Seizure Treatment and Management

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Introduction

Known in its clinical form as an uncontrolled burst of electrical activity in the brain, seizures cause an interruption of the brain’s normal function. Epilepsy is described as recurrent seizures. Those affected by these conditions may have muscle tone changes—twitching, flaccid, or stiffness—or cognitive awareness. Age plays a large factor when it comes to seizures and can often set precedence for the rest of an individual’s life. Genetics, trauma, birth defects, and drug or alcohol use are all factors that can contribute to a seizure, though not all warrant a seizure diagnosis as some may resolve on their own.  

It is important to understand the various types, appropriate care protocols, and special populations that may require extra consideration when it comes to seizure treatment and management. Healthcare providers may encounter individuals with this diagnosis in or outside the healthcare setting, and when time is of the essence, it is crucial to provide the best and quickest care possible. This course aims to educate the healthcare provider on effective seizure treatment and management. 

Types of Seizures 

Seizures vary from person to person and often have several stages that they may progress through. It is vital for nurses to differentiate and be aware of these phases in order to provide effective seizure treatment and care to patients.  

3 Phases of Seizures

1. Prodromal Phase: This is the first stage in seizures that a patient will progress through. It may include any signs or activities that precede the seizure.  
2. Aural Phase: The aural phase is the second stage of seizure progression. In this phase, if an individual experiences it, an aura or warning sign occurs. The aura can be different for each individual and can be a variety of things. Some individuals report smelling, hearing, seeing, tasting, or feeling something. Others report visual changes, nausea, feelings of anxiety, or a sense of being disconnected from their bodies. How often a seizure occurs after the aura presents itself varies. Sometimes individuals are given only seconds before the event; others have experienced the seizure an hour later. If an aura precedes a seizure, it is often the same one for each seizure (10).  
3. Ictal Phase: The third stage is called the ictal phase and is when the seizure occurs. After the seizure ends, the person may immediately return to their baseline or have an extended period of recovery time known as the postictal phase. Patent safety is important in these last two phases as the individual may not be able to protect their airway or body from harm. Those in the postictal phase can become combative or confused (10). 

3 Categories of Seizures

Seizures come in three distinct categories: focal, generalized, and psychogenic. It is important for a nurse to be able to differentiate between these categories in order to provide effective seizure treatment and management.  

Focal and generalized seizures have a few subcategories that are broken down even further. 

Focal seizures: 

Are also known as partial or partial focal seizures that start in one section of the brain and may travel to other areas, creating a variety of presentations (9).  

• Simple Focal Seizure: In simple focal seizures, the individual experiencing the seizure is still conscious while having feelings of unexplainable emotion or changes in their senses — hearing, smelling, tasting, seeing, or feeling things that are not there.

• Complex focal seizures: These seizures created a change in the person’s level of consciousness. This period of change may be a total loss or a partial loss of consciousness. People who experience these types of seizures may exhibit repetitive behaviors or continue doing the task they were doing prior to the seizure. This behavior is known as automatisms and can be displayed in a variety of ways. People may pick at their clothes, struggle with real or imaginary objects, smack their lips, or walk away from what they were doing. These types of seizures usually last for a few seconds, and the individual experiencing the seizure has no memory of what occurred during the episode (10).  

Generalized Seizures:  

As opposed to focal seizures, generalized seizures affect both parts of the brain that result in abnormal amounts of electrical discharge in the brain. These episodes may last for a few seconds to a few minutes.  

• Tonic-Clonic Seizure: Out of the several types of seizures, tonic-clonic seizures are the most common and recognized type. Previously identified as grand mal seizures, tonic-clonic seizures are separated into two distinct parts.  

1. The tonic phase, where the person’s body becomes stiff or tense that lasts for 10 to 20 seconds.  
2. The clonic phase is where the body begins to shake, lasting for 30 to 40 seconds.  

Since the person experiencing the seizure loses control of their body, things like biting the tongue or cheeks may occur. If standing upright or sitting before the seizure occurs, the person may fall, leading to other injuries. People may experience some form of incontinence or excessive salivation, leading to potential airway compromise. Those who experience these types of seizures are often tired after the episode and may sleep for several hours after. They may report muscle soreness, and it is possible that they may not feel normal for hours to days after the seizure. They do not have memory of the event (10).  

