its for students

1. It makes me want to SHAKE
!!!!
Assessing & Treating the Seizure
Patient
Jason N. Cook
Captain / Paramedic
Layton City Fire Department

2. Case #1
• Midvale/Sandy Call

3. Case #2
• 9 yr. old febrile seizure

4. Incidence
• Seizure disorders are a common neurological
problem. In the United States alone, it has been
estimated that more than 4 million people have
some form of epilepsy.
• The risk of epilepsy from birth through age 20 is
approximately 1 percent. Within this group, the risk
is highest during the first year of life and increases
somewhat at the onset of puberty. From age 20 to
55 it decreases again, but increases after age 55.
• The prevalence of epilepsy (defined as the total of
the population suffering from a disorder at a
particular time) has been estimated to be about 5 to
8 in every 1,000 people.

5. Seizures
• Seizures (or convulsions) are
temporary abnormal
electrophysiologic phenomena of
the brain, resulting in abnormal
synchronization of electrical
neuronal activity.
• They can manifest as an
alteration in mental state, tonic or
clonic movements and various
other symptoms.
• The medical syndrome of
recurrent, unprovoked seizures is
termed epilepsy.

6. Seizures
• Causes of provoked seizures include head
trauma, intoxication, infection, metabolic
disturbances, withdrawal symptoms (from
sedatives such as alcohol, barbiturates
and benzodiazepines) and space-
occupying processes in the brain
(abscesses, tumors).
• Seizures during (or shortly after)
pregnancy can be a sign of eclampsia.

7. Seizures
• Seizure is often associated with a sudden
and involuntary contraction of a group of
muscles. Seizures can cause involuntary
changes in body movement or function,
sensation, awareness, or behavior.

8. Seizures
• A seizure can also be as subtle as
marching numbness of a part of body, a
brief loss of memory, sparkling of flashes,
sensing an unpleasant odor, a strange
epigastric sensation or a sensation of fear.
• A seizure can last from a few seconds to
status epilepticus, a continuous seizure
that will not stop without intervention.

9. Seizures
• Sometimes seizures may go unnoticed,
depending on their presentation, and
sometimes seizures may be confused with
other events, such as a stroke, which can
also cause falls or migraines.

10. Seizures
• Persons who have lived with epilepsy for
much of their lives may find that their
seizures change as they age. The duration
of the seizures may become longer or
shorter; the intensity of the seizures may
worsen or improve; seizure episodes may
occur more or less frequently

11. Important Facts to Remember…
• Although seizures look different, they have
certain things in common:
– During a seizure, a person may stop
breathing, generally only for only a few
seconds.
– Although some can last as long as 3-5
minutes, most seizures only last 1-2 minutes.
– The brain almost always stops the seizures
safely and naturally.

12. Important Facts to Remember…
– Unless a seizure persists an excessive
duration, once a seizure has begun, you
cannot stop it - just let it run its course.
– People don't feel pain during a seizure,
although muscles might be sore afterwards.
– Seizures are usually not life threatening, but
the risk is increased in seniors by the extra
strain on the heart, the possibility of injury, or
a reduced intake of oxygen.

13. Diagnosing Seizures & Epilepsy
• The doctor usually orders a variety
of tests to help make the
diagnosis. These include:
– A brain wave test, also called an EEG
(electroencephalogram), to look for
changes in the brain's electrical
patterns that are related to seizures
– Blood tests, to look for certain medical
disorders
– Either a special x-ray of the brain, a
CT scan (sometimes called a CAT
scan), or an MRI scan (magnetic
resonance imaging), to look for
abnormal areas such as a tumor or
infection.

14. Diagnosing Seizures & Epilepsy
• Depending on the urgency of the situation, other
tests also might be recommended, such as a
lumbar puncture (also called a spinal tap), EKG
(electrocardiogram, to check the heart), or a
sleep test.
• The results of these tests often appear
completely normal in people with epilepsy.
• Normal test results do not mean that the
seizures are not real or that epilepsy is not
present.

15. Types of Seizures
• While there are over 40 types of seizure,
most are classed within 2 main categories:
– Generalized seizures occur when the
excessive electrical activity in the brain
encompasses the entire organ. The 2 most
common forms are generalized absence
seizures and tonic-clonic seizures.

16. Types of Seizures
• While there are over 40 types of seizure,
most are classed within 2 main categories:
– Partial seizures occur when the excessive
electrical activity in the brain is limited to one
area. The 2 most common forms are simple
partial seizures and complex partial seizures.

