DRG Category: 100
Mean LOS: 5.9 days
Description: Medical: Seizures With Major Complication or Comorbidity
Epilepsy is a paroxysmal neurological disorder characterized by a predisposition to generate recurrent episodes of convulsive movements or other motor activity, loss of consciousness, sensory disturbances, and other behavioral abnormalities. It has not only neurological consequences but cognitive, psychological, and social consequences as well. Because epilepsy occurs in more than 50 diseases, it is considered a syndrome rather than a disease. It is the fourth most common neurological problem (after migraine, stroke, and Alzheimer disease) in the United States. Approximately 1% of the U.S. population (2 to 3 million people) has been diagnosed with epilepsy. Each year, approximately 150,000 new cases of epilepsy occur.
Convulsive seizures are the most common forms of attacks of epilepsy. Seizures occur with abnormal electrical discharges from brain cells, and these discharges are caused by the movement of ions across the cell membrane. Although seizures are the dominant manifestation of epilepsy, patients can have a seizure and not have epilepsy. For over 35 years, a classification system was used to characterize seizures on the basis of whether the person was conscious during the seizure and whether one or two sides of the body were involved. A new classification system was announced in 2017 by the International League Against Epilepsy. The new system is based on the location in the brain where the seizure begins, the level of awareness during a seizure, and other features of the seizure. The Epilepsy Foundation provides an explanation of the new classification at https://epilepsy.com, which is incorporated in Table 1.
Table 1 Classification of Seizure Types, 2017
| FEATURES | DESCRIPTION |
|---|
| Where they begin | Focal seizures: Seizure involves one side of the brain at onset
- Generalized seizure: Seizure involves both sides of the brain at onset
- Unknown onset
- Focal to bilateral seizure: Seizure starts on one side and spreads to both sides
| Level of awareness | Focal aware: Awareness remains intact
- Focal impaired awareness: Awareness is impaired
- Awareness unknown
- Generalized seizure: Presumed to affect awareness or consciousness
| | Other features | Describing motor and other symptoms in focal seizures
- Focal motor seizure: Some form of movement occurs during the seizure
- Focal nonmotor seizure: Other symptoms occur before movement
- Auras: Symptoms the person may feel at the beginning of the seizure; are not in the above descriptions
Describing generalized onset seizures
- Generalized motor seizure: Generalized tonic-clonic seizure
- Generalized nonmotor seizure: Absence seizures with brief change of awareness, staring, and possibly automated movements
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Status epilepticus is defined as more than 30 minutes of unconsciousness with continuous or intermittent convulsive seizure activity. Usually, status epilepticus results when more than six seizures occur in 24 hours or when the patient progresses from one seizure to the next without resolution of the postictal period. Pseudoseizures are the physical appearance of seizure activity without the cerebral electrical activity. Complications include pulmonary aspiration; airway occlusion; injury to the head, extremities, or tongue; memory loss or personality changes after seizures; cardiac changes (blood pressure instability, cardiac dysrhythmias, cardiac arrest); and status epilepticus.
The cause of epilepsy is often unknown, but there are also many genetic disorders that lead to seizure activity (see Genetic Considerations). Seizures may be caused by primary central nervous system (CNS) disorders, metabolic or systemic disorders, or idiopathic origins. Primary CNS disorders include any potential mass effect (tumor, abscess, atrioventricular malformation [AVM], aneurysm, or hematoma) and all types of strokes, especially those that are embolic. Metabolic and systemic causes include acute overdose, acute drug withdrawal (especially CNS depressants, alcohol, benzodiazepines, and barbiturates), febrile states, hypoxia, hyperosmolarity, hypertensive encephalopathy, hyperthermia, and a multitude of electrolyte disturbances. A seizure occurs when there is a sudden imbalance of the electrical properties of the cerebral cortex, leading to neural excitation and decreased inhibition.
