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Presentation to participants undertaking the: Critical Care Transition Program at ACT Health, 2008

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  • Seizure - an uncontrolled paroxysmal discharge of the CNS that interferes with normal function. Epilepsy - repeated occurrence of any of the various forms of seizures. Prodrome - Mood or Behavior change that precedes a seizure. Aura - Localized symptom that may be the first part of a seizure. Tonic - A sustained muscular contraction. Clonic - Intermittent muscular contractions and relaxation.
  • Abnormal electrical discharges in the brain that can usually be detected by EEG, Not a disease but a symptom, Increased permeability of neuronal cell membranes causes an increase in neuronal cell excitability.
  • 70% have one classification, 30% have multiple Generalised seizures: Seizures that originate in several parts of the brain – sometimes start with a scream, then fall to the ground Tonic-clonic: Spasmodic alternation of muscle contraction and relaxation; characteristic of grand mal seizures. Myoclonis is brief, involuntary twitching of a muscle or a group of muscles. Atonic lack of muscle tone – person falls to ground Absent seizure: (petit mal) brief, abrupt loss of consciousness (5 to 10 seconds) followed by a rapid, complete recovery; also associated with staring or repetitive eye Partial – 1 part of the brain, either simple or complex Simple Seizures that transiently disrupt or alter speech, motor activity, vision, smell or taste. Simple partial seizures are not associated with any alteration in a child's level of consciousness. Complex This type of seizure affects consciousness and originates from the temporal lobes of the brain. Complex partial seizures are characterized by automatisms, which are involuntary, repetitive behaviors such as head turning and random movement that is not remembered by the person after the seizure is over. Febrile: type of generalized tonic-clonic, occur in 2-5% of the US population. usually no medication Status epilepticus: most often a generalized tonic-clonic, Repeated convulsions that occur without a break of consciousness between them. This is a medical emergency that can result in permanent brain damage. Pseudo: Clinically resemble epileptic seizures but without epileptic discharges from the brain. Also called psychogenic or nonepileptic seizures, most often caused by severe psychosocial stress Other: fake!
  • Primary and secondary %s relate to recurrent seizures only
  • Primary and secondary %s relate to recurrent seizures only
  • Medications - Because several drugs are equally effective for controlling seizures, adverse effects, age, gender and cost all become factors in medication selection. - Patients who have seizures typically take a single medication in dosages sufficient to maintain therapeutic concentrations. - Dosage is individualized - some patients develop toxicity at lower concentrations. - Anticonvulcants are sometimes used as mood stabilizers Hydantoins - Phenytoin: A drug that blocks sodium channels and inhibits persistent sodium currents reducing electrical conductance among brain cells by stabilizing cellular membranes Valproylamides sodium valporate: After the sodium channels open to start the action potential, they inactivate, essentially closing the channel. Carbamazepine stabilizes the inactivated state of sodium channels, meaning that fewer of these channels are available to open, making brain cells less excitable (less likely to fire). Barbiturates – phenobarbetone – requies a anaestheic level for anticonvuslant effects, second line drug Benzos – midazolam, clonazepam: central nervous system depressant, first line durg – diazapam less used
  • History EEGs were first used on animals in the late 1800 by Rischard Caton who identified three wave forms by placing electrodes on the scalp and the cortex of dogs and apes. He noted that electrical activity altered between consciousness, dying and death. In 1929 a German psychiatrist Hans Berger who initially was studying cerebral blood flow and temperature undertook the first EEG recording on humans. Fistly he discovered the alpha and beta waves Purpose An EEG is the recording of the electrical activity of the brain through the scalp. It is thought to reflect the activity on the surface of the cortex, which reflects the underlying structures of the brain.
  • Electrode Placement Numbers: Odd = left, even = right, Z=middle or centre. Numbers increase as they move away from the midline. Letters: F = Frontal, FP = Frontal Parietial, C = centre, T = Temporal, O = Occipital, P = Parietal. Placement is based on the clinical need. Placement can be seen on the montage. Montage is Latin for picture or pattern. The monitor shows you where to place your leads.
  • Symmetry Both hemispheres of the brain are symmetrical, therefore expressing the same frequency and amplitude Frequency Pattern of EEG wave expressed in Hz. A frequency is the number of times a wave repeats itself within a second. It can be compared to the frequencies that you tune into on your radio. If any of these frequencies are deficient, excessive, or difficult to access, our mental performance can suffer. Amplitude Measurement in mV in the height of the EEG wave.
