Lecture Objectives
Upon completion of this lecture , the student will be able to:
 Describe what the pathophysiology of a seizure
 Differentiate between a Grand Mal and Petit Mal seizure
 List two causes of seizures
 Explain the difference between Phase 1 and Phase 2 video
EEG monitoring
 State two additional modes of diagnosing seizure disorders
 Discuss two Anticonvulsant medications and their aim for
treatment
 List three common side effects of Anticonvulsant medication
 Describe immediate care of a seizing patient in the acute
setting
 List three important assessment and documentation
considerations post seizure
 State three initial interventions when someone is in Status
Epilepticus
What is a seizure?
A seizure is a sudden disruption of the brain's normal electrical
activity accompanied by altered consciousness and/or other
neurological and behavioral manifestations. Epilepsy is a condition
characterized by recurrent seizures with symptoms that vary from
a momentary lapse of attention to severe convulsions.
Types of seizures
Grand-Mal Seizures – This type of seizure presents as a
generalized tonic-clonic seizure that often begins with a loud cry
before the person having the seizure loses consciousness and falls
to the ground. The muscles become rigid for about 30 seconds
during the tonic phase of the seizure and alternately