Page 1 of 7 SEIZURE DISORDERSSeizures Seizures are episodic, stereotypic behavioral syndromes that have an abrupt onset,generally are not provoked by external stimuli & result in loss of responsiveness. Seizures arecaused by excessive and disorderly neuronal discharges in the brain. The manifestation ofseizure depends on the region of the brain in which they originate and may includeconsciuousness; involuntary movements; and changes in perception, behaviors, sensationsand posture. Seizures are the most common treatable neurologic disorder in children and can occur withvariety of conditions involving CNS.EpilepsyEpilepsy is a condition characterized by two or more unprovoked seizures and can be causedby a variety of pathologic processes in the brain. Seizures are a symptom of an underlyingdisease process. A single seizure event should not be classified as epilepsy and is generallyno treated with long-term anti-epileptic drugs. Some seizures may result from an acute medicalor neurological illness and cease ones the illness is treated. In other cases, children may havea single seizure without the cause ever being known. Once it is determined that the child hashad the seizure, it is important to classify the seizure. Optimum treatment and prognosisrequire accurate diagnosis and determination of etiology whenever possible.Incidence & Etiology: An estimated 0.5% of all children experience at least 1 afebrile seizure (Huff, 2000).Etiology can be caused by many factors. The cause of seizure is often unknown, or idiophatic,although there maybe genetic factors present predisposing children to particular types ofseizure. Febrile seizures are brief, clonic, or tonic-clonic nature; can be simple or complex,and can develop with temperatures as low as 37.8°C (100°F). Simple febrile seizure usuallylast less than 15 mins. & don’t recur within a 24-hour period. However, complex febrileseizures can have focal attributes, recur on the same day, and last longer than 30 mins(Blosser & Burns, 2004). They are also an example of a type of seizure that has an unknowncause. Seizures can also be acquired, resulting from traumatic brain injury, central nervoussystem infection, hypoglycemia or other endocrine dysfunction, toxic ingestion or exposure, orintracranial lesion or vascular malformation. Typically, infants develop seizures because ofbirth injury, anoxic episodes, infection, intraventricular hemorrhage, or a congenital brainanomaly. Seizures in older children occur most often secondary to trauma or infection. Inaddition, changes in diet or hydration status, fatigue, or not taking prescribed medications mayprecipitate seizure activity. Prognosis depends on etiology, the type & the age of initial onset.PathophysiologySeizures are the result of a spontaneous electrical discharge of hyper-excited brain cells in anarea called the epileptogenic focus. These cells can be triggered by either environmental orphysiological stimuli such as emotional stress, anxiety, fatigue, infection or metabolicdisturbances. The exact location of the epileptogenic foci & the number involved determinesthe nature of the seizure. If a small area of the brain is affected, a focal (localized) seizure mayoccur. However, if the electrical discharge continues, it may become generalized. Ageneralized seizure will occur if the epileptogenic focus is located in the brain stem, midbrainor reticular formation.
Page 2 of 7 Status epilipticus is a prolonged seizure or series of convulsions where loss ofconsciousness occurs for at least 30 mis. Refractory seizures last more than 60 mins.Epilepsy refers to achronic seizure disorder often associated with central nervous systempathology.Clinical Manifestations Clinical manifestations depend on the specific type of seizure.Types of Seizure: 1. Partial Seizure – arise from the abnormal electrical activity in a small area of the brain, most often the temporal, frontal, or parietal lobes of the cerebral cortex, will have symptoms associated with the area of the brain affected. It is characterized by local motor, sensory, psychic & somatic manifestations. It has 2 types: a. Simple Partial Seizures (Focal seizure) – can be manifested at any age. There is no aura (a somatic, or psychic warning that it will occur, which is often described as a strange sensation in the stomach that rises up to the throat) associated with these episodes & consciousness is generally not lost. Most often, the symptoms seen are motor or sensory in nature. Movements, may involve one extremity, a part of that extremity, or the head & eyes will twist in the opposite direction of the extremities. The arm toward which the head is turned is abducted & extended with the fingers clenched. There maybe numbness, tingling or painful sensations as well that begins in one area of the body & spreads out to others. Alterations in sensory perception may also be present. The child may have visual hallucinations & report seeing images or light flashes. In addition, a buzzing sound maybe heard, unusual odors identified, or an odd taste experienced. The child may also report feeling emotional or anxious (Behrman