how to handle possible future seizures.
FACTORS TO NOTE
Neonatal seizures
The newborn period is the time of life with the highest risk of seizures and epilepsy. The newborn brain is more susceptible to a large number of cerebral and systemic insults. The immature brain is relatively ‘excitable’ and more likely to seize (Appleton & Gibbs 2004). Neonatal seizures can be difficult to recognise. Many babies in the neonatal period can have abnormal and involuntary movements that must be differentiated from seizures, i.e. jitteriness, startling or spontaneous clonus (Lissauer & Clayden 2001, Appleton & Gibbs 2004).
The features of neonatal seizures are different from those seen in the older infant or child. Most seizure activity in neonates may be subtle, tonic, clonic or myoclonic. The main causes of neonatal seizures are (Crisp & Rainbow 2007):
Infants and older children
Convulsions in the infant and older child can still be due to some of the causes seen in neonates.
Febrile convulsions are one of the most common neurological disorders in childhood, affecting about 3% of children. They usually occur between 6 months and 3 years but can go up to 6 years of age (Lissauer & Clayden 2001). They are generalised seizures and occur in children as a result of rapid temperature rise above 39°C (102°F). Up to 75% of all febrile seizures involve a generalised onset, tonic–clonic seizure that lasts <15 min with no post-ictal neurological deficit or sequelae (Appleton & Gibbs 2004).
Status epilepticus
Status epilepticus is defined as a continuous tonic-clonic seizure lasting >30 min or a series of repeated seizures between which the child does not fully regain consciousness (Moules & Ramsey 2008). It is an emergency situation which is life-threatening and in which the child is at risk of permanent brain damage. It is important to support the child’s vital functions, i.e. maintain a patent airway, adequate oxygenation and hydration. Monitor vital signs and assess neurologic level. NICE (2002) recommends the use of benzodiazepines such as rectal diazepam or buccal midazolam for pre-hospital treatment, which if there was no response, could be repeated. Treatment with intravenous anticonvulsant/sedative drugs (i.e. lorazepam) will possibly be required. Loading doses of phenytoin, or phenobarbital, may be necessary if seizures persist. McIntyre et al (2005) suggest that buccal midazolam is more effective than rectal diazepam and does not have the side-effects of respiratory depression. Clonazepam or thiopental may then be necessary, but these drugs will suppress not only the epileptiform activity but also normal brain function. As this includes the breathing centres, these children will most probably require mechanical ventilation in an intensive care unit.
Epilepsy
Epilepsy is the commonest chronic neurological condition in childhood (SIGN 2003). It means having a tendency to experience recurrent seizures that originate in the brain, which happen when ordinary brain activity is suddenly disrupted. As the brain is responsible for a wide range of functions, seizures associated with epilepsy can take on many forms and affect areas such as memory, sensation, personality, consciousness, mood and movement. Any of these functions may be temporarily disturbed during the course of a seizure (NSE 2002a). The diagnosis of epilepsy has important health, educational and social implications for both the child and family (SIGN 2003). These can include behavioural and emotional problems that are sometimes caused by embarrassment or frustration associated with their epilepsy. Having epilepsy can affect your independence by restricting your access to driving and some people and their families live in fear of the next seizure.
Children diagnosed with epilepsy will be commenced on regular anticonvulsant medication. The type of seizure will determine which medications will be prescribed. Approximately 70–75% of children with epilepsy can be controlled with a single anticonvulsant drug. The current ‘recommended’ first-line drugs are sodium valproate for generalised seizures and carbamazepine for partial seizures (RCPCH 2003). It often takes time to find the drug most suitable for optimum treatment and dose adjustment is ongoing as the child grows and develops.
Adolescents
Teenagers with epilepsy are frequently caught between paediatric and adult services with neither service being able to understand, or satisfy, their specific needs and concerns. Emotional and social development is also important during this period, as young people try and find their place in society. Many young people at this time are emotionally impressionable (Barnes 2003). Adolescents who have epilepsy may find that the onset of puberty and its accompanying hormonal changes can lead to further seizures. This may occur, even although they were previously well controlled on medication. This can be particularly distressing, especially if they had been free of seizures for some time. In addition to the distress of seizures recurring, the adolescent in particular may be extremely sensitive about involuntary loss of control of bladder and bowel which can occur with some seizures.
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