06.

Management of
Patients with Seizure
Disorders
 Seizure Disorders
● Seizures- are episodes of abnormal motor, sensory, autonomic, or psychic
activity (or a combination of these) that result from sudden, excessive
discharge from cerebral neurons.

- Part of all the brain may be involved.

 Classification of Seizures
● Generalized Seizures
- Tonic-clonic
- Myoclonic
- Atonic
● Focal seizures
● Unknown
 Classification of Seizures
● Generalized Seizures
- Often involved both hemispheres of the brain causing both body react.
- Intense rigidity of the body to occur, followed by: Alternating muscle
relaxation and concentration.
- The simultaneous contraction of the diaphragm and chest muscles
produced a characteristic epileptic cry.
- The tongue is often chewed.
- Incontinent of urine and feces.
- After 1 to 2 minutes, the convulsive movements begin to subside.
 Classification of Seizures
● Generalized Seizures
- Patient relaxes and lies in deep coma, breathing noisily.
- During the postictal, confused and difficult to arouse and may sleep for
hours.
- May report headache, sore muscles, depression.
● Tonic-clonic Seizure (grand mal seizure)
- Generalized seizure that affects the entire brain
- Most commonly associated with epilepsy.
 Classification of Seizures
● Tonic Seizure
- The tone is greatly increased, and the body, arms, or legs make sudden
stiffening movements.
- Consciousness usually preserved.
- Most often occur during sleep.
- Usually involved all/most of the brain.
● Clonic Seizure
- rare, common are tonic-clonic seizure
- Jerking is preceded by stiffening.
 Classification of Seizures
● Myoclonic Seizure
- brief, shock-like jerks of a muscle/group of muscles.
- Person is usually awake and able to think clearly.
● Atonic seizure (drop seizure, akinetic seizure, drop attacks)
- Type of seizure that consists of brief lapse in muscle tone caused by
temporary alterations in brain function.
- Usually brief, usually less than 15 sec.
 Classification of Seizures
● Focal Seizure
- Also called partial and localized seizure
- Initially affect only one hemisphere of the brain
- No natural classification
- There may be impairment of awareness or consciousness
- Other dyscognitive features
- Progression of ictal events
 Pathophysiology
● The underlying cause is an electrical disturbance (dysrhythmia) in the nerve
cells in one section of the brain.
● The cells emit abnormal, recurring, uncontrolled electrical discharges
resulting to seizures.
● There is associated loss of consciousness.
● Excess movement or loss of muscle tone or movement.
● Disturbances of behavior, mood, sensation and perception.
● The specific causes of seizures are varied and can be categorized as
genetic, structural, or metabolic condition, or may be unknown.
 Pathophysiology
● May include: - Allergies
- Cerebrovascular disease - CNS infection
- Hypoxemia of any cause - Metabolic and toxic conditions
(renal failure, hypoglycemia,
- Fever (childhood)
hyponatremia, hypocalcemia,
- Head injury pesticide exposure)
- Hypertension
- Brain tumor
- Drug and alcohol withdrawal
 Clinical Manifestations
● Depending on the location of discharging neurons.
● May range from simple staring to prolonged convulsive movements with
loss of consciousness.
● Initial pattern of seizure indicates the region in which the seizure
originates.
● A hand or finger shake
● Mouth may jerk uncontrollably.
● May talk unintelligibly
● May be dizzy
● May experience unusual or unpleasant sights, odors, tastes, but without
loss of consciousness
 Assessment and Diagnostic Findings
● The diagnostic assessment is aimed at determining
- The type of seizure
- Frequency and severity
- Precipitating Factors
● Developmental history, including events of pregnancy and childbirth
● Illnesses and head injuries
● EEG furnishes diagnostic evidence
 Epilepsy
● Group of syndromes characterized by unprovoked, recurring seizures
● Classified by spectrum patterns of clinical features, age at onset, family
history, and seizure type.
CLASSIFICATION:
- Primary (idiopathic)
- Secondary (known cause- secondary to brain tumor)
 Pathophysiology
● Message from the body are carried by the neurons of the brain by means of
discharges of electrochemical energy.
● These impulses occur in bursts wherever they perform a task.
● Sometimes, the cells continue firing even after the task is finished with
resultant dysfunction which may range from mild to incapacitating and
often causes loss of consciousness.
● If these uncontrolled, abnormal discharges occur repeatedly, the person
has epileptic syndrome.
 Pathophysiology
● Epilepsy is not associated with intellectual level.
● Without other brain/ nervous system disabilities will have same
intelligence with the general population.
● Epilepsy is not synonymous with mental retardation or illness.
 Medical Management
Pharmacologic Therapy:
● The exact mechanism of action is unknown.
● The goal is to control seizure with minimal side effects.
