Epilepsy is a group of syndrome characterized by unprovoked, recurring seizures.

Epilepsy can be primary (idiopathic) or secondary (when the cause is known and the epilepsy is a symptom of another underlying condition such as brain tumor. Epilepsy is a condition characterized by recurrent seizures with symptoms that vary from a momentary lapse of attention to severe convulsions.

Grand-Mal Seizures This type of seizure presents as a generalized tonic-clonic seizure that often begins with a loud cry before the person having the seizure loses consciousness and falls to the ground. The muscles become rigid for about 30 seconds during the tonic phase of the seizure and alternately contract and relax during the clonic phase, which lasts 30-60 seconds. The skin sometimes acquires a bluish tint and the person may bite his tongue, lose bowel or bladder control, or have trouble breathing.

Absence (petit mal) seizures This type of seizure generally begin at about the age of four, and usually stops by the time the child becomes an adolescent. Petit Mal seizures usually begin with a brief loss of consciousness and last between one and 10 seconds. A person having a petit mal seizure becomes very quiet and may blink, stare blankly, roll his eyes, or move his lips. A petit mal seizure lasts 15-20 seconds. When it ends, the person who had the seizure resumes whatever he was doing before the seizure began. He will not remember the seizure and may not realize that anything unusual has happened. Untreated, petit mal seizures can recur as many as 100 times a day and may progress to grand mal seizures.

Myoclonic seizures This type of seizure is characterized by brief, involuntary spasms of the tongue or muscles of the face, arms, or legs. Myoclonic seizures are most likely to occur first thing in the morning. Simple Partial seizures This type of seizure does not spread from the focal area where they arise. Symptoms are determined by what part of the brain is affected. The patient usually remains conscious during the seizure and can later describe it in detail.

Complex Partial seizures This type of seizures presents with a distinctive smell, taste, or other unusual sensation (aura) may signal the start of a complex partial seizure. Complex partial seizures start as simple partial seizures, but move beyond the focal area and cause loss of consciousness. Complex partial seizures can become major motor seizures. Although a person having a complex partial seizure may not seem to be unconscious, he does not know what is happening and may behave inappropriately. He will not remember the seizure, but may seem confused or intoxicated for a few minutes after it ends.

Brain tumor (Lesions that occupy space) Cerebral hypoxia (breath holding, carbon monoxide poisoning, anesthesia) Cerebrovascular accident (infarct or hemorrhage) Convulsive or toxic agents (lead, alcohol, picrotoxin, strychnine) Alcohol and drug use withdrawal Eclampsia Hormone changes during pregnancy and menstruation Exogenous factors (sound, light, cutaneous stimulation) Fever (especially in children Head injury (highest incidence is found in young adults) Heat stroke Infection (acute or chronic) Metabolic disturbances (diabetes mellitus, electrolyte imbalances) Withdrawal from, or hereditary intolerance of, alcohol Kidney failure (uremia, phenylketonuria) Degenerative disorders (senile dementia)

PREDISPOSING -genetics -young age -acquired brain insults

PRECIPITATING -fatigue -sleep deprivation -alcohol -stress -withdrawal of medication

Grandmal Seizures
Aura

A scream
Loss of bowel and bladder control Unresponsiveness after convulsion

Confusion
Fatigue Severe headache

During the seizure, the person may: Stop walking and start again a few seconds later Stop talking in mid-sentence and start again a few seconds later After the seizure, the person may: Wide awake Thinking clearly

Unaware of the seizure Specific symptoms of petit mal seizures: Changes in muscle Changes in alertness(consciousness) May be triggered by hyperventilation or flashing lights, in some cases Myoclonic seizures -sporadic jerks Simple partial seizures -motor -sensory -autonomic -psychic Complex partial seizure -feeling of uneasiness or nausea -feel sleepy and confused afterwards

Neurological examination to test the behaviour, motor abilities, mental function and other areas to diagnose the condition and determine the type of epilepsy . Blood tests. To check for infections, genetic conditions or other conditions signs of which may be associated with seizures. Electroencephalogram (EEG). This is the most common test used to diagnose epilepsy.

Computerized tomography (CT) scan. CT scans can reveal abnormalities in the brain that might be causing seizures, such as tumors, bleeding and cysts. Magnetic resonance imaging (MRI) Functional MRI (fMRI). A functional MRI measures the changes in blood flow that occur when specific parts of the brain are working. Doctors may use an fMRI before surgery to identify the exact locations of critical functions, such as speech and movement, so that surgeons can avoid injuring those places while operating.

Positron emission tomography (PET). PET scans use a small amount of low-dose radioactive material that's injected into a vein to help visualize active areas of the brain and detect abnormalities. Neuropsychological tests. In these tests, doctors assess patients thinking, memory and speech skills. The test results help doctors determine which areas of the brain are affected.

Position patient on their side to facilitate drainage of secretions Provide adequate ventilation by maintaining a patent airway Suction secretions if necessary to prevent aspiration Allow the patient to sleep post seizure On awakening, orient patient to what has occurred

Pharmacologic Therapy Letvetiracetam (Keppra) - is an anticonvulsant that is a synaptic vesicle protein. It is believed to impede nerve conduction along the nerve synapses and therefore inhibit seizure activity. Benzodiazepines which are a family of drugs, used to treat insomnia, anxiety, panic attacks, muscle spasms, and seizure disorders. Examples include: *Clonazepam (Klonipin) *Clorazepate (Tranxene) *Diazepam (Valium)

Phenytoin (Dilantin) a synthetic drug that is classified as a hydantoin. It is used for the treatment of simple partial, complex partial and generalized tonic-clonic seizures. Phenytoin blocks post-tetanic potentiation by influencing synaptic transmission through voltage sensitive sodium channels. Carbamazepine (Tegretol) used as a first line agent for the treatment of simple partial, complex partial and generalized tonic-clonic seizures. The mechanism of action is depression of transmission via the nucleus ventralis anterior thalamus, which acts to decrease the spread of seizure discharge. Lamotrigine (Lamictal) used when seizures are focal in onset, tonicclonic, atypical absence and/or myoclonic in nature. Valproate (Depakote) used for the management of myoclonic, tonic, atonic, absence and generalized tonic-clonic seizures especially with patients with one or more type of generalized seizure. Phenobarbital (Luminal) Once a mainstay in the treatment of seizures (especially status epilepticus), Phenobarbital is now being replaced by other anticonvulsants but can still be used for the treatment of generalized seizures except for absence and partial seizures.

