APPROACH TO SEIZURECME PPW 13HAFFIZ MOHD NOOR

• Sudden temporary change in…

PHYSICAL movementSENSATIONBEHAVIOUR

… because of abnormal discharged of electrical impulses from nerve cells.

DEFINITION

CLASSIFICATION

PARTIAL SEIZURE

/FOCAL

SEIZURE

GENERALISED SEIZURE

CLASSIFICATION

PARTIAL SEIZURE / FOCAL SEIZURE(AFFECT / BEGIN IN ONE PART OF THE BRAIN)

SIMPLE COMPLEX(CONCIOUSNESS REMAIN INTACT)1. MOTOR Jerking Muscle Rigidity Head Turning

2. SENSORY (Unusual sensation affect ) Visual Hearing Taste Touch

3. PSCYCHOLOGY Emotional Memory disturbance

(IMPAIRMENT OF CONCIOUSNESS)

Begin in one part of brain and spreading to another part of brain.

Postictal Symptoms (Seizure State)

Aura Phase Motionless / Automatic

movement but inappropiate Excessive emotion – irritate /

anger etc Not remember when episode is

over.

Leading to Generalised Seizure

GENERALISED SEIZUREABSENSE SEIZURE (PETIT-MAL)

Sudden onsetDuration 5-10 sec / happen 100x dailyCommonly cause by

STRESSFatigueHypoglycemia

Some known as ‘day dreaming’Sign & Symptoms

LOR but still maintain postureTwitching eyelids / Lips smackingLong starring (most common)

GENERALISED SEIZUREMYOCLONIC SEIZURE

• Movement Disorder• Seen when awake / fall asleep• Cause by touch / visual stimuli• Symmetrical / Asymmetrical• Sign & Symptoms :

No LOCSudden and simpleShoclike involuntaryDropping things (most common)

• 90% individuals who have syncope hx.

GENERALISED SEIZURETONIC SEIZURE

• Muscle are maintained in continuous contracted state. (Rigidity)

• Sign & Symptoms :Variable LOCPupils dilatedEyes roll upPossible incontinenceMay foam at mouth

GENERALISED SEIZURECLONIC SEIZURE

• Opposing muscle contract and relax alternately. (Jerking)

• May occur only one limb or more.

• Sign & Symptoms :• Mucus production• Muscle Stiffness

GENERALISED SEIZURETONIC-CLONIC SEIZURE

(GRAND-MAL)• Violent total body seizure

• Sign & Symptoms :Usually LOC / CollapseTonic phase (30-60 sec)Clonic phasePostictal Symptoms - Apneic

TONIC – CLONIC PHASE

GENERALISED SEIZUREATONIC SEIZURE

• Drop or fall attack• Loss of posture tone

UNCLASSIFIED SEIZURE

• FEBRILE FIT Convulsion associated with a HIGH GRADE (38C) body

temperature. They most commonly occur in children between the ages of 6 months and 5 years of age

• STATUS EPILEPTICUS Acute prolonged seizure activity. Ictus more than 15-20 min. Series of generalized seizures that occur without full

recovery of consciousness between attacks

• EPILEPSY Group of syndromes characterized by unprovoked, recurring

seizures Ictus more than 30 min.

1. Cerebral Vascular Accident (CVA)2. Central Nervous System (CNS) Infection3. Head Injury / Trauma4. Hypoxemia / Anoxia5. Hypertension6. Metabolic / Toxic Condition7. Brain Tumour8. Drugs and Alcohol Withdrawal9. Fever in childhood

ETIOLOGY

PATHOPHYSIOLOGYETIOLOGY

Many neurons fire in a synchronous pattern, resulting

in a transient physiologic disturbance

Physiologic disturbances

include abnormal movements,

abnormal sensations and change in LOC

SEIZURE STATE!