● Medication therapy controls, rather than cures seizures.
● If properly prescribed and taken, it controls 70% to 80% of seizure.
● 20-30% may not improve/ will not tolerate the side effects.
● Medications may need to be adjusted.
 Surgical Management
● Indicated for patient with intracranial tumors, abscesses, cysts/ vascular
anomalies.
● In focal atrophic process, a well-circumscribed area of the brain may be
excised without producing significant neurologic deficits.
 Status Epilepticus
● Acute prolonged seizure activity, series of generalized seizures that occur
without full recovery of consciousness between attacks.
● Continuous clinical/electrical seizures (on EEG) lasting at least 30 minutes
even without impairment of consciousness.
● A medical emergency as it produces cumulative effect.
● Vigorous muscular contractions impose a heavy metabolic demand and can
interfere with respirations.
● Some respiratory arrest at the height of each seizure produces venous
congestion and hypoxia of the brain.
● Repeated episodes of anoxia and edema to the brain may lead to
irreversible and fatal brain damage.
 Status Epilepticus
Precipitating Factors:
● Withdrawal of antiseizure medication
● Fever
● Concurrent infection/other illness
Medical Management:
● Goal: to stope the seizure as quickly as possible, to ensure adequate
cerebral oxygenation, and to maintain the patient in a seizure-free state.
 Status Epilepticus
Medical Management:
● Establish an airway and adequate oxygenation.
● ET if patient remains unconscious and unresponsive.
● Pharmacologic Management: IV diazepam (Valium), Lorazepam (Ativan),
Phenytoin, phenobarbital administered later to maintain a seizure free
state.
 Status Epilepticus
Nursing Management:
● Initiates ongoing assessment and monitoring of respirations and cardiac
function due to the delay of depression of respiration and BP secondary to
administration of anti-seizure medication and sedatives.
● Monitoring and documenting seizure activity and the patient’s
responsiveness.
● Turn to sides to assist in draining pharyngeal secretions.
 Status Epilepticus
Nursing Management:
● Suction equipment due to risk of aspiration.
● Side effects of long-term seizure medication: Puts the person at risk for
fractures resulting from bone disease (osteoporosis, osteomalacia,
hyperthyroidism)
● Person should be protected from injury during seizure.
07.
Management of
Patients with
Cerebrovascular
Disorders
 Cerebrovascular Disorder
● An umbrella that refers to a functional abnormality of the CNS that occurs
when the blood supply to the brain is disrupted.
● Stroke is the primary cerebrovascular disorder in the US and 4th leading
cause of death after heart disease, cancer and lower respiratory disease.
● Approximately, 297,000 people experience stroke each year in the U.S.
 Cerebrovascular Disorder
Two Major Categories of Stroke:
● Ischemic- 87% of cases, vascular occlusion and significant hypoperfusion.
● Hemorrhagic- 13% of cases, there is extravasation of blood in the
brain/subarachnoid space.
● The two types differ in etiology, pathophysiology, medical management,
surgical management, and nursing care.
 Ischemic Stroke
● A.k.a. “Cerebrovascular Accident” CVA/”brain attack”
● Sudden loss of brain function resulting from disruption of blood supply to a
part of the brain.
● Subdivided into:
- Thrombotic
- Embolic
 Ischemic Stroke
Five Different Types Based on the Cause:
● Large artery thrombotic stroke- 20%
● Small penetrating artery thrombotic stroke- 25%
● Cardiogenic embolic strokes- 20%
● Cryptogenic stroke- 30%
● Others- 5%
 Ischemic Stroke
Large Artery Thrombotic Stroke
● By atherosclerotic plaques in the large blood vessel of the brain.
● Thrombus formation and occlusion at the site of atherosclerosis result in
ischemia and infarction.
Small Penetrating Artery Thrombotic Stroke
● Is the most common type of Ischemic Stroke.
● Also called lacunar stroke, because of the cavity created after the death of
infarcted brain tissue.
 Ischemic Stroke
Cardiogenic Embolic Stroke
● Associated with dysrhythmias, usually chronic atrial fibrillation.
● Also associated with valvular heart disease/thrombi in the left ventricle.
● Emboli originate from the heart and circulate in the cerebral vasculature,
usually the left middle cerebral artery.
● Can be prevented with anticoagulation therapy in patient with atrial
fibrillation.
Cryptogenic stroke– no known cause
 Ischemic Stroke
Strokes from other Causes
● Illicit drug use
● Coagulopathies
● Migraine
● Spontaneous Dissection of the carotid/vertebral arteries.
 Risk Factors of Stroke
Modifiable Non-Modifiable
● Hypertension ● Age
● Cardiovascular diseases and Atrial ● Gender
fibrillation
● Family History
● DM
● Race
● Prior stroke, history of TIA
(Transient Ischemic Attack)
● Other factors: Hyperlipidemia,
cigarette smoking, heavy alcohol
consumption.
Pathophysiology
In ischemic attack, there is disruption of blood flow due to obstruction of
a blood vessel.