Preventing injury Reducing Fear of Seizures Improving Coping mechanisms Position patient to avoid aspiration or inadequate oxygenation Suction and O2 must be available Monitor respiratory function with ongoing pulse oximetry IV access should be secured Frequent monitoring of neuro exam and vital signs Monitor ABGs Monitor Glucose Treat hyperthermia (occurs often with status epilepticus) aggressively

Generalized convulsive status epilepticus Generalized convulsive SE is the most frequent and potentially dangerous type of SE. Subtle status epilepticus Subtle SE consists of electrical seizure activity in the brain that endures when the associated motor responses are fragmentary or even absent. Nonconvulsive status epilepticus Nonconvulsive SE is divided into 2 categories: absence SE and complex partial SE. Differentiating these subtypes is important, since they indicate major differences in treatment, etiology, and prognosis.

Absence Se Complex Partial Se Simple Partial SE Seizures that are localized to a discrete area of cerebral cortex and produce no alteration in consciousness

Acute or remote cerebrovascular disease Metabolic disturbances Encephalopathies Head trauma Drug toxicity Alcohol intoxication or withdrawal Central nervous system infection

Stroke Hypoxic injury Tumor Subarachnoid hemorrhage Head trauma Alcohol withdrawal Electrolyte abnormalities Neoplasms CNS infections Toxins, notably sympathomimetics

Yound age Genetic Predisposition Acquired brain insults Fever is common risk in children,stroke in adults

By clinical history, nonmotor simple partial status epilepticus involves subjective sensory disturbances, including the following: Focal or unilateral paresthesias or numbness Focal visual changes, usually characterized by flashing lights Focal visual obscuration or focal colorful hallucinations Olfactory or gustatory hallucinations Atypical rising abdominal sensations Epilepsy partialis continua, or focal status epilepticus of the motor cortex, may occur in various contexts, with some authors subdividing it into type I (nonprogressive) and type II (progressive). Type I epilepsy partialis continua features include the following: Intermittent, semi-rhythmic, involuntary twitching involving a discrete subset of muscles Most commonly affects the face and ipsilateral distal hand musculature Myoclonus of this variety may evolve into partial or generalized convulsion Type II epilepsy partialis continua features include the following: Usually linked with Rasmussen encephalitis Gradual loss of unilateral function, with parallel focal or unilateral hemispheric atrophy Impaired intellectual skills to various degrees Possible effect on language skills

Glucose and electrolyte levels (including calcium, magnesium) Complete blood count Renal and liver function tests Toxicologic screening and anticonvulsant drug levels Arterial blood gas results Other tests that may be appropriate depending on the clinical setting include the following: Electroencephalography: Criterion standard for diagnosing status epilepticus[3, 4] ; however, neurologic consultation is usually required Blood cultures Urinalysis and/or cerebrospinal fluid analysis Imaging studies Imaging modalities used to evaluate status epilepticus may include the following: CT scanning and/or MRI of the brain Chest radiography Procedures If a central nervous system infection is suspected, consider performing a lumbar puncture (after neuroimaging to rule out potential cerebral herniation).

The goals of treatment: *to stop the seizures as quickly as possible *to ensure adequate cerebral oxygenation *to maintain the in a seizure-free state An airway and adequate oxygenation is established. If the patient remains unconscious and unresponsive,a cuffed endotracheal tube is inserted. IV diazepam (Valium),lorazepam (Ativan), or fosphenytoin (Cerebyx) is administered slowly in an attempt to halt seizures immediately. Phenytoin and Phenobarbital are administered later to maintain a seizure-free state. An IV line is established, and blood samples are obtained to monitor serum electrolytes,glucose and phenytoin levels. EEG monitoring may be useful in determining the nature of the seizure activity. Vital signs and neurologic signs are monitored on a continuing basis. An IV infusion of dextrose is administered if the seizure is caused by hypoglycemia. If initial treatment is unsuccessful,general anesthesia with a short-acting barbiturate may be used. Serum concentration of the antiseizure mediication is measured.

The nurse initiates ongoing assessment and monitoring of respiratory and cardiac function because of the risk for delayed depression of respiration and blood pressure. Monitoring and documenting the seizure activity and the patients responsiveness. The patient is turned to a side-lying position,if possible,to assist in draining pharyngeal secretions. Suction equipment must be available because of the risk of aspiration. IV line is closely monitored because it may become dislodged during seizures. The patient is protected from injury with the use of seizure precautions and is monitored closely. ABCs of life support Position patient to avoid aspiration or inadequate oxygenation Monitor respiratory function with ongoing pulse oximetry IV access should be secured Frequent monitoring of neuro exam and vital signs Monitor ABGs (profound metabolic acidosis can occur during seizures) Monitor Glucose (hyperglycemia followed by hypoglycemia is common) Treat hyperthermia (occurs often with status epilepticus) aggressively