Seizures

1. Seizures • A seizure is sudden, abnormal, and excessive electrical discharges from the brain that can change motor or autonomic function, consciousness, or sensation • Epilepsy is a chronic neurological disorder characterized by recurrent seizures • Seizures may be a symptom of epilepsy or another neuro disorder

2. Etiology Normal stability of neuron cell membrane is impaired • Idiopathic • No Cause Identified • Usually onset before age 20 • Acquired • Underlying Neurological Disorder • Brain Injury

3. Classification of seizures • Partial • Begin on one side of cerebral cortex, may progress to other side and become generalized • Generalized • Both cerebral hemispheres involved S+S depend on area where abnormal electrical discharges occur

4. Signs & Symptoms • Aura • Visual distortion • Odor • Sound Patients may have this warning, allowing time to improve safety

5. Signs & Symptoms • Partial Seizures • Automatisms • Repetitive, purposeless movements while in dream-like state • Maintain consciousness • Usually <1 minute • Paresthesias if begins in parietal lobe • Visual disturbances if occipital lobe • Involuntary movements if motor cortex, usually begin in arm and hand, progress to leg and face

6. Signs & Symptoms • Complex Partial/Psychomotor • Partial seizure as described, but… • Lose consciousness • May last 2 – 15 minutes

7. Signs & Symptoms • Generalized Seizures • Absence (Petit Mal) • Staring that lasts several seconds • http://www.youtube.com/watch?v=z9V2sNmIoJk&feature=related

8. Signs & Symptoms • Generalized Seizures • Tonic Clonic (Grand Mal) May have aura, usually lose consciousness • Tonic phase • Rigidity • Clonic phase • Muscle contraction and relaxation • Incontinence • Postictal period-recovery period after a seizure

9. http://www.youtube.com/watch?v=nV40H_g-NJo&NR=1 • http://www.youtube.com/watch?v=H2vH1igOoh0&feature=related • http://www.youtube.com/watch?v=p5U2tpaH3fA&feature=related • http://www.youtube.com/watch?v=VC6HJPZr1VU&feature=related

10. Diagnosis • EEG • Can determine site of origin, frequency and duration, dx subclinical • Look for underlying cause • Accurate observation/reporting of seizure

11. Therapeutic Interventions • Correct Cause • Anticonvulsant Medication • Taper slowly • Common side effect-drowsiness • Surgical Resection • If focus is located in nonvital tissue, resceting area can prevent spread to other areas of brain

12. Emergency Care: Seizures Prevent injury • Pad side rails • Keep away from furniture, walls • Do not restrain • Loosen tight clothing, belts, jewelry • Monitor airway • Turn on side to prevent aspiration • Once seizure has begun, do not force airway/suction into patient’s mouth • Suction, CPR PRN (suction, oral airway at bedside) • Observe and document

13. Status Epilepticus • 30 minutes of seizure activity without return to consciousness • Therapeutic Interventions • Ensure airway and oxygenation • Intubation and mechanical vent • Administer IV diazepam (Valium) or lorazepam (Ativan) or phenobarbitol

14. Spinal Trauma • Characterized by a decrease or loss of sensory and motor function below the level of the injury • Damage results from bruising, tearing, cutting , edema or bleeding into the spinal cord • Causes? • Complete injury means no motor or sensory function below the level of the injury • Incomplete means some functioning remains

15. Spinal Trauma • Injury to C3 or above is usually fatal • C4-C5 injuries likely require ventilation • Quadriplegia vs. quadriparesis • Paraplegia vs. paraparesis • Spinal Shock • SCI affects autonomic nervous system • Lasts from a week to months • Immediately after injury, sympathetic NS is disrupted • Vasodilation • Hypotension • Bradycardia • Hypothermia

16. Whiplash • See handout

17. Increased Intracranial Pressure • Pathophysiology • Increase in • Brain • Blood • CSF

18. ICP • Normal ICP 0-15mm Hg • Affected by pathologic conditions • Most Common causes of IICP • Brain Trauma • Brain Tumor • Intracranial Hemorrhage • Also affected by positioning, arterial pulsations, increase in intrathoracic pressure