The disruption of blood flow initiates a complex series of cellular

metabolic events called the “ischemic cascade”.

The ischemic cascade begins when cerebral blood flow decreases to

less than 25 mL/100 g of blood/minute.

Cell death and permanent changes occur in 3-10 minutes

Cells at the center of the infarcted “core” die almost immediately after
the stroke onset the cause of primary neuronal damage.
Pathophysiology

Around is the zone of hypoperfusion called “penumbra”.

Ischemic cascade- cytotoxic edema and cell death (secondary neuronal

injury)
 Clinical Manifestations
● May cause a variety of neurologic deficits depending on the location of the
lesion.
● Thrombotic stroke may have warning signs, TIA.
● FAST (Facial Asymmetry, Arm weakness, Slurred speech, Time)
- May present with any of the ff signs and symptoms:
- Numbness/weakness of the face, arm /leg, especially on one side of the
body.
- Confusion or change in mental status
- Trouble speaking or understanding speech.
 Clinical Manifestations
- Visual disturbances
- Difficulty walking, dizziness/loss of balance or coordination.
- Sudden severe headache.
Motor Loss
● Hemiplegia
● Hemiparesis
● Dysphagia
 Clinical Manifestations
Communication Loss
● Aphasia- impaired speech
- Expressive aphasia (Broca’s)
- Receptive aphasia (Wernicke’s)
- Global aphasia
● Dysarthria- difficulty speaking due to muscle paralysis responsible for
producing speech.
● Apraxia- inability to perform previously learned reaction.
 Clinical Manifestations
Perceptual Disturbances
● Homonymous hemianopia- blindness in half of the visual field
● Diplopia
● Loss of peripheral vision
Sensory Loss
● Agnosia- deficits in the ability to recognize previously familiar objects
perceived by one/more of the senses.
● Paresthesia
 Clinical Manifestations
Cognitive Impairment and Psychological Effects
● Frontal Lobe- learning capacity, memory
● Reflected as short attention span, difficulties in comprehension,
forgetfulness, lack of motivation.
● Depression, emotional lability, hostility, lack of cooperation, frustration,
resentment.
Bowel and Bladder Incontinence
 Clinical Manifestations
Generalized Findings when Patient arrived in the ED
● Increased BP
● Headache
● Vomiting
● Seizures
● Changes in mental status
● Fever
● ECG changes
 Prevention
● Healthy Lifestyle
- Not smoking, maintaining a healthy weight.
- Maintaining a healthy diet, including modest alcohol consumption.
- Regular exercise
- DASH diet (Dietary Approaches to Stop Hypertension)
• High in fruits and vegetables, moderate low-fat dairy products, low in
animal protein, plant protein and legumes.
● Stroke Risk Screenings
 Medical Management
● Goals: early diagnosis and early identification of patients who can benefit
from thrombolytic therapy.
● Preserving cerebral oxygen
● Preventing complications and stroke recurrence.
● Rehabilitation
 Medical Management
● Patients who have TIA/stroke should have medical management for
secondary prevention.
- Coumadin
- Aspirin
- Clopidogrel
● Thrombolytic Therapy
- Window period of 3 hours (may be extended to 4.5 hrs)
- rt-PA
- 0.9 mg/kg over one hour
- Maximum dose is 90 mg.
 Medical Management
● Eligibility criteria for rt-PA activator administration.
- 18 years old and above
- Clinical diagnosis of Ischemic Stroke
- Time of onset known and within guidelines.
- SBP less than 185 mmHg, DBP less than 110 mmHg.
- No seizure onset at stroke.
- Not taking warfarin
- Not receiving heparin within 48 hours, PTT not elevated.
- Platelet count above 100,000/mm3
 Medical Management
● Eligibility criteria for rt-PA activator administration.
- No prior intracranial hemorrhage.
- No major surgical procedure in 14 days.
- No GI/urinary bleeding within 21 days.
● Rehabilitation
- Physical Therapy
- Occupational Therapy
- Speech Therapy
- Classify ADL needs
 Hemorrhagic Stroke
● Primarily caused by intracranial or subarachnoid hemorrhage.
● Bleeding into the brain tissue, ventricles or subarachnoid space.
● Primary intracerebral hemorrhage
- From rupture of small vessels- 80%, chiefly caused by hypertension.
- Subarachnoid hemorrhage from ruptured intracranial aneurysm.