APPOACH TO SEIZURE

ASSESSMENT FINDINGS

Aimed to determine:1. Type of seizure2. Frequency 3. SeverityAuraLOCDyspneaFixed and dilated pupilIncontinence

4. Factors that precipitate them.5. Developmental history taking (events of pregnancy and

childbirth)6. Questioned about illnesses or head injury

APPROACH TO SEIZURE

MANAGEMENT

• Provide privacy and protect the patient from curios on-lookers,

• Ease the patient to the floor or the lowest position, if possible.

• Protect the head with a pad to prevent injury (from striking a hard surface)

• Loosen constrictive clothing• Push aside any furniture that may injure the

patient during the seizure.

APPROACH TO SEIZURE

MANAGEMENT

• Do not attempt to pry open jaws that are clenched in a spasm to insert anything. Broken teeth and injury to the lips and tongue may result from such an action

• No attempt should be made to restrain the patient during the seizure because muscular contractions are strong and restraint can produce injury

• If possible, place the patient on one side with head flexed forward, which allows the tongue to fall forward and facilitates drainage of saliva and mucus. If suction is available, use it if necessary to clear secretions

Guidelines for Seizure Care

APPROACH TO SEIZUREMEDICATION MANAGEMENT

Rx GOAL : Prevent neuronal injury to the brain ( 20 min – 1hour)

FIRST LINE THERAPY (Benzodiazephines) : Diazepam (Valium) / Lorazepam• Function as Anti-convulsants : To prevent the prolonged time in seizure.• Diazepam (Valium)

• IV : Adults – 5 – 10 mg/kg , Peads – 0.2 mg/kg• Per Rectal 10 mg (> 5 min) – IV access unsuccessful – 0.5 mg/kg/dose

• Lorazepam - IV : 0.1 mg/kg

SECOND LINE THERAPY (Phenobarbital) : Phenytoin (Cerebyx) • Function as Anti-Epileptic• Patient still in aggressive seize after first line therapy.

• IV : 20 mg/kg usually use doses 1 gram in ED• Need BP & cardiac monitoring – develop hypotension and cardiac arrythmias

THIRD LINE THERAPY (Sedative) : Propofol / Midazolam• Function more as sedation• Greater sedative effect and more effective in infusion.

• Propofol IV 2-5 mg/kg – IVI : 20 – 100 mcg/kg/min• Midazolam IV 0.2 mg/kg – IVI : 0.05 – 2 mg/kg/h

APPROACH TO SEIZUREMEDICAL MANAGEMENT

• Diet: Ketogenic (a diet high in fats and proteins, and low in carbohydrates)

• I.V. therapy: Secure line. Give medication.• Activity: bed rest• Monitoring: Vital signs, I/O chart• Laboratory studies: glucose, potassium, and

anticonvulsant drug levels if applicable.• Special care: seizure precautions- ABC ,

temperature, blood glucose, spinal care• Anticonvulsants: phenytoin (Dilantin), Valium

(Diazepam), Lorazepam (Ativan)

INVESTIGATION• BLOOD INVESTIGATION : RBS , ABG • EEG: abnormal wave patterns, focus of seizure

activity• CT scan: a space occupying lesion• MRI: pathologic changes / tissue lession• Lumbar Puncture: need pt consideration

Persistent fever/AMS/headache

POSTICTAL STATE CARE(after seizure)

• Keep the patient on one side to prevent aspiration. Make sure the airway is patent

• There is usually a period of confusion after a grand mal seizure

• A short apneic (sleeping) period may occur during or immediately after a generalized seizure

• The patient, on awakening, should be reoriented to the environment

• If the patients becomes agitated after a seizure (postictal), use calm persuasion and gentle restraint

PATIENT EDUCATION

• Take medications at regular basis• Avoid alcohol. This lowers seizure threshold• Adequate rest• Well-balanced diet• Avoid driving, operating machines, swimming until

seizures are well controlled• Lead an active life• Parents/relative education

THANK YOU!

Xie Xie!