  • Delta (0.1 to 3 Hz)   The lowest frequencies are delta . These are less than 4 Hz and occur in deep sleep and in some abnormal processes also during experiences of "empathy state". Delta waves are involved with our ability to integrate and let go. It reflects unconscious mind. It is the dominant rhythm in infants up to one year of age and it is present in stages 3 and 4 of sleep. It tends to be the highest in amplitude and the slowest waves. We increase Delta waves in order to decrease our awareness of the physical world. We also access information in our unconscious mind through Delta. Peak performers decrease Delta waves when high focus and peak performance are required. However, most individuals diagnosed with Attention Deficit Disorder, naturally increase rather than decrease Delta activity when trying to focus. The inappropriate Delta response often severely restricts the ability to focus and maintain attention. It is as if the brain is locked into a perpetual drowsy state. Another way to look at Delta is to imagine you are driving in a car and you shift into 1st're not going to get anywhere very fast. So Delta would represent 1st gear. Delta (0.1-3 Hz): Distribution: generally broad or diffused may be bilateral, widespread Subjective feeling states: deep, dreamless sleep, non-REM sleep, trance, unconscious Associated tasks & behaviors: lethargic, not moving, not attentive Physiological correlates: not moving, low-level of arousal Effects of training: can induce drowsiness, trance, deeply relaxed states
  • Theta (4-8 Hz) The next brainwave is theta . Theta activity has a frequency of 3.5 to 7.5 Hz and is classed as "slow" activity. It is seen in connection with creativity, intuition, daydreaming, and fantasizing and is a repository for memories, emotions, sensations. Theta waves are strong during internal focus, meditation, prayer, and spiritual awareness. It reflects the state between wakefulness and sleep. Relates to subconscious. It is abnormal in awake adults but is perfectly normal in children up to 13 years old. It is also normal during sleep. Theta is believed to reflect activity from the limbic system and hippocampal regions. Theta is observed in anxiety, behavioral activation and behavioral inhibition. When the theta rhythm appears to function normally it mediates and/or promotes adaptive, complex behaviors such as learning and memory. Under unusual emotional circumstances, such as stress or disease states, there may be an imbalance of three major transmitter systems, which results in aberrant behavior. Back to our car example, Theta would be considered 2nd gear. Not as slow as 1st gear (Delta) but still not very fast. Distribution: usually regional, may involve many lobes, can be lateralized or diffuse; Subjective feeling states: intuitive, creative, recall, fantasy, imagery, creative, dreamlike, switching thoughts, drowsy; "oneness", "knowing" Associated tasks & behaviors: creative, intuitive; but may also be distracted, unfocused Physiological correlates: healing, integration of mind/body Effects of Training: if enhanced, can induce drifting, trance-like state. If suppressed, can improve concentration, ability to focus attention
  • Alpha (8-12 Hz) Alpha waves are those between 7.5 and 13(Hz). Alpha waves will peak around 10Hz. Good healthy alpha production promotes mental resourcefulness, aids in the ability to mentally coordinate, enhances overall sense of relaxation and fatigue. In this state you can move quickly and efficiently to accomplish whatever task is at hand. When Alpha predominates most people feel at ease and calm. Alpha appears to bridge the conscious to the subconscious. It is the major rhythm seen in normal relaxed adults - it is present during most of life especially beyond the thirteenth year when it dominates the resting tracing. Alpha rhythms are reported to be derived from the white matter of the brain. The white matter can be considered the part of the brain that connects all parts with each other. Alpha is a common state for the brain and occurs whenever a person is alert (it is a marker for alertness and sleep), but not actively processing information. They are