Epilepsy is a broad condition that includes several disorders that have different etiologies. Overall, epilepsy has a significant genetic component, with heritability estimated at 77% to 85%. The most significant genetic association with epilepsy is the gene SCN1A, which encodes for a sodium channel protein. Mutations in SCN1A are usually inherited in an autosomal dominant pattern and can cause several different epileptic disorders. There are also many diseases and disorders that include propensity for seizures as a feature. Some examples include tuberous sclerosis and fragile X syndrome.
Epilepsy affects males and females equally. The incidence is approximately 1 in every 100 to 300 persons. Although epilepsy can occur in any age group, usually the onset is before age 20. Different age groups have distinct associated causes. In newborns up until 6 months of age, seizures are generally caused by birth trauma or metabolic disturbances, such as hypoxemia, hypoglycemia, and hypocalcemia. In children from 6 months to 5 years of age, etiology is related to febrile episodes or metabolic disturbances such as hyponatremia or hypernatremia, hypoglycemia, or hypocalcemia. In the 5- to 20-year-old age group, seizures are primarily idiopathic (50%). In adults from 20 to 50 years of age, a new onset of seizures is almost exclusively caused by trauma or tumors. In older adults, seizures are generally caused by vascular disease and cardiac dysrhythmias.
Native American and Alaskan Native persons have the longest time lapse between a seizure and the diagnosis of epilepsy, which leads to important disparities in health outcomes. People with epilepsy who have low incomes have also been found to have more frequent visits to emergency departments for the management of seizures, more adverse effects from medications, higher levels of depression and anxiety, worse quality of life, and are less likely to be seen by an epilepsy provider than those with high incomes.
Transgender is a term used to describe persons whose gender identity is different from their sex assigned at birth. Approximately 1% of the U.S. population identify themselves as transgender. Sexual and gender minority persons have higher odds for multiple chronic conditions, cancer, and poor quality of life and are more apt to have disabilities than cisgender males and females. (Cisgender is a term used to describe persons whose gender identity and gender expression are aligned with their assigned sex listed on their birth certificate.) Gender-affirming hormone therapy is the use of hormone therapy for gender transition or gender affirmation and can be masculinizing or feminizing. Antiepileptic drugs (AEDs) may interact with the hormones that are used for gender-affirming therapy for both transwomen (male-to-female transgender persons) and transmen (female-to-male transgender persons) and may thereby change the effective dose of both the AEDs and hormones (Johnson & Kaplan, 2017).
In many parts of the world, having epilepsy leads to stigmatization, presents barriers to marriage, and may limit employment or education. Based on the principles of social justice, the World Health Organization is attempting to remedy the stigma associated with the condition. Epilepsy affects people of all global regions, whether they are high- or low-resourced countries. Of the 50 million people affected with epilepsy, almost 90% live in developing countries, and of those people, 75% have not received the treatment they require to manage the disorder.
PLANNING AND IMPLEMENTATION
Collaborative
Medical
In general, the management of seizures is done pharmacologically. The patient with status epilepticus is considered a medical emergency. Airway management is critical, often endotracheal intubation is needed, and IV medications are administered. If there is a delay in treatment or if the patient is unresponsive to treatment, irreversible brain damage, coma, or death can occur.
Surgical
Over 200,000 people in the United States have intractable epilepsy, and at least 50% of these people are potential surgical candidates. Left untreated, they are at risk for sudden death and personal injury and are less likely to be employed as compared to people with controlled seizures. Surgical management results in an excellent prognosis for seizure control and has low surgical morbidity, improved quality of life, and improved occupational outcomes. In some cases, the epileptogenic zone is mapped using video-EEG monitoring or intracranial electrodes. Examples of common surgical techniques include anteromedial temporal resection (AMTR; most common surgery for medial temporal lobe epilepsy): corpus callosotomy (surgery for generalized epilepsy syndromes); modified hemispherotomy; and multiple subpial transection (MST; newer type of epilepsy surgery with limited applications). Vagal nerve stimulation is a palliative strategy that involves implanting a stimulating device to treat refractory focal-onset epilepsy.