• Absent seizures: Absent seizures are another type of generalized seizure that are broken down into typical or atypical.  

1. Typical absent seizures, once known as petit mal seizures, often occur in children that rarely progress to adolescence. They usually start around the ages of 4 to 6 years; however, they can start in the teenage years and progress into adulthood. If juvenile absent seizures occur, they are often accompanied by tonic-clonic seizures when the adolescent transitions into an adult. Absent seizures are classified as the individual “daydreaming” or having a staring spell episode that lasts for a few seconds.  
2. Atypical absent seizures have the “daydreaming” appearance that typical absent seizures have, with the addition of other signs and symptoms. These signs can include a warning before the event, bizarre behavior during, and confusion or disorientation after. These types of seizures last longer than typical absent seizures, and the individual who experiences the seizure may have a loss in postural tone (10).

• Myoclonic seizure: These seizures occur when there is excessive sudden jerking of extremities or the entire body, possibly resulting in the person hurling themselves to the ground. Often, they occur in clusters and are brief. 

• Atonic Seizure: Atonic or “air drop” seizures include either a tonic or paroxysmal loss of a person’s muscle tone that begins suddenly and causes the person to fall to the ground. The period of unconsciousness is usually resolved by the time the person hits the ground, and there is no recovery or postictal phase. This means the person can immediately return to what they were doing before the seizure. These types of seizures put the person at risk for severe head or brain injuries and are often required to wear a helmet to protect them.  

Psychogenic Seizures:  

The last type of seizure is classified as a psychogenic seizure. People who experience these pseudoseizures often have some history relating to emotional or physical abuse, traumatic episodes, or physical neglect. They are psychiatric in nature and may appear to be an actual epileptic event, resulting in a misdiagnosis (10). 

Status Epilepticus 

While the safety of all seizure patients is a priority, the seizures experienced are often self-limiting, usually two minutes or less, and the individual eventually returns to baseline. However, the most important complication of a seizure or epilepsy diagnosis is the potential for the individual to have recurrent seizures with no return to baseline or a seizure that lasts longer than five minutes; this is known as status epilepticus (4).  

Status epilepticus is considered a medical emergency and should be treated efficiently and effectively to prevent life-threatening complications. If you will recall, a seizure was defined as a burst of electrical activity; that burst of activity requires energy, and after a while, the brain and body will use more energy than what is available. If this happens, neurons in the brain can cease function and die, resulting in permanent brain damage. While anyone with a seizure history can go into status epilepticus, those who have a history of tonic-clonic seizures are at a higher risk for inadequate ventilation and hypoxemia, hyperthermia, cardiac dysrhythmias, and systemic acidosis due to the nature and characteristics of their seizures. All of these can lead to severe injury or death so recognizing the signs and a patient’s history are vital in status epilepticus and seizure treatment (10). 

While status epilepticus presents enough complications when happening, the patient is also at risk for physical harm, a topic lightly touched on above. An individual may be going about their day and have an episode, leaving them in a vulnerable situation. They could fall down a flight of stairs or into traffic. They could drown in a pool, lake, or bathtub. People who experience convulsing seizures like tonic-clonic ones may hit themselves on nearby objects during the episode, leading to severe harm. Those who lose consciousness during their seizures are at the highest risk for trauma or death from these injuries (10). 

Management 

Status epilepticus or seizure treatment and management revolve around stopping the seizure, protecting the airway, and further preventing patient harm. Always ensure that the airway is open, and the patient has supplemental oxygen. In some cases, the patient may need to be intubated to protect the airway; however, utilizing short-acting paralytics are discouraged as it can mask a seizure (6).  