17. Generalized Seizures
• Primary Generalized Seizures
Absence seizures
Myoclonic seizures
Atonic seizures
Tonic seizures
Clonic seizures
Tonic-clonic seizures

18. Absence Seizures
• Absence Seizures (aka petit-mal) typically
have a sudden onset, present with motor
arrest, sometimes eye blinking, and last a
few seconds.
• In an absence seizure, epileptic activity
occurs throughout the entire brain. It is a
milder type of activity which causes
unconsciousness without causing
convulsions. After the seizure, there is no
memory of it. Usually there is no aura, or
warning.
• An absence seizure begins abruptly and
without warning, consists of a period of
unconsciousness with a blank stare, and
ends abruptly. There is no confusion after
the seizure, and the person can usually
resume full activity immediately. An absence
seizure may be accompanied by chewing
movements, rapid breathing, or rhythmic
blinking.

19. Absence Seizures
• Absence seizures are short, usually lasting only 2-10
seconds. They are very mild, and may go unnoticed by
parents and teachers. Because absence seizures may
recur frequently during the day, a child who experiences
them may have difficulty learning if they are not recognized
and treated
• Simple absence seizures are just stares. Many absence
seizures are considered complex absence seizures, which
means that they include a change in muscle activity. The
most common movements are eye blinks. Other
movements include slight tasting movements of the mouth,
hand movements such as rubbing the fingers together, and
contraction or relaxation of the muscles.

20. Myoclonic Seizures
• They involve abrupt muscle jerks in
part or all the body. A hand may
suddenly fling out, a shoulder may
shrug, a foot may kick, or the entire
body may jerk. Myoclonic seizures
usually cause abnormal movements
on both sides of the body at the same
time
• Consciousness and memory are not
impaired. A myoclonic seizure may
cause a patient to spill or drop what
s/he is holding or to fall from his/her
chair.
• Even people without epilepsy can
experience myoclonus in hiccups or in
a sudden jerk that may wake you up
as you're just falling asleep.

21. Atonic Seizures
• Muscle "tone" is the muscle's normal
tension. "Atonic" (a-TON-ik) means
"without tone," so in an atonic seizure,
muscles suddenly lose strength. The
eyelids may droop, the head may nod,
and the person may drop things and
often falls to the ground. These
seizures are also called "drop attacks"
or "drop seizures." The person may or
may not remain conscious.
• Although there is no convulsion, without
warning the patient will collapse and fall
to the floor and may bang their heads
as they fall. Recovery occurs after a few
seconds. After regaining
consciousness, the patient can again
stand and walk.

22. Tonic Seizures
• In a "tonic" seizure, the tone is greatly increased and the body,
arms, or legs make sudden stiffening movements.
Consciousness is usually preserved.
• The more prolonged seizures usually are convulsive and may
manifest pupillary dilation, tachycardia, apnea, cyanosis,
salivation, and the loss of bladder or bowel control. Tonic
seizures are often followed by postictal confusion.
• Tonic seizures most often occur during sleep and usually involve
all or most of the brain, affecting both sides of the body. If the
person is standing when the seizure starts, he or she often will
fall.
• Tonic seizures are very uncommon, especially when they occur
without clonic jerking. They usually are manifest with Lennox-
Gastaut syndrome or, less commonly, with multiple sclerosis.
• Tonic seizures most often develop in childhood, although they
can occur at any age.

23. Tonic Seizures
• Tonic seizures are very
uncommon, especially when
they occur without clonic
jerking. They usually are
manifest with Lennox-Gastaut
syndrome or, less commonly,
with multiple sclerosis.
• Tonic seizures most often
develop in childhood, although
they can occur at any age.

24. Clonic Seizures
• "Clonus" (KLOH-nus) means rapidly alternating
contraction and relaxation of a muscle -- in other
words, repeated jerking. The movements cannot
be stopped by restraining or repositioning the
arms or legs. Consciousness may be temporarily
lost and followed by confusion.
• Clonic (KLON-ik) seizures are rare, however.
Much more common are tonic-clonic seizures, in
which the jerking is preceded by stiffening (the
"tonic" part).
• Sometimes tonic-clonic seizures start with
jerking alone. These are called clonic-tonic-
clonic seizures!