strongest over the occipital (back of the head) cortex and also over frontal cortex. Alpha has been linked to extroversion (introverts show less), creativity (creative subjects show alpha when listening and coming to a solution for creative problems), and mental work. When your alpha is with in normal ranges we tend to also experience good moods, see the world truthfully, and have a sense of calmness. Alpha is one of the brain's most important frequency to learn and use information taught in the classroom and on the job. You can increase alpha by closing your eyes or deep breathing or decrease alpha by thinking or calculating. Alpha-Theta training can create an increase in sensation, abstract thinking and self-control. In our car scenario, Alpha would represent neutral or idle. Alpha allows us to shift easily from one task to another. Distribution: regional, usually involves entire lobe; strong occipital w/eyes closed Subjective feeling states: relaxed, not agitated, but not drowsy; tranquil, conscious Associated tasks & behaviors: meditation, no action Physiological correlates: relaxed, healing Effects of Training: can produce relaxation Sub band low alpha: 8-10: inner-awareness of self, mind/body integration, balance Sub band high alpha: 10-12: centering, healing, mind/body connection
  • Beta (above 12 Hz) Beta activity is 'fast' activity. It has a frequency of 14 and greater Hz. It reflects desynchronized active brain tissue. It is usually seen on both sides in symmetrical distribution and is most evident frontally. It may be absent or reduced in areas of cortical damage. It is generally regarded as a normal rhythm and is the dominant rhythm in those who are alert or anxious or who have their eyes open. It is the state that most of brain is in when we have our eyes open and are listening and thinking during analytical problem solving, judgment, decision making, processing information about the world around us. Beta would represent overdrive or hyperdrive in our car scenario. The beta band has a relatively large range, and has been divided into low, midrange and high. Low Beta (12-15 Hz), formerly "SMR": Distribution: localized by side and by lobe (frontal, occipital, etc) Subjective feeling states : relaxed yet focused, integrated Associated tasks & behaviors: low SMR can reflect "ADD", lack of focused attention Physiological correlates: is inhibited by motion; restraining body may increase SMR Effects of Training: increasing SMR can produce relaxed focus, improved attentive abilities, Midrange Beta (15-18 Hz) Distribution: localized, over various areas. May be focused on one electrode. Subjective feeling states: thinking, aware of self & surroundings Associated tasks & behaviors: mental activity Physiological correlates: alert, active, but not agitated Effects of Training: can increase mental ability, focus, alertness, IQ High Beta (above 18 Hz): Distribution: localized, may be very focused. Subjective feeling states: alertness, agitation Associated tasks & behaviors: mental activity, e.g. math, planning, etc. Physiological correlates: general activation of mind & body functions. Effects of Training: can induce alertness, but may also produce agitation, etc.
  • Head Injury with uncontrolled ICPs resulting in Barbiturate / Thiopentone Coma as a form of management. Barbiturates are known to reduce the cerebral metabolic rate and therefore the need for oxygen has been shown to reduce by 50% of normal brain activity. EEG monitoring allows the clinician to effectively titrate the dose of medication that results in the desired effect of a barbiturate coma. Thiopentone half-life is 2.5 mins in plasma, however once plasma is saturated, thiopentone moves into the intracellular spaces where its half life is increased to 8 hours! EEG displays generalised slowing. Variable EEG = good outcome, Monotonous EEG = poor outcomes.
  • Early detection EEG is a definite way to diagnose seizures. Seizures manifest in various formations: Rhythmic pattern Gradually building Multiple channels with high amplitude Return to normal or decreased frequency Sedated patient Background: The pattern that indicates what the brain is doing all the time. Transient: A single wave such as a spike, that differs from the background pattern Paroxysmal: Sudden burst of change, such as, multiple spikes, which return to normal. Treatment required if lasting 3 seconds or longer
