Epilepsy 101

Aileen Rodriguez ARNP-BCComprehensive Epilepsy Program

Aileen.Rodriguez@mch.com

About Me:2006 BSN from UM School of Nursing

Started working @ MCH (3 south nights)July 2006

Worked Days shift on 3 south for 2 years

Worked 8 months with Neurosurgery Team: multidisciplinary clinical coordinator

August of 2011 Graduated from University of Phoenix with my MSN

December of 2011 Started Clinical Educator for 3 south

September of 2014 started as the RN epilepsy Coordinator and started the ARNP PEDS Post Masters

November 2016- Hired as ARNP for the Comprehensive Epilepsy Program

Statistics• 2.3 million Americans lives with Epilepsy

• 50 million world-wide live with Epilepsy

• 181,000 new cases diagnosed each year

• 10% of the population will experience a seizure in their lifetime

• 3% will develop epilepsy by age 75

• 1 in every 4 of all newly-diagnosed people will have persistent seizures despite treatment

What is Epilepsy?

SEIZURE

A sudden alteration in behavior or

motor function caused by an electrical discharge from the brain

Certification: Seizure (convulsion) is defined as paroxysmal involuntary disturbance of brain function

that may be manifested as an impairment of loss of consciousness, abnormal motor activity, behavioral

abnormalities, sensory disturbances, or autonomic dysfunction”

• Individual attacks are called seizures

• Repeated attacks are called seizure disorders or epilepsy

Causes

Spectrum

Clinical Findings

I. Partial seizures – caused by abnormal electric discharges, no interruption in consciousness with simple seizures; usually impaired with complex seizures

a. Simple partial1. Consciousness usually maintained2. Abnormal movements of an arm or leg (Jacksonian march); orderly

sequence of movements3. Olfactory or auditory sensations4. Tachycardia, diaphoresis, flushing, pallor, nausea5. Anger, fear or hallucinations6. Length of seizure approx. 10 – 20 seconds

Clinical Findings

b. Complex partial- originates in a circumscribed portion of one cerebral hemisphere with impaired level of consciousness1. May begin with a simple partial seizure and progress to brief unconscious period

2. Or child may demonstrate altered states of consciousness; may have no other symptoms

3. An aura consisting of visual or auditory sensations (unpleasant feelings), nausea, vomiting, weakness is present in 1/3 of child with simple and complex seizure

4. Automatisms are common feature (picking at bed linens, clothing,

5. Rubbing objects repetitively, nondirective walking, running

6. Length of seizure 1 – 2 minutes

COMPLEX PARTIAL SEIZURES

Clinical Findings

II. Generalized seizures – bilateral cerebral cortical involvement always accompanied by some degree of unconsciousness

A. Absence (petit mal- old name)1. Brief period of unconsciousness (lasting seconds) with cessation of any motor activity;

2. transient staring episode may be only manifestation

3. Automatisms such as “lip smacking” or eye blinking (Atypical absent)

4. May occur several times a day

5. Often mistaken as learning disability , inattention or behavioral problem

6. Uncommon prior to age 5 years and are more common in girls

GENERALIZED ABSENCE SEIZURE

Seizures- cont.

Generalized tonic-clonic (grand mal)1. Most common seizure; may be preceded by an aura

2. Tonic phase characterized by rigidity, extension of extremities and fixed jaw; cessation of respirations; nonreactive dilated pupils; usually lasts less than 1 minute.