19. Signs & Symptoms • Restlessness • Irritability • Decreased LOC • Hyperventilation • Pupil changes (due to compression of occulomotor nerve) • Cushing’s Response (classic late response) • Body attempts to compensate for IICP caused cerebral perfusion deficits with increased systemic blood pressure

20. ICP Monitoring • Monitors are placed thru burr hole drilled thru skull • Cared for in ICU-often ventilated and pharmacologically sedated/paralyzed • External Ventricular Monitor and Drain • Subarachnoid Bolt Monitor-ease of placement • Intraparenchymal Monitor-directly into brain tissue

21. Interventions to prevent IICP • Keep HOB elevated 30* • Keep head and neck in proper alignment • Avoid neck flexion • Antiemetics and antitussives PRN • Stool softeners PRN • Minimize suctioning • Avoid hip flexion • Prevent noxious stimuli • Space care activities

22. Traumatic Brain Injury (TBI) • Trauma • Hemorrhage • Contusion • Laceration • Can Cause • Cerebral Edema • Hyperemia • Hydrocephalus • Brain Herniation • Death

23. Etiology • MVA most common • Falls • Assaults • Sports-related injuries

24. Mechanisms of Injury • Closed or nonpenetrating head injury (blunt) • Rapid back and forth movement causing bruising and tearing of brain tissues and vessels • Open or penetrating head injury • Break in the skull with brain tissue/vessel damage • Acceleration • Moving object hits stationary head • Deceleration • Head in motion hits a stationary object • Acceleration-Deceleration/Contra-Coup • Combination of two

25. Types of Injury • Concussion: see handout • Brief or no LOC, <5 mins • Headache, dizziness, N/V, vertigo • May have amnesia • CT/MRI negative • Rest, fluids, Tylenol, frequent LOC monitoring • Avoid narcotics, sedatives, opiods, no driving • Concussion syndrome may last months

26. Types of Injury • Contusion • Bruising of brain tissue • May develop hemorrhage • Symptoms depend on area(s) and severity • Brainstem-decreased LOC (may be permanent), motor response, pupil reaction, eye movement, elevated RR, fever • CT scan shows tissue swelling • Treatment supportive

27. Types of Injury • Hematoma • Subdural (A) • Usually venous • Between dura and arachnoid membranes • Epidural (B) • Usually arterial • Between dura and skull

28. Types of Injury • Subdural Hematoma • Acute vs Chronic • If chronic, may be months from injury to S+S • Forgetful • Lethargic • Irritable • Headache • Damage to brain tissue as blood accumulates • LOC changes • Hemiparesis • Dilated pupil • Extremity weakness

29. Types of Injury • Epidural Hematoma • Often associated with skull fracture • Arterial, so usually progresses quickly • Loss of consciousness after injury>regain consciousness, coherent>then rapid deterioration • Decreased LOC, seizures

30. Diagnosis • CT-test of choice, rapid results • MRI • Neuropsychological Testing

31. Therapeutic Interventions • Surgical Removal of Hematoma • Burr holes, craniotomy • Control IICP • ICP Monitoring • Drainage of CSF • Osmotic Diuretic • Mannitol (Osmitrol) • Mechanical Hyperventilation • Therapeutic Coma

32. Complications of TBI • Brain Herniation • Diabetes Insipidus • Damage to Pituitary=too little ADH • Acute Hydrocephalus • Ventriculoperitoneal shunt • Labile Vital Signs • Cognitive and Personality Changes • Often life-long deficits

33. Brain Herniation

34. Persistent Vegetative State (PVS) • PVS-Continual condition of complete unawareness of the environment, there is at least partial preservation of hypothalmic and brain stem functioning • Coma-state of unconsciousness from which one cannot be aroused and is unresponsive

35. Nursing Diagnoses TBI • Ineffective Cerebral Tissue Perfusion • Ineffective Airway Clearance • Ineffective Breathing Pattern • Disturbed Thought Processes • Self-Care Deficit • Pain • Sensory-Perceptual Disturbance • Impaired Physical Mobility • Risk for Injury

36. Nursing Care TBI • ICU-monitoring ICP • Monitor neuro status frequently • Glasgow Coma Scale • Pupil response • Muscle strength • Vital signs • Monitor for seizures • Posturing • Decorticate • Decerebrate