  • Seizures

    1. 1. Jamie Ranse : Critical Care Education Coordinator, Staff Development Unit, ACT Health. Neurological Emergencies: Seizures
    2. 2. overview <ul><li>Definition and key terms </li></ul><ul><li>Incidence </li></ul><ul><li>Pathophysiology </li></ul><ul><li>Causes </li></ul><ul><li>Management </li></ul>
    3. 3. definition and key terms <ul><li>Seizure </li></ul><ul><li>Epilepsy </li></ul><ul><li>Prodrome </li></ul><ul><li>Aura </li></ul><ul><li>Tonic -- </li></ul><ul><li>Clonic -- </li></ul>
    4. 4. incidence <ul><li>~1% of the population have had a seizure </li></ul><ul><li>Highest prevalence between 2 and 5 years of age </li></ul><ul><li>Increase of first time seizures >50 years of age </li></ul>
    5. 5. pathophysiology <ul><li>“ A seizure is a temporary involuntary disturbance of brain function that may be manifested as impaired consciousness, abnormal motor activity, sensory disturbances or autonomic dysfunction” </li></ul>
    6. 6. pathophysiology <ul><li>Abnormal electrical discharges in the brain </li></ul><ul><li>A symptom </li></ul><ul><li>Membrane instability </li></ul><ul><ul><li>Deficiency in oxygen </li></ul></ul><ul><ul><li>Deficiency in glucose </li></ul></ul><ul><ul><li>Deficiency in calcium </li></ul></ul>
    7. 7. <ul><li>Classifications </li></ul><ul><li>Generalized Seizures: </li></ul><ul><ul><li>Tonic-clonic -- </li></ul></ul><ul><ul><li>Myoclonic </li></ul></ul><ul><ul><li>Atonic </li></ul></ul><ul><ul><li>Absence seizures -- </li></ul></ul><ul><li>Partial Seizures: </li></ul><ul><ul><li>Simple </li></ul></ul><ul><ul><li>Complex </li></ul></ul><ul><li>Other: </li></ul><ul><ul><li>Febrile </li></ul></ul><ul><ul><li>Status epilectus </li></ul></ul><ul><ul><li>Pseudo </li></ul></ul><ul><ul><li>Other -- -- </li></ul></ul>pathophysiology
    8. 8. causes <ul><li>Primary </li></ul><ul><ul><li>Genetic (65%) </li></ul></ul><ul><li>Secondary </li></ul><ul><ul><li>Acquired (35%) </li></ul></ul><ul><ul><li>Common causes </li></ul></ul><ul><ul><ul><li>Metabolic and Toxic Disorders </li></ul></ul></ul><ul><ul><ul><li>Head Trauma </li></ul></ul></ul><ul><ul><ul><li>Tumors </li></ul></ul></ul><ul><ul><ul><li>Vascular Disease </li></ul></ul></ul><ul><ul><ul><li>Degenerative Disorders </li></ul></ul></ul><ul><ul><ul><li>Infectious Diseases </li></ul></ul></ul>
    9. 9. causes <ul><li>Predisposing factors </li></ul><ul><li>Fatigue </li></ul><ul><li>Decreased physical health </li></ul><ul><li>Alcohol ingestion </li></ul><ul><li>Emotional stress </li></ul><ul><li>Flashing lights </li></ul><ul><li>Missed meals </li></ul>
    10. 10. management <ul><li>Key questions : </li></ul><ul><li>What medications are you taking? </li></ul><ul><li>What type of seizure do you have? </li></ul><ul><li>How often do you have a seizure? </li></ul><ul><li>What signals the onset of your seizure? </li></ul><ul><li>How long do your seizures last? </li></ul><ul><li>Have you ever been hospitalized? </li></ul>
    11. 11. management <ul><li>Minimizing or preventing the recurrence of acute seizures </li></ul><ul><li>Oxygenation </li></ul><ul><li>Medication </li></ul><ul><ul><li>Hydantoins </li></ul></ul><ul><ul><li>Valproylamides </li></ul></ul><ul><ul><li>Barbiturates </li></ul></ul><ul><ul><li>Benzodiazepines </li></ul></ul><ul><li>cEEG Monitoring </li></ul>
    12. 12. Jamie Ranse : Critical Care Education Coordinator, Staff Development Unit, ACT Health. Neurological Emergencies: c ontinuous electroencephalogram monitoring
    13. 13. overview <ul><li>Introduction </li></ul><ul><li>Pathophysiology </li></ul><ul><li>Set-up and preparation </li></ul><ul><li>Care during use </li></ul><ul><li>Care after use </li></ul><ul><li>Advantages and </li></ul><ul><li>Disadvantages </li></ul>
    14. 14. introduction <ul><li>History </li></ul><ul><li>Purpose </li></ul>
    15. 15. pathophysiology