et al., 2004; Blosser & Burns, 2004). There are several types of simple partial seizures: - Jacksonian seizures are motor episodes beginning with tonic contractions of either the fingers of one hand, toes of one foot, or one side of the face. The spasm progress into tonic-clonic movements that march up adjacent muscles of the affected extremity or side of the body (Encyclopedia Britannica, 2001). - Rolandic or Sylvian Seizure are manifested as tonic-clonic movements of the face with increased salivation & arrested speechthat occur commonly during sleep (Huff, 2000). b. Complex Partial Seizures, also known as partial psychomotor or temporal lobe episodes. They can be manifested from age 3 years through adolescence. Just before the event, the child may have an aura. In addition, the youngster may have feelings of anxiety, fear, or de javu, the sense an event has occurred before, or complain of abdominal pain, having an unusual taste in the mouth, smelling an odd odor, or visual or auditory hallucinations. Consciousness is not completely lost during complex partial seizures. Rather, the child will appear confused or dazed, especially at the onset. When the seizure begins, the child stops activity involved in & begins purposeless behaviors such as starting into space or assuming an unusual posture. The child may also perform automatisms, or repeated non-purposeful actions, such as lip smacking, chewing, sucking, or uttering the same word over & over, wander aimlessly or remove clothing. Violent acts or rages are rare. A postical period follows this type of seizure
Page 3 of 7 when the child will be drowsy, confused aphasic, or display sensory or motor impairments. Children usually do not remember the behaviors displayed (Wertz, 2002).c. Simple or Complex seizures secondarily generalized – simple or complex partial seizures that evolve into generalized, usually a toni-clonic event.2. Generalized seizures – secondary to diffuse electrical activity throughout the cortex & into the brain stem, will cause the child to loose consciousness as well as demonstrate uncontrolled motor involvement with movements & spasm bilateral & symmetricalin nature (Blosser & Burns, 2004; Huff 2000). This can occur at any time & last from several seconds to hours. There is no aura, but always loss of consciousness. Generalized seizures appearing in children under 4 years of age are frequently associated with developmental delays, learning disabilities, and behavior disorders. There are four types of generalized seizures: a. Tonic-clonic seizures, often referred to as grand mal seizures, can occur at any age. Onset is usually abrupt & begins when the child loses consciousness & falls to the ground. The initial phase is tonic when there are intense muscle contractions. The jaw clenches shut; the abdomen& chest become rigid; and often the child emits a cry or grunt as exhaled air is forced out because the taut diaphragm. Pallor or cyanosis may occur as oxygenation & ventilation are impaired. The airway is compromised because of increased salivation the youngster cannot manage because of muscular contractions as well as the diminished mental status. The neck & legs are also extended while the arms are flexed or contracted. The eyes roll upward or deviate to one side, the pupils dilate, and there may also be bladder or bowel incontinence. The tonic phase of the seizure usually persists for 10-30 seconds. During the clonic phase, jerking movements are produced as a result of contraction & relaxation of the muscles. These spasms dissipate as the seizure ends & can last from 30 sec – 30 mins after onset of the seizure(Behrman et al., 2004; Blosser & Burns, 2004; Wetz, 2002). A postical or post-convulsive state follows a tonic-clonic seizure. Hence, the child may become somnolent or if awake, confused or combative; there maybe no memory of the event, hypertension & diaphoresis. Headache, nausea, vomiting, poor coordination, slurred speech, or visual disturbances may follow. b. Absence seizure, which used to be called petit mal seizures, appear around the 4th birthday& generally disappear near adolescence. They are characterized by a transient loss of consciousness, which may appear as cessation of current activity. The child seems to stare into space or the eyes may roll upward with ptosis or fluttering of the lids. There also maybe lip smacking or a loss of muscle tone causing the head to droop or any objects in the hands to be dropped. These events usually last from 5-10 seconds & can occur as often as 20 or more times per day. Children with this type of seizure are often accused of daydreaming & being inattentive in school Behrman et al., 2004; Burns e al., 2004; Huff, 2000; Wetz, 2002). c. Myoclonic seizures are sudden repeated contractures of the muscles of the head, extremities, or torso. The child, who can be as young as 2 years but is usually school-age or an adolescent, recovers quickly. These seizures occur when the child is drowsy & just falling asleep, or just waking up. There is usually no loss of consciousness nor is there any postictal period (Burns et al., 2004).