● Secondary intracerebral hemorrhage is associated with arteriovenous
malformation, intracranial aneurysm, intracranial neoplasm or medications
like anticoagulants.
● Symptoms produced when primary hemorrhage, aneurysm, or AVM press on
nearby cranial nerves, or brain tissue, or bleeding to the subarachnoid space.
 Assessment and Diagnostic Findings
● CT Scan
- to determine the type of stroke.
- Size and location of hematoma
- Presence or absence of ventricular blood
- Hydrocephalus
● MRI
● Lumbar puncture if no signs of increased ICP, as it can cause herniation on
the brain stem or rebleeding.
● Toxicology for patients below 40, due to illicit drug use.
 Assessment and Diagnostic Findings
● Cerebral angiography- to confirm diagnosis of intracranial aneurysm or AVM.
- Shows location and size of lesion
- Provide info about the affected arteries, veins, adjoining vessels and vascular
branches.
 Clinical Manifestations
● Hemorrhagic stroke presents a variety of neurologic deficits similar to patient with
ischemic stroke.
- headache, common complaint of conscious patient
- Some motor, sensory, cranial, cognitive and other functions that are disrupted.
- Rupture aneurysm and AVM
• sudden, unusually severe headache
• Loss of consciousness
• Nuchal rigidity
• Visual loss, diplopia, ptosis, tinnitus, dizziness, hemiparesis may occur.
• Severe bleeding will result in cerebral damage, followed rapidly by coma and death.
 Medical Management
● Goals:
- Allow the brain to recover from initial insult (bleeding).
- Prevent/minimize the risk of rebleeding.
- Prevent/treat complications.
● Bedrest with sedation to prevent agitation and stress.
● Manage vasospasm.
● If caused by warfarin, may be corrected with fresh frozen plasma and vitamin
K.
 Medical Management
● Prothrombin complex concentrates.
● Hemodialysis
● Antiseizure drug for seizure. (e.g. phenytoin)
● Sequential compression device or anti-embolism stocking to prevent DVT.
● If mobile for 1-4 days and bleeding ceases, DVT prevention medication like
unfractionated heparin may be prescribed.
● Analgesic for head and neck pain.
● Acetaminophen, cooling blanket for fever.
● After discharge, anti-hypertensive medication to decrease risk of another
intracerebral hemorrhage.
 Surgical Management
● Craniotomy- if showing signs of worsening neurologic deficit, increased ICP,
signs of brain stem compression.
 Prevention
● Managing hypertension and ameliorating other significant factors.
- Primary hypertension (essential hypertension), secondary hypertension
(disease)
- Malignant hypertension- persistent elevation of BP. Medication, diet exercise
cannot control the hypertension.
● Control of hypertension can reduce the risk of hemorrhagic stroke.
● Additional risk factors: increasing age, male gender, excessive alcohol intake.
● Health Education
● Stroke risk screening
 Potential Complications include:
● Cerebral hypoxia and decreased blood flow and extension of the area of the
injury.
- Immediate complications of hemorrhagic stroke
- Administering supplemental oxygen and maintaining the hemoglobin and
hematocrit at acceptable levels will assist in maintaining tissue oxygenation.
● Vasospasm- narrowing if the lumen
- Serious complication of subarachnoid hemorrhage, leading cause of
morbidity and mortality of those who survive the initial attack.
- 15%-20% with vasospasm die, frequently occurs 7-10 days after initial
hemorrhage.
 Potential Complications include:
- Based on theory, vasospasm is caused by an increased influx of calcium into
the cell.
- Nimodipine (Nimotop) antagonizes/ blocks this action and prevent or reverse
the action of vasospasm.
 Potential Complications include:
● Increased Intracranial Pressure
- Increased ICP can occur after either ischemic stroke or a hemorrhagic stroke
but almost always follows a subarachnoid hemorrhage due to disturbed
circulation of CSF by blood.
- CSF drainage may be instituted by ventricular catheter drainage.
- Mannitol
- Monitor fluid and electrolyte imbalance as this will be caused by long term
mannitol use.
Thank you!
God Bless
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