25. Tonic-Clonic Seizures
• This type is what most people think of when they hear the word
"seizure.“
• An older term for them is "grand mal."
• As implied by the name, they combine the characteristics of tonic
seizures and clonic seizures. The tonic phase comes first: All the
muscles stiffen. Air being forced past the vocal cords causes a
cry or groan. The person loses consciousness and falls to the
floor. The tongue or cheek may be bitten, so bloody saliva may
come from the mouth. The person may turn a bit blue in the face.
• After the tonic phase comes the clonic phase: The arms and
usually the legs begin to jerk rapidly and rhythmically, bending
and relaxing at the elbows, hips, and knees. After a few minutes,
the jerking slows and stops. Bladder or bowel control sometimes
is lost as the body relaxes. Consciousness returns slowly, and
the person may be drowsy, confused, agitated, or depressed.

26. Tonic-Clonic Seizures
• Drooling, biting of the tongue, and
incontinence of urine may occur.
• After a seizure, the person may feel
fatigue, confusion and
disorientation. This may last from 5
minutes to several hours or even
days. Rarely, this disorientation
may last up to 2 weeks. The person
may fall asleep, or gradually
become less confused until full
consciousness is regained.
• The patients may experience
prolonged weakness after the
event; this is termed Todds
paralysis.

27. Partial Seizures
• Partial Seizures
Simple partial seizures
Complex partial seizures

28. • Simple partial seizures result from epileptic activity which
is localized in one part of the brain, usually the cortex or
limbic system.
• Consciousness is not impaired: people experiencing a
simple partial seizure can talk and answer questions.
They will remember what went on during the seizure.
• Simple partial seizures usually last just a few seconds,
although they may be longer. If there are no convulsions,
they may not be obvious to the onlooker.
• In some children, simple partial seizures lead to complex
partial seizures, or to tonic-clonic convulsions.
Simple Partial Seizures
(Jacksonian Seizures, Focal Cortical Seizures)

29. Simple Partial Seizures
• Simple partial seizures take different forms in
different people. They are further classified
according to their symptoms:
– Autonomic Seizures - These seizures are
accompanied by autonomic symptoms or signs, such
as abdominal discomfort or nausea which may rise
into the throat (epigastric rising), stomach pain, the
rumbling sounds of gas moving in the intestines
(borborygmi), belching, flatulence and vomiting. This
has sometimes been referred to as abdominal
epilepsy. Other symptoms may include pallor,
flushing, sweating, hair standing on end (piloerection),
dilation of the pupils, alterations in heart rate and
respiration, and urination. A few people may
experience sexual arousal, penile erection, and
orgasm.

30. Simple Partial Seizures
– Emotional and Other - Simple partial seizures which
arise in or near the temporal lobes often take the form
of an odd experience. One may see or hear things
that are not there. One feels emotions, often fear, but
sometimes sadness, anger, or joy. There may be a
bad smell or a bad taste, a funny feeling in the pit of
the stomach or a choking sensation. These seizures
are sometimes called simple partial seizures of
temporal lobe origin or temporal lobe auras.

31. Simple Partial Seizures
– Motor - Other simple partial seizures include (clonic,
jerking) convulsive movements. Jerking typically
begins in one area of the body -- the face, arm, leg, or
trunk -- and may spread to other parts of the body.
These seizures are sometimes called Jacksonian
motor seizures; their spread is called a Jacksonian
march. It cannot be stopped.
– Sensory Seizures - Some simple partial seizures
consist of a sensory experience. The person may see
lights, hear a buzzing sound, or feel tingling or
numbness in a part of the body. These seizures are
sometimes called Jacksonian sensory seizures.

32. Simple Partial Seizures
• When motor symptoms
spread slowly from one part
of the body to another, this
"epileptic march" has been
termed jacksonian epilepsy
(first described by Hughlings
Jackson).

33. Complex Partial Seizures
(Psychomotor/Temporal Lobe Seizures)
• A complex partial seizure occurs when epileptic activity spreads to
both temporal lobes in the brain. A complex partial seizure often
occurs after a simple partial seizure of temporal lobe origin.
• A complex partial seizure does not involve convulsions, but
consciousness is impaired. Someone experiencing one will no
longer respond to questions after the seizure starts.
• A complex partial seizure often begins with a blank look or empty
stare. They will appear unaware of their surroundings and may
seem dazed. The seizure may progress to include chewing
movements, uncoordinated activity, or sometimes performing
meaningless bits of behaviour which appear random and clumsy.
• These automatisms may include actions such as picking at their
clothes, trying to remove them, walking about aimlessly, picking up
things, or mumbling.