3. Clonic phase follows tonic phase and is characterized by rhythmic jerking of all extremities; expiratory grunts may be evident in addition to bowel and bladder incontinence; usually lasts several minutes, but may vary

4. Postictal phase- semiconscious initially and may sleep for a few minutes to

several hoursa. May be associated with visual and speech difficulties

b. May awaken with severe headache, fatigue and generalized muscle soreness

5. May be precipitated by infections, fatigue, fever, stress, drugs

Seizures –cont-

III. Myoclonic- generalized brief abrupt muscle contractions withduration of a few seconds; seizures may be clustered with several in one day or can be seizure free for weeks

IV. Atonic- sudden loss of muscle tone with possible loss of consciousness; may cause child to drop to the floor (“drop

attacks”)V. Infantile spasms – rare disorder with onset during first year of life

1. Brief flexion of neck, trunk and/or legs lasting for a few seconds2. Peak age of onset between ages 4 and 12 months3. May experience hundreds each day4. Prognosis for normal development is poor; 75 to 90% are abnormal5. May mimic “colic”

VI. Febrile seizures1. Occur in the context of extremes in temperature (fever going up fast or coming down fast)2. Normal till age 6-73. Not treated with AED

MYOCLONIC SEIZURES

Seizure Treatments

• Medications

• Surgery

• Ketogenic Diet

• Vagus Nerve Stimulator

Medications

PARTIAL• Carbamazepine• Oxcarbazepine• Lamotragine• Valproate• Fycompa• Gabapentin• Zonisamide• Levatracetam (IV/PO)• Lacosamide (IV/PO)• Tegretol

GENERALIZED• Valproate (IV/PO)• Lamotrigine• Topiramate• Levatracetam (IV/PO)• Zonisamide• Topiramate• Rafinamide• Sabril• Clobazam• Steroids (ACTH)

Rescue AED

• Ativan (Lorazepam): 0.05-0.2 mg/Kg IV

• Valium (Diazepam): 0.1- 0.3 mg/ kg IV

• Diastat (Diazepam Rectal): see chart

• Versed (ICU): 0.1- 0.3 mg/ kg IV (Drip)– Intranasal

– Buccal

• Clonazepam

Failed 2 medications

• Less than 10% chance another medication will work

• Need to looks for alternative treatments

Seizure Treatments

• Medications

• Surgery

• Ketogenic Diet

• Vagus Nerve Stimulator

Surgery Work upPhase I admission• MRI, fMRI, DTI, 3D MRI• VEEG- to capture seizures• Neuropsych testing (if testable)• Pet/Spect• TMS• Genetics work up

• Elective admission• 5 days (Monday to Friday)

MRI

fMRI

DTI

VEEG• Used to capture seizures and brain activity simultaneously• Usually stop medications- risk for status

– Having a working IV (check it often)

• Seizure logs:– Give them out on admission– Pick them up every day @ 6am– Do not make it up*

• Patient needs to be on camera– Ask techs to move camera if needed– Keep wires out of the way (tripping hazard)– Get child life/ medical library to help with activities

Neuropsych testing

• Dr. Brandon Korman

• Dr. Reshma Naidoo

PET Scan• NM ext:4379• No glucose in fluids• Limit sugar intake

night before• Dex stick before scan• No seizure during

exam• Lasts about 20-30

minutes• First part with EEG

leads

Spect scan• Must be NPO

• Must be injected within seconds of onset of seizure

TMS

• No prep- no NPO

• EEG off

• Magnet stimulation for language and motor mapping

• Done in the BI

After Discharge?

• Discharged Friday

• 1-2 weeks after discharge (Wednesday 12pm BI conference room) Team meeting (Epilepsy Conference)

https://www.hemr.org/hemr/notes/59587/show

• MD gets back to family

• Then scheduled to meet with neurosurgery

Surgical options:

Surgery

• Invasive

– 1 or 2 stage surgery

• Minimally Invasive

Laser Ablation

Surgery for Epilepsy

Hemispherectomy Lobectomy Corpus Callosotomy

VNS

Reminders:• Seizure logs• Test patients during seizures-

– Oxygen is not always needed/ nor pupil checks– Ask them questions– Ask them to squeeze your hand

• Keep families up to date• Be proactive• Explain tests• Keep kids on camera• Keep cables out of the way• Get child life and music therapy involved

Community Referrals

• Epilepsy Foundation

– http://www.efof.org/

• Epilepsy.com

– http://www.epilepsy.com/

• Camp Boggy Creek

– http://www.boggycreek.org/

Questions