Intravenous (IV) access is critical when it comes to patients and seizures. It is always advisable to establish access before a situation occurs rather than wait until one happens. However, that is not always possible as patients may present during a seizure, making it difficult to obtain access. IV or intraosseous (IO) access is preferred for the administration of several types of medications. Using anticonvulsants to stop seizures varies depending on the type of access a patient has. As mentioned, IV or IO is preferred as medications like Cerebyx, Dilantin, and Phenobarbital can only be given via these routes. Benzodiazepines like Valium, Ativan, or Versed can be given intramuscular (IM), intranasal, or rectal in addition to IV/IO (6).  

When developing an effective seizure treatment plan, it is vital for the healthcare provider to consider any potential causes. People who utilized narcotics may experience narcotic toxicity and need Narcan to reverse the seizure. Hypoglycemic seizures can be treated by given infusions of dextrose; if it is suspected that the individual having the seizure is an alcoholic, administer thiamine first and then dextrose (6).  

As mentioned, paralytics can create a problem for those having status epilepticus. While they prevent the individual from having the physical presentation of their seizure — convulsions and posturing — it does not stop the electrical activity in the brain. This means that the person is still having the seizure, but they do not have the external signs. This is known as a subclinical seizure and often occurs when a patient is paralyzed while intubated (10).  

Diagnostics and Treatment

Since a diagnosis of epilepsy is life-altering, it is important for the diagnosis to be correct. Extensive medical history regarding birth, development, family, injury, and illness is combined with an in-depth neurological examination done by a neurologist. Descriptions of the seizures, including precipitating factors or auras, duration, characteristics, onset, frequency, and presence of a postictal phase, are utilized if available.  

Basic and specialized bloodwork can rule in or out a diagnosis of seizures as well as eliminate or produce probable causes. Complete blood count, metabolic panel — basic or complete — fasting blood glucose, electrolytes, kidney function, urinalysis, urine drug screen, and alcohol levels should all be considered (10).  

Individuals often undergo extensive imaging when the possibility of a seizure disorder is presented. In the emergent setting, CT scans are often done to rule out causes like hemorrhages or masses, preferably to be done within 24 hours of a new-onset seizure. MRI, magnetic resonance spectroscopy (MRP), MRA, positron emission tomography (PET), angiography, and single-photo emission computed tomography (SPECT) can be utilized as well (10).  

The most useful test for seizures is the electroencephalogram (EEG). This is a device that reads and records brain electricity. Tiny discs are pasted onto the scalp and are used to detect the electric charges from brain activity. The EEG is usually left on for a few hours to days to determine the baseline of brain activity and how it varies. Seizures can cause spikes or changes on an EEG, and with an observation of the seizure (when possible) can lead to a proper diagnosis (8).  

There is no definitive cure for seizures, but medications and surgeries have been designed to assist individuals with their diagnosis. Not every seizure treatment regimen is the same, and sometimes it takes many adjustments and plans to get desired results. Often treatment starts off with one antiseizure medication that is dosed based on the individual’s age and weight, type of seizure, frequency, and cause. The dose is then increased until the seizures are controlled or there becomes a toxic effect from the medication. Some people require several medications to control their seizures, and sometimes they may still have breakthroughs (10). 

If medications do not control the seizures an individual is having, they may be a candidate for alternative treatment in the form of surgery. The most common type of surgery is an anterior temporal lobe resection. This surgery is designed to remove the epileptic focus or prevent the spread of seizure-like activity around the brain by removing a portion of the lobe where the seizures originate from. 

 If the patient is not a candidate for this type of surgery—three criteria must be met: epilepsy diagnosis, failed medication regimen, and a type of seizure disorder known as a defined electroclinical disorder — they may be a candidate for a vagal nerve stimulator. The vagal nerve stimulator is a device inserted into the neck that is programmed to administer electrical impulses to the vagus nerve. When the person senses a seizure is going to occur, they can activate the device with a magnet (10). 

Another feasible way to manage seizures is a diet known as the ketogenic diet. It consists of high-fat, low-carbohydrate meals that cause ketones to be produced. These ketones travel to the brain as an energy substitute for glucose. While this has proven to be effective in some individuals, the long-term effects of this diet are unknown (10). 