Page 4 of 7 d. Atonic or astatic-akinetic seizures (drop attacks) occur between ages 2 & 5 years & are manifested by sudden loss of muscle tone with the head dropping forward for a few seconds. More significant events occur when the youngster losses consciousness & falls to the ground, most often face down. In either case, amnesia follows. These seizure often cause repetitive head injuries if the child is not protected by wearing a football or hockey helmet. Many have underlying brain abnormalities & are mentally retarded (Behrman et al., 2004; Burns et al., 2004; Wetz, 2002). e. Akinetic Seizures are manifested by total lack of movement as the child appears frozen in a position. Mental status during the event is diminished. 3. Unclassified Epileptic Seizure- seizures that lack sufficient information to classify. a. West Syndome Infantile spasm are a rare disorder that has an onset within the first 6-8 months of life. The underlying cause of infantile spasms is often not found. The pathophysiology is poorly understood. Nearly all children with this will have some degree of mental retardation. Also known as massive spasm, salaam seizures, flexion spasm, jackknife seizures, massive myoclonic jerks, or infantile myoclonic spasm. It is twice common in boys as in girls. Types: a.1. Flexor spasms- consists of brief contractions of the neck, trunk, arms and legs. The arms may either adduct or abduct with the arms flexed at the elbow. a.2. Extensor spasms- consists predominantly of extensor contractions resulting in abrupt extension of the neck and trunk with extensor adduction or abduction of the arms and legs. Eye deviation or nystagmus often occurs. b. Lennox-Gastaut Syndrome (LGS) Many children who have infantile spasms eventually develop LGS. LGS is diagnosed on the evidence of mixed seizure types (atonic, myoclonic, tonic, and atypical absence), slow EEG changes. Onset of LGS is between 1 to 7 years of age, after which it is far less common. Children with this typically have multiple seizures daily. Tonic seizures are most common seizure type in this syndrome. In addition to mental retardation, many of these children develop other problems, including hyperactivity, aggression, or autistic features. Treatment is difficult and most cases do not respond to therapy. The prognosis is typically poor. Additional family support is often required to maintain the child at home.Diagnosis The objectives of diagnosis are threefold: to ascertain whether or not the child truly hada seizure, to determine the cause of the episode, & to classify the type of seizure. This processbegins with obtaining a thorough history from the caregivers or witnesses. In addition, acomplete medical history must be obtained, noting any illnesses, medications, hospitalizations,or toxic exposures the child may have had as well as if previous episodes occurred. Familyhistory is also important because of genetic predisposition to some types of seizures (Berhmanet al., 2004; Burns et al., 2004; Huff, 2000). A detailed account of the event must be explored, and an assessment made of whetheror not the child suffered any trauma, had been ill or febrile, ingested any toxin or poison, or
Page 5 of 7was exposed to dangerous chemicals. It is also important to determine if the youngster had anaura just before the event. Once the history is obtained, a complete physical examination must be performed. ACBC can determine the presence or absence of infection such as meningitis or encephalitis,and serum electrolytes should be analyzed to rule out metabolic disturbances, particularlyhypoglycemia. A lumbar puncture may also be performed to investigate for infectiousprocesses or bloody cerebrospinal fluid. If a toxic investigation is suspected, both urine & bloodcan be checked for its presence (Huff, 2000). A complete neurological evaluation should follow including checking the level ofconsciousness, reflexes & sensory & motor responses. Radiologic imaging such as CT Or MRImaybe performed to note any structural abnormality while angiography would pinpoint vascularirregularities. In addition, an EEG might be indicated to assess the brain’s electrical activitywhile the child is asleep, awake or receiving noxious stimuli & a positron emission tomography(PET) scan done to highlight areas of brain abnormality (Huff, 2000).Treatment The child with tonic-clonic seizures must be managed quickly. The airway must beassured; a short term method is to perform the jaw thrust. Nothing including a tongue bladeshould never be placed in the child’s mouth. The child may then be placed on the side if theairway is patent to help prevent secretions from pooling in the mouth, and suction should bereadily available. Because of thoracic & diaphragmatic muscle rigidity, air exchange isimpaired & hypoxia may result. Therefore, children having tonic-clonic seizures should receiveoxygen during the event either by face mask or assisted ventilations. Many seizures are self-limiting & last less than 5 mins. these require no further management other than the jaw thrust& oxygen administration (Behrman et al., 2004). However, the child in status epilipticus will need intravenous medications. Thebenzodiazepines (Diazepam [Valium] or Lorazepam [Atavan] are usually administered first,and if seizures continue , phenytoin (Dilantin) or fospenytoin (Cerebyx) are administered next>Phenobarbital (Luminal) may also be given but it takes 30 mins before onset. It is important toplace the child on a cardiorespiratory monitor during medication administration as an apneicresponse may follow administration of the benzodiazepines. There is alsothe risk ofhypotension or cardiac dysrhythmias when phenytoin is administered. Once the seizure isover, the child should be closely monitored during the postical period. If the episode is a first-time event, diagnostics should begin after recovery. Once the diagnosis & the type & cause of the seizure are identified, more definitetreatment can begin. If the cause was infectious, a toxic exposure, metabolic abnormality, anintracranial lesion, or a vascular malformation, that particular cause would be treated. For thechild with convulsions caused by nonstructural pathology, anticonvulsant medications would beprescribed, and the child followed by neurologists who would carefully monitor during serumlevels to ensure they remained within the therapeutic ranges. If episodes continue,medications could be changed or added to the youngster’s current regimen. Over the last several years, the Ketogenic Diet has gained popularity in treating arecarbohydrates thereby forcing the body to use ketones for fuel. The amount of protein in thediet is regulated so that 90% of the calories are derived from fat, & the fat to carbohydrate ratiois 4:1. The reason ketones have an effect on seizure is not ell understood, but theoreticallythey (1) change lipid concentrations, (2) change fluid & electrolyte balances, (3) modify theseizure threshold, or (4) stabilize the central nervous system. The diet is especially useful in young children with infantile spasms, myoclonic oratonic-kinetic seizures & those with mixed seizures of Lennox-Gastaut Syndrome when sideeffects to medications are intolerable or when allergies preclude administration.