34. • Often accompanying these symptoms are the presence
of unusual thoughts, such as the feeling of deja vu
(having been someplace before), uncontrollable
laughing, fear, visual hallucinations, and experiencing
unusual unpleasant odors. These interesting symptoms
are thought to be caused by abnormal discharges in the
temporal lobe.
• Someone experiencing a complex partial seizure may
become frightened and try to run and struggle.
• Following the seizure, there will be no memory of it.
• A complex partial seizure usually lasts about 2 to 4
minutes. It may be followed by a state of confusion
lasting longer.
• Complex partial seizures sometimes resist
anticonvulsant medication.
Complex Partial Seizures
(Psychomotor/Temporal Lobe Seizures)

35. Complex Partial Seizure
• Some people can have seizures of this kind
without realizing that anything has happened.
Because the seizure can wipe out memories of
events just before or after it, however, memory
lapses can be a problem.
• Complex partial seizures starting in the frontal
lobe tend to be shorter than the ones from the
temporal lobe. The seizures that start in the
frontal lobe are also more likely to include
automatisms like bicycling movements of the
legs or pelvic thrusting.

36. Psychogenic Seizures
(Pseudo-Seizures)
• Psychogenic seizures are not classified as an epilepsy.
• People of all ages may experience psychogenic seizures.
• They occur 3 times more frequently in women than men.
• They may arise from various psychological factors, may be
prompted by stress, and may occur in response to suggestion.
• It has also been found that such disorders may be self-induced.
They may be used to get attention, to be excused from work, to
collect financial compensation, or merely to escape an intolerable
social situation. They seldom occur in the absence of others.
• Psychogenic seizures can be characterized by features common
with epilepsy like writhing and thrashing movements, quivering,
screaming or talking sounds, and falling to the floor.
• Psychogenic attacks differ from epileptic seizures in that out-of-
phase movements of the upper and lower extremities, pelvic
thrusting, and side-to-side head movements are evident.

37. Psychogenic Seizures
(Pseudo-Seizures)
• Psychogenic seizures may last a couple of minutes or hours, ending
as abruptly as they began.
• Anxiety may be experienced prior to an attack, followed by relief and
relaxation afterwards, leading some to postulate that psychogenic
seizures may occur as a direct response to stress in order to relieve
tension.
• Afterwards, patients usually have a vague recollection of the
seizure, without the usual post ictal symptoms of drowsiness and
depression.
• It is difficult to differentiate between psychogenic and epileptic
seizures. Statistics indicate that, in 20-30% of cases, epileptologists
are incorrect in attempting to distinguish one from the other.
• Medications are ineffective in the treatment of psychogenic
disorders. Patients are usually referred to a therapist, to learn to
control stress and become familiar with coping techniques. Since the
vast majority of psychogenic seizures operate on a psychological
level, behavioral manipulation methods may be used.

38. Febrile Seizures
• Febrile seizure occurs when a child has a high fever, most
commonly above 38.3°C (101°F), and usually on the first day of a
rapid rise in body temperature.
• A febrile seizure is usually seen in children between 6 months and 3
years of age, although they can occur in children to 10 years of age.
Febrile seizures will be experienced by only 3-4% of children and
only with a fever
• There are 2 types of febrile seizures: simple and complex.
– Simple febrile seizures are more common and relatively
harmless. They usually last less than 15 minutes and have no
after-effects. A neurological examination following a simple
seizure will yield no abnormalities.
– Complex febrile seizures may be more threatening: they can
occur at body temperatures lower than 38.3°C and can last
longer than 15 minutes. Only 1 side of the body is affected
during a complex febrile seizure and neurological reports may
indicate abnormalities.

39. Febrile Seizures
• There are a number of possible causes of febrile seizures.
Children have a higher susceptibility to seizure activity in
the brain -- a lower seizure threshhold -- because of their
age and the immaturity of their body's immune system.
Complicated by a rapidly rising fever and possibly the
general condition of health, a febrile seizure may occur.
• Several other factors may increase the risk of seizure: a
family history of seizures, chronic maternal ill health,
parental fertility problems, breech birth, Caesarean birth,
small birth weight, developmental delay, and cerebral
problems may increase the incidence of febrile seizures.
Smoking and drug intake (including anti-epileptic drugs)
during pregnancy can further increase the risk.