| Medication or Drug Class | Dosage | Description | Rationale |
|---|
| Anticonvulsants | Varies with drug | Multiple drug therapies are available: Phenytoin sodium (Dilantin), carbamazepine, lacosamide, felbamate, perampanel, valproate, lamotrigine, gabapentin; phenobarbital, lorazepam (Ativan), diazepam (Valium) | Lorazepam (Ativan) or diazepam (Valium) may be used to stop seizures quickly; phenytoin (Dilantin) is the preferred maintenance anticonvulsant for status epilepticus; a newer drug, fosphenytoin (Cerebyx), has been developed that is safer for parenteral administration; phenobarbital may be given if seizures occur after phenytoin loading |
Other Drugs: Thiamine 100 mg and 50 mL of 50% dextrose in water may be administered in an emergency to rule out seizures because of thiamine deficiency or hypoglycemia.Other Information About Anticonvulsants: The primary treatment for epilepsy is one or more of the multitude of AEDs or anticonvulsants. The choice of AED or combination of AEDs depends on seizure type, patient tolerance, and cost. Carbamazepine (Tegretol) is a widely used and cost-effective anticonvulsant. Valproic acid, primidone (Mysoline), clonazepam, and ethosuximide are prescribed depending on the seizure type. Lamotrigine (Lamictal), levetiracetam, and gabapentin are among the AEDs approved for partial seizures.
Independent
The most important nursing interventions are to maintain adequate airway, breathing, and circulation during the seizure and to prevent injury. Have an oral airway and suction apparatus at the bedside at all times. A patient who begins a seizure should not be left alone. If in the hospital setting, use the call light to obtain assistance, and if the patient is upright, gently ease the patient to the floor. Position the patient to maintain the airway, but do not force anything into the patient's mouth if the teeth are clenched. If the patient's mouth is open, protect the patient's tongue by placing a soft cloth or a well-padded tongue blade between the teeth. Help the patient to a lying position, remove constricting clothing, and place a pillow or sheet under the patient's head to cushion the patient from injury. Clear the area of objects that are hard or sharp. Do not restrain the patient's movement during the seizure. Assist the patient with hygiene and linen changes should incontinence occur during the seizure.
To lower the risk of injury, provide a safe environment at all times. Pad and raise the side rails, but do not use pillows for padding because of the possibility of suffocation. The extent of seizure precautions should be consistent with the type of seizures. Good oral hygiene is important. Also observe for signs of infection if there is any damage to the tongue and oral mucosa.
Educate the patient and family about providing care during a seizure, the medication schedule and side effects, and the importance of regular follow-up. Involve the family as much as possible in patient care. Use patient and family teaching to dispel any myths and misconceptions about epilepsy. Assure the family that most patients can control the syndrome if they follow the prescribed routine. Because epilepsy can be a debilitating, restrictive disease, provide support and encouragement. Refer patients to national organizations (Epilepsy Foundation of America) and local support groups.
Evidence-Based Practice and Health Policy
Jothi, A., Ramamoorthy, L., & Nair, P. (2020). The effect of comprehensive video assisted epilepsy education on drug adherence and self-care in people with epilepsy. Journal of Neurosciences in Rural Practice, 11, 538–544.
- The authors set out to determine the effectiveness of video-assisted epilepsy education on drug adherence and self-care in patients with epilepsy. They used a single group, experimental design (pretest-posttest) to evaluate the effect of a video-assisted teaching program on self-care efficacy and level of knowledge of patients with epilepsy.
- At 3 months, the levels of drug adherence, self-care, and knowledge were assessed. Following video-assisted teaching, the proportion of participants with adequate knowledge increased, the percentage of participants who had good drug adherence increased, and the percentage of participants who had a high level of self-care increased. The authors recommended that people with epilepsy should be personally educated to increase their knowledge of drug adherence and self-care.