Page 6 of 7 For the child with intractable seizures, surgery maybe the last hope for control. Theepileptogenic focus maybe removed if there are no critical structures involved. The temporallobectomy or a hemispherectomy could be performed on the client with unrelenting partialseizures with widespread hemispheric origin. Oftentimes, these youngsters will also displaypre-existing motor, cognitive & sensory deficits. The goal of surgery is not only to decreaseseizure activity, but also to improve child’s behavior & intellectual status.Nursing Diagnosis • Ineffective breathing patterns as evidenced during tonic-clonic motions • High risk for injury secondary to tonic-clonic movements as well diminished level of consciousness • High risk for injury related to medication administration during the acute episode • Interrupted family dynamics related to caring for a child with a chronic condition.Nursing Management The nurse caring for the child with seizures has multiple responsibilities. If the child os activelyconvulsing, a patent airway & adequate oxygenation must be assured. Prescribed medications need tobe administered safe & efficient manner noting the specific rates of delivery, need for cardiorespiratorymonitoring & watching for potential adverse reactions. Once the episode is controlled, the nurse mustdocument the event in detail, including the onset of any aura to resolution. Nurses should provide a safe environment for the child with seizures to ensure injury will notoccur. Suction & oxygen should be at hand & bed rails padded. If the event occurs when the child is ina chair or standing, the child should be gently helped to the ground & place on one side & any nearbyobjects moved out of the way. Children with recurrent seizures may wear helmets to protect their headsduring falls. The nurse must also care for the emotional needs of the child & family as seizures can oftenhave a negative sigma, making the victim as well as the caregivers & siblings uncomfortable &ashamed. The child may resent feeling different from peers & taking medications several times per day,or fear having a seizure in front of friends. The nurse should encourage the child to talk about thesefeelings & provide help so the condition can be accepted.Family Teaching The nurse must work with the family as well. Some caregivers feel guilty, especially if theepisodes are a result of trauma, or genetic predisposition. The nurse should allow these familymembers to express their feelings & frustrations. Caregivers may also worry about the financial aspectsof having a youngster with a chronic condition, requiring daily medications, visits to the neurologist, andfrequent drug serum monitoring. The nurse can arrange for caregivers to speak with social services forassistance in working out these issues. Caregivers must also be taught how to give medications & the importance of not missing doses.They also need to know drug serum levels should be checked periodically as the child grows. School-age children should be encourage to accept responsibility for taking their own medications as this givesthem feelings of control over their illness. Safety is another issue to discuss with the child, caregivers, teachers, baby sitters & familymembers. All should know what to do when seizure occurs, & when to call emergency medicalservices. The child should wear a Medical Alert bracelet or necklace & people caring for this youngstershould be aware of activities that can & should not be encouraged. While most play is acceptable,contact sports are ill-advised. In addition, the child with seizure disorder must be carefully watch at alltimes during a bath or if involved in any water activities such as swimming or boating. Instruct what todo if child seizes & whom to call for help. It will also be helpful to teach them CPR. Provide teachers,classroom assistants, school nurse or school aides & administrative staff with information on what to doif the child has seizure in school. If the school nurse or health aide must give a medication during theday, provide information about the drug. If the child & caregiver agree, talk to the children in the class atschool about the child’s condition as well as what a seizure is & what looks like in order to reduce fears
Page 7 of 7& anxieties about their classmate. Refer family & child to groups offering support to families whose childhas a seizure disorder.