    16. 16. pathophysiology <ul><li>Critical Care Environment </li></ul><ul><li>Severe Head Injury: Burst Suppression </li></ul><ul><li>Status Epilepticus </li></ul><ul><li>Other Applications </li></ul><ul><li>Any Head Injury </li></ul><ul><li>Sedation </li></ul><ul><li>CNS Infection </li></ul><ul><li>Post-operative </li></ul><ul><li>Intra-operative </li></ul>
    17. 17. set-up and preparation: equipment <ul><li>EEG Module </li></ul>
    18. 18. set-up and preparation: equipment <ul><li>EEG Module </li></ul><ul><li>Cable </li></ul>
    19. 19. set-up and preparation: equipment <ul><li>EEG Module </li></ul><ul><li>Cable </li></ul><ul><li>Leads </li></ul>
    20. 20. set-up and preparation: equipment <ul><li>EEG Module </li></ul><ul><li>Cable </li></ul><ul><li>Leads </li></ul><ul><li>Electrodes </li></ul>
    21. 21. set-up and preparation: equipment <ul><li>EEG Module </li></ul><ul><li>Cable </li></ul><ul><li>Leads </li></ul><ul><li>Electrodes </li></ul><ul><li>Monitor </li></ul>
    22. 22. set-up and preparation: electrode placement
    23. 23. set-up and preparation: electrode placement
    24. 24. set-up and preparation: electrode placement
    25. 25. set-up and preparation: electrode placement
    26. 26. set-up and preparation: electrode placement
    27. 27. set-up and preparation: electrode placement
    28. 28. set-up and preparation: electrode placement
    29. 29. set-up and preparation: electrode placement
    30. 30. set-up and preparation: electrode impedance <ul><li>Reduce impedance by: </li></ul><ul><li>Shaving hair, </li></ul><ul><li>Wash site with warm soapy water </li></ul>
    31. 31. set-up and preparation: electrode impedance
    32. 32. care during use: wave formation <ul><li>Symmetry </li></ul><ul><li>Frequency </li></ul><ul><li>Amplitude </li></ul>
    33. 33. care during use: wave formation <ul><li>Delta </li></ul><ul><li>Theta </li></ul><ul><li>Alpha </li></ul><ul><li>Beta </li></ul><ul><li>Compressed Spectral Array </li></ul><ul><li>Burst Suppression </li></ul><ul><li>Status Epilepticus </li></ul>“ D on’t T alk A bout B oys”
    34. 34. care during use: delta wave formation <ul><li>0.1 to 3 Hz </li></ul><ul><li>Lowest frequency </li></ul><ul><li>Unconscious mind </li></ul><ul><li>Deep sleep </li></ul><ul><li>1st Gear </li></ul>
    35. 35. care during use: theta wave formation <ul><li>3 to 8 Hz </li></ul><ul><li>Slow activity </li></ul><ul><li>Strong with internal focus </li></ul><ul><li>2nd Gear </li></ul>
    36. 36. care during use: alpha wave formation <ul><li>8 to 12 Hz </li></ul><ul><li>Alertness </li></ul><ul><li>Resourcefulness </li></ul><ul><li>Bridge the conscious and unconscious </li></ul><ul><li>Neutral </li></ul>
    37. 37. care during use: beta wave formation <ul><li>Above 12 Hz </li></ul><ul><li>Highest frequency </li></ul><ul><li>Fast thinking </li></ul><ul><li>Problem solving and processing information </li></ul><ul><li>Top gear </li></ul>
    38. 39. Time (mins) Hz 0 10 20 30 0 15 30 <ul><li>Provides a quick and easy to read trend of the electrical activity. </li></ul><ul><li>Displayed in Hz and Time. </li></ul>care during use: csa
    39. 40. care during use: csa
    40. 42. PPF = Peak Power Frequency MDF = Mean Dominant Frequency SEF = Spectral Edge Frequency care during use: csa
    41. 44. care during use: evoked response <ul><li>Visual </li></ul><ul><li>Auditory </li></ul><ul><li>Sensory </li></ul>
    42. 45. care during use: evoked response
    43. 46. care during use: burst suppression <ul><li>Severe head injury with Barbiturate coma </li></ul><ul><li>Medical order for EEG monitoring parameters </li></ul><ul><li>Titrate Barbiturate </li></ul>
    44. 47. care during use: burst suppression CSA1 CSA2
    45. 48. care during use: burst suppression <ul><li>Early detection </li></ul><ul><li>Sedated patient </li></ul>Spike Multiple Spikes
    46. 49. care after use <ul><li>Continue neurological assessment </li></ul>
    47. 50. advantages <ul><li>Early detection of pathology </li></ul><ul><li>Assessment of neurological deficit </li></ul>
    48. 51. disadvantages <ul><li>Assumes user knowledge </li></ul><ul><li>Assumes user knowledge </li></ul>
    49. 52. Jamie Ranse : Critical Care Education Coordinator, Staff Development Unit, ACT Health. Neurological Emergencies