40. Febrile Seizures
• A febrile seizure produces no
lasting effects. Only 25-30%
of children who experience
one will ever have another.
• Febrile seizures are rare;
recurrence even rarer.

41. Status Epilepticus
• Status epilepticus is prolonged, repetitive seizure
activity that lasts more than 20 to 30 minutes, during
time which the patient is unconscious.
• A patient is also considered to be in “status” if he/she
experiences multiple seizures without becoming lucid
between seizures.
• Status epilepticus is a medical emergency with a
significantly poor outcome; it can result in death if not
treated aggressively.
• Its causes include improper use of certain
medications, stroke, infection, trauma, cardiac arrest,
drug overdose, and brain tumor.

42. Atypical Seizures
• Catamenial Seizures
Catamenial refers to seizure activity associated with a
woman's menstrual cycle.
• Studies have shown that fluctuations in female
hormones prior to and during menstruation may elevate
seizure frequency in some women.
• In a small percentage of women, catamenial seizures
may occur only during the days just before their periods;
for others, during the period itself.
• Higher ratios of estrogen to progesterone may increase
seizure frequency. Water retention, electrolyte
imbalance, and even poor sleep are also contributing
causes.

43. Non-traditional Therapies
• Diet
– Ketogenic Diet – Specialized high fat, low carbohydrate diet
– Modified Atkins Diet – Less restrictive than Ketogenic Diet.
• Surgery
– Dramatically increased in 80’s & 90’s
– Studies suggest the earlier the surgery, the better the outcome.
– Often done after only 1-2 yrs. of trying multiple medications.
– Especially effective in those with associated structural brain
abnormalities, such as benign brain tumors, malformations of
blood vessels (including disorders known as arteriovenous
malformations, venous angiomas, and cavernous angiomas),
and strokes.

44. Non-traditional Therapies
• Vagus Nerve Stimulating Devices
– The VNS device is sometimes referred to as a
"pacemaker for the brain." It is placed under the
skin on the chest wall and a wire runs from it to
the vagus nerve in the neck and is often
activated with a magnet worn as a watch.
– Patients who suffer from complex partial seizures
or generalized seizures where consciousness is
lost, and who do not respond to anticonvulsant
medication, and patients who cannot undergo
brain surgery are considered good candidates for
vagus nerve stimulation therapy. It also may be
ecommended as a treatment for photosensitive
epilepsy and epilepsy resulting from head injury

45. Assessment & History
• When obtaining history, remember to include the
following:
– History of seizures, including length of seizures,
auras, generalized or focal,
– History of head trauma.
– Alcohol/drug use
– Recent history of fever, headache, or stiff neck.
– History of diabetes, heart disease, stroke.
– Medications, including compliance

46. Assessment & History
– Description of seizure activity
• Duration
• Typical/Atypical pattern of seizure activity for
patient.
• Post ictal phase
• Incontinence
• Tongue biting

47. Common Anticonvulsant
Medications
• Carbamazepine
• Carbatrol
• Clobazam
• Clonazepam
• Depakene
• Depakote
• Depakote ER
• Diastat
• Dilantin
• Felbatol
• Frisium
• Gabapentin
• Gabitril
• Keppra
• Klonopin
• Lamictal
• Lyrica
• Mysoline
• Neurontin
• Phenobarbita
l
• Phenytek
• Phenytoin
• Sabril
• Tegretol
• Tegretol XR
• Topamax
• Trileptal
• Valproic Acid
• Zarontin
• Zonegran
• Zonisamide

48. Resistance to Medications
• Approximately
– 50% of seizures are eliminated by medication,
– 30% of seizures are reduced in intensity and
frequency by medication,
– 20% of seizures are resistant to medication.

49. Prehospital Treatment
• Assess / Address Inadequate ABC’s
– Provide ventilatory support
• Determine Level of Consciousness.
• Protect patient from additional harm. Consider C-spine
precautions.
• Apply O2 via Nasal Cannula. Obtain O2 Sats.
• Determine blood sugar level.
– Administer D50W in the hypoglycemic patient
• Determine patient temperature.
• Establish IV access / Obtain blood tubes.
• In actively seizing patient administer anticonvulsants
– Midazolam (Versed)
– Diazepam (Valium)
– Observe for respiratory depression.
• Transport