Special Populations 

Geriatric

Various populations have certain risk factors that can increase the risk of developing seizures or epilepsy. The geriatric population is at risk for developing seizures later in life due to strokes, neurological diseases like Alzheimer’s, brain tumors, and head injuries related to falls. Geriatric individuals who take medication for seizures may also have a difficult time managing their medications or their daily lives (2). Certain seizure medications that are commonly used may not be reasonable in those with kidney or liver disease (10). 

Obstetric

Women who have a history of seizures must be careful when it comes to pregnancy. There are many risks involved that can put both the mother and baby in danger. Many antiseizure medications pose a risk for fetal birth defects. The most common ones are cardiac abnormalities with others being cleft lip and/or palate, urologic, skeletal, or neural tube defects. However, on the oppositive side of this, uncontrolled seizures can lead to physical injury as mentioned above. Women may also go into preterm labor or have a miscarriage. The baby could become deprived of oxygen during the seizure, resulting in fetal death or other severe complications from hypoxia (5). 

In some cases, women with no seizure history develop seizures during their pregnancy, which can be known as eclampsia. The process of this stems from gestational hypertension and preeclampsia (11). Preeclampsia is comprised of a few symptoms: hypertension—greater than 140/90 on two separate occasions that are at least four hours apart—proteinuria or other signs of kidney problems like decreased urine output; severe headaches; vision changes; thrombocytopenia; upper abdominal pain; shortness of breath due to fluid in the lungs; edema in face, hands, and/or feet; nausea or vomiting; and impaired liver function (12). 

If or when a woman develops an eclamptic seizure is not based on how severe the preeclamptic symptoms are. Some women may be considered “stable” with a minimal rise in blood pressure and have a seizure, while others may have every symptom mentioned above and never have an episode. Seizure treatment in this population is initially guided toward the prevention through the careful administration of magnesium sulfate and antihypertensive medications such as hydralazine. Women must be monitored for signs of magnesium toxicity—decreased deep tendon reflexes and bradypnea. If a seizure does occur, it should be treated as any other seizure, ensuring the woman is stabilized before focusing on the baby, uterus, and cervix. Definitive treatment is the delivery of the baby and placenta (11). 

Psychiatric

As mentioned above, the psychiatric patient may experience psychogenic or pseudoseizures; however, not all seizures are psychogenic in nature. Antipsychotic medications, especially with atypical antipsychotics and clozapine, can decrease the seizure threshold in those who have a history of seizures (13). Those who have a history of alcohol abuse may be at a risk for withdrawal seizures and status epilepticus when they suddenly stop drinking. Among the other signs of alcohol withdrawal, seizures have been attributed with substantial amounts of alcohol consumption over months to years. Those who do experience seizures are at a higher risk for them as they progress through the withdrawal and delirium tremens phases. If they revert to drinking and go through another withdrawal period, the seizures they have are likely to increase in severity (1). 

Trauma

The trauma patient is a complex individual that requires many skilled hands and knowledge to recognize injuries, treat them, and prevent them from worsening. When it comes to head trauma, seizures may be a cause or a result. Regardless, seizures can increase intracranial pressure (ICP) and decrease cerebral perfusion, leading to patient demise (3). Like all cases, early detection as well as proper seizure treatment and management is vital.  

Seizure Education 

Individuals who have a history of seizures are strongly encouraged to take their medications as prescribed. Inconsistency and dose adjustments outside provider recommendations can lead to serious complications. It is recommended that medical alert jewelry be worn, and a medical card be carried to ensure that bystanders or medical professionals have as much information as possible while providing care to the individual in case an episode occurs, and they become unconscious. Maintaining a proper diet and eating when feelings of shakiness, faintness, or hunger arise may help prevent hypoglycemic events and seizures. Identifying resources in the community can be helpful to those with a seizure diagnosis in obtaining support and additional education or recommendations for managing the diagnosis (10). 

Summary 

Seizures are a complex diagnosis with many factors; those who are affected face many daily challenges. It is important for healthcare providers to understand the overall concepts of seizures and how they relate to the patients they treat. Being aware of emergency status epilepticus and seizure treatment and management are vital for healthcare providers. Taking this information and applying it to all walks of life will benefit the healthcare provider and the community in which they educate and care for.  

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