• Definition • Causes • Pathophysiology • Assessment and common findings p 882,/p 899 PCCM 216 o Petit mal o Grand mal o Partial seizures o Complex partial seizure • Management p 882/p 899 / PCCM 216 o Drug therapy o Break through seizure PCC M 218 • Complications • Status epilepticus p 883/p 900 / PCCM 219 (T&E Periods) o Definition o Effects o Causes o Management • Essential health information p 883/p 900 PCCM 217 o General o Seizure diary o Drug interaction vigilance o Lifestyle education • Convulsions in children p 883/p 900 • Epilepsy in the elderly p 1058/ p1087

1. EPILEPSY
BY C SETTLEY

2. Epilepsy
•A disorder in which nerve cell activity in the brain is disturbed,
causing seizures.
2018/07/30 COMPILED BY C SETTLEY 2

3. Epilepsy: Causes
•Trauma
• Car accidents
•Congenital defects
• Defects of the CNS
•Inborn errors of metabolism
• Inborn errors of metabolism (IEM) are the consequence of genetic
defects that lead to a metabolic block in a biochemical pathway critical
to cellular function, targeting many organs including the brain.
•Infection
• E.g. meningitis
2018/07/30 COMPILED BY C SETTLEY 3

4. Epilepsy: Causes
•Hyperexia
• Especially in children
•Brain tumours
• In brain tumour patients, seizures may be related to cells around the
tumour that have developed abnormally.
• Or they may be due to an imbalance of chemicals in the brain caused by
the tumour.
•Vascular lesions
• E.g. hemorrhagic lesions
•Acidosis, hypoxia or electrolyte imbalances
2018/07/30 COMPILED BY C SETTLEY 4

5. Epilepsy: Pathophysiology
•Seizures are caused by paroxysmal discharges from groups of neurons, which
arise as a result of excessive excitation or loss of inhibition.
•The key unit of neurotransmission is the synapse, and the fundamental
components of synapses are ion channels.
•Thus, the cause of seizures boils down to malfunction of ion channels.
•Patients with lesions usually have additional neurological abnormalities.
•In about half of seizure disorders, no genetic or structural abnormality is
evident.
•In addition to genes and the environment, brain (synapse) development has a
strong influence on seizures.
2018/07/30 COMPILED BY C SETTLEY 5

6. Epilepsy
•In the nervous system, a synapse is a
structure that permits a neuron (or
nerve cell) to pass an electrical or
chemical signal to another neuron or
to the target efferent cell.
2018/07/30 COMPILED BY C SETTLEY 6

7. Epilepsy
•Neurotransmitters are often referred
to as the body's chemical
messengers.
•They are the molecules used by the
nervous system to transmit messages
between neurons, or from neurons
to muscles.
•Communication between two
neurons happens in the synaptic cleft
(the small gap between the synapses
of neurons).
2018/07/30 COMPILED BY C SETTLEY 7

8. Epilepsy
•An axon or nerve fiber, is a long
projection of a nerve cell, or neuron,
in vertebrates, that typically conducts
electrical impulses known as action
potentials, away from the nerve cell
body.
2018/07/30 COMPILED BY C SETTLEY 8

9. Epilepsy
•Neurons have specialized projections
called dendrites and axons.
•Dendrites bring information to the
cell body and axons take information
away from the cell body.
•Information from one neuron flows
to another neuron across a synapse.
•The synapse contains a small gap
separating neurons.
2018/07/30 COMPILED BY C SETTLEY 9

10. Epilepsy: Petit mal epilepsy
•A form of epilepsy with very brief,
unannounced lapses in
consciousness.
•A petit mal seizure involves a brief
loss of awareness, which can be
accompanied by blinking or mouth
twitching.
•Petit mal seizures take the form of a
staring spell: the person suddenly
seems to be "absent."
2018/07/30 COMPILED BY C SETTLEY 10

11. Epilepsy: Grand mal epilepsy
•A grand mal seizure causes a loss of consciousness and violent muscle
contractions.
•A grand mal seizure is caused by abnormal electrical activity throughout the
brain.
•Many people who have a grand mal seizure never have another one and
don't need treatment.
•But someone who has recurrent seizures may need treatment with daily
anti-seizure medications to control and prevent future grand mal seizures.
2018/07/30 COMPILED BY C SETTLEY 11

12. Epilepsy: Grand mal epilepsy
•Grand mal seizures have two stages:
• Tonic phase. Loss of consciousness occurs, and the muscles suddenly
contract and cause the person to fall down. This phase tends to last
about 10 to 20 seconds.
• Clonic phase. The muscles go into rhythmic contractions, alternately
flexing and relaxing. Convulsions usually last one to two minutes or less.
2018/07/30 COMPILED BY C SETTLEY 12

13. Epilepsy: Grand mal epilepsy
•The following signs and symptoms occur in some but not all people with
grand mal seizures:
• A scream. Some people may cry out at the beginning of a seizure.
• Loss of bowel and bladder control. This may happen during or following a
seizure.
• Unresponsiveness after convulsions. Unconsciousness may persist for several
minutes after the convulsion has ended.
• Confusion. A period of disorientation often follows a grand mal seizure. This is
referred to as postictal confusion.
• Fatigue. Sleepiness is common after a grand mal seizure.
• Severe headache. Headaches may occur after a grand mal seizure.
2018/07/30 COMPILED BY C SETTLEY 13

14. Epilepsy: Grand mal epilepsy
2018/07/30 COMPILED BY C SETTLEY 14

15. Epilepsy: Partial seizures
•A focal onset seizure, also known as a partial seizure, is when a
seizure occurs in just one area.
2018/07/30 COMPILED BY C SETTLEY 15

16. Epilepsy: Complex Partial seizures
•A complex partial seizure is also known as a focal impaired
awareness seizure or a focal onset impaired awareness seizure.
•This type of seizure starts in a single area of the brain. This area
is usually, but not always, the temporal lobe of the brain.
•Partial seizures are divided into simple, complex and those that
evolve into secondary generalized seizures.
•The difference between simple and complex seizures is that
during simple partial seizures, patients retain awareness; during
complex partial seizures, they lose awareness.
2018/07/30 COMPILED BY C SETTLEY 16

17. Epilepsy: Diagnosis
•An electroencephalogram (EEG) to measure the electrical activity of the
brain
•A spinal tap to collect spinal fluid for analysis
•Imaging tests, like an MRI or CT scan, of the head
•These blood tests are also commonly used to help diagnose epilepsy or rule
out other disorders:
• Tests of liver and kidney function
• Blood glucose tests
• Complete blood count and chemistry of the blood
• Tests to diagnose or rule out any infectious diseases
2018/07/30 COMPILED BY C SETTLEY 17

18. Epilepsy: Nursing Management
•Stay with the patient
•Reassure patient
•Because the simple partial seizure is a warning of a stronger
seizure, the nurse should assess the immediate environment to
ensure that, should the patient fall, any potential hazards are
removed that could cause injury.
2018/07/30 COMPILED BY C SETTLEY 18

19. 2018/07/30 COMPILED BY C SETTLEY 19

20. Epilepsy: Drug therapy
•Phenytoin
• Phenytoin is used to control certain type of seizures, and to treat and prevent
seizures that may begin during or after surgery to the brain or nervous system.
• Phenytoin is in a class of medications called anticonvulsants.
• It works by decreasing abnormal electrical activity in the brain.
•Barbiturates
• Barbiturate anticonvulsants are a group of drugs derived from barbituric acid
and they act by suppressing activity of the central nervous system.
• Barbiturate anticonvulsants enhance the action of GABA, which is an inhibitory
neurotransmitter, and inhibits initiation of discharge that would start the
seizure.
2018/07/30 COMPILED BY C SETTLEY 20

21. Epilepsy: Drug therapy
•Primidone
• Primidone belongs to a class of drugs known as barbiturate
anticonvulsants.
• It works by controlling the abnormal electrical activity in the brain
that occurs during a seizure.
•Valproic acid
• Valproic acid is used to treat certain types of seizures (epilepsy).
• This medicine is an anticonvulsant that works in the brain tissue to
stop seizures.
2018/07/30 COMPILED BY C SETTLEY 21

22. Epilepsy: Drug therapy
•Carbemazepine
• Carbamazepine is a sodium channel blocker. It binds preferentially
to voltage-gated sodium channels in their inactive conformation,
which prevents repetitive and sustained firing of an action
potential.
•Succinimides
• Succinimide anticonvulsants are thought to increase the seizure
threshold
• Suitable to treat petit mal seizures.
2018/07/30 COMPILED BY C SETTLEY 22

23. Epilepsy: Drug therapy
•The following drug therapy for the treatment of Epilepsy is
according to the:
STANDARD TREATMENT GUIDELINES AND ESSENTIAL MEDICINES
LIST OF SOUTH AFRICA
2018/07/30 COMPILED BY C SETTLEY 23

24. 2018/07/30 COMPILED BY C SETTLEY 24

25. 2018/07/30 COMPILED BY C SETTLEY 25

26. 2018/07/30 COMPILED BY C SETTLEY 26

27. 2018/07/30 COMPILED BY C SETTLEY 27

28. 2018/07/30 COMPILED BY C SETTLEY 28

29. 2018/07/30 COMPILED BY C SETTLEY 29

30. 2018/07/30 COMPILED BY C SETTLEY 30

31. Epilepsy: Drug therapy
•Benzodiazepines
• Prevents the spread of seizure discharge.
2018/07/30 COMPILED BY C SETTLEY 31

32. Epilepsy: Complications
•Permanent damage to brain tissue
•Injuries during convulsions
•Status epilepticus
• a dangerous condition in which epileptic fits follow one another without
recovery of consciousness between them.
2018/07/30 COMPILED BY C SETTLEY 32

33. Status epilepticus:
Management
•Must be viewed as medical emergency
•Admission to ICU
•Management consists of adequate airway, oxygenation and circulation
•Cardiorespiratory function should be stabilised
•Initial therapy- Phenytoin (IV)
•IV Phenobartbitone as continuous infusion after convulsions have stopped
•General anaesthesia
•Intubation
•Nurse adequately
2018/07/30 COMPILED BY C SETTLEY 33

34. Essential health education
• Patient must understand treatment
• Medic alert bracelet
• Effects of medication
• Alcohol increases frequency
• Stress and anxiety
• Balanced lifestyle
• Good diet
• Hazardous- activities & daily living
2018/07/30 COMPILED BY C SETTLEY 34

35. Convulsions in children
• History
• Illnesses
• Pyrexia
• Hypoglycaemia
• Turn child on side
• Diazepam
• Reduce fever
• Test blood sugar
• Glucose administration
2018/07/30 COMPILED BY C SETTLEY 35

36. Convulsions in the elderly
• Misdiagnosed
• Common after strokes, tumours or adverse effects of drugs
• Confusion
• Suspended awareness
• Hearing or seeing things
• Sporadic memory loss
2018/07/30 COMPILED BY C SETTLEY 36

37. Case scenario 1
Leanne is a 6-year-old girl whose teachers have suggested that her parents take to her GP. They
have noticed that she seems to have problems listening and to be daydreaming a lot in class.
The GP asks whether her parents have also seen her daydream. Her mother has, but has not
thought much about it. However, more recently, it seems to have been happening more
frequently. On direct questioning by the GP, Leanne's mother thinks that these daydreams or
‘trances’ as she calls them sometimes occur when Leanne is in the middle of doing or saying
something, and they interrupt her activity.
Leanne’s birth and early medical history, including her development, have been normal. There
was a history of epilepsy on her father’s side of the family. Her younger brother and older sister
are well.
2018/07/30 COMPILED BY C SETTLEY 37

38. Questions
1. What should Leanne's GP consider as a possible diagnosis?
2. What further investigations should the paediatrician or paediatric neurologist request, and
what considerations should be taken into account?
3. The diagnosis of childhood-onset absence epilepsy is confirmed. What are the next steps?
4. What should the discussion around medication include, and what AEDs may be prescribed?
2018/07/30 COMPILED BY C SETTLEY 38

39. Case scenario 2
Christopher, a 13-month-old infant, presents to the accident and emergency department (A&E)
of his local hospital with his first prolonged tonic−clonic afebrile seizure. He has experienced
three febrile seizures in the past. The first two occurred at eight months of age due to a chest
infection. They were prolonged, lasting over 15 minutes, and he required emergency medication
and a three-day admission. The third febrile seizure was at nine months and associated with an
upper respiratory tract infection. It only affected the left side of Christopher's body and lasted
for over 30 minutes before it was stopped with intravenous lorazepam and intravenous
phenytoin.
A magnetic resonance imaging (MRI) brain scan and cerebrospinal fluid analysis are normal. His
early development has been normal but he only started crawling at 12 months of age and he has
no recognisable words. There is no family history of epilepsy.
2018/07/30 COMPILED BY C SETTLEY 39

40. Questions
1. What should the A&E staff looking after Christopher consider as a possible diagnosis, and
what investigations should be carried out to confirm this? Also what referrals, if any, should be
made?
2. What else should be considered, and what information should be provided?
3. What AED medication should the paediatric neurologist prescribe for Christopher?
2018/07/30 COMPILED BY C SETTLEY 40

41. Case scenario 3
The parents of Charlie, an 8-month-old boy, visit the GP because they are concerned about some
strange episodes he has been having over the previous three weeks. The episodes usually occur
soon after he has woken but may sometimes happen as he is about to go to sleep. In these
episodes his knees suddenly come up towards his chest, his arms bend at the elbows and his
hands may clench. Each episode lasts a few seconds but they may occur repeatedly over many
minutes. He is very upset after them.
Over the past two weeks Charlie has become more irritable and has stopped showing any
interest in his toys. His birth and perinatal period were normal. There is no family history of
epilepsy.
2018/07/30 COMPILED BY C SETTLEY 41

42. Questions
1. What steps should Charlie's GP take next?
2. What should the paediatrician or paediatric neurologist do next?
3. What further investigations should Charlie have, and what information should be given to his
parents about these?
4. Charlie’s MRI brain scan will be undertaken in a few days. What treatment options should the
paediatrician or paediatric neurologist offer his parents, and what information should they be
given?
2018/07/30 COMPILED BY C SETTLEY 42

43. Case scenario 4
Presentation
Suzanne, a 10-year-old girl presents to A&E reported to have had a generalised tonic−seizure
while on an aeroplane from Australia. It has stopped by the time she is seen by the ambulance
staff, and she has fully recovered by the time she reaches the hospital.
Past medical history
Suzanne's delivery was normal and full term. Early developmental milestones were achieved at a
similar time to her older sister. She had recurrent otitis media between 2 and 5 years of age.
There have been no concerns since starting school.
On examination
Suzanne is fully orientated in time and space. She is apyrexial. There is no focal neurological
deficit.
2018/07/30 COMPILED BY C SETTLEY 43

44. Questions
1. What should the casualty officer do?
2. What investigation(s) should be performed?
3. What other information should be given to the family so that a decision about treatment can
be made?
4. How long should the treatment be continued for?
2018/07/30 COMPILED BY C SETTLEY 44

45. Reference list
http://neuropathology-web.org/chapter2/chapter2dseizures.html
https://www.mayoclinic.org/diseases-conditions/grand-mal-seizure/symptoms-causes/syc-
20363458
2018/07/30 COMPILED BY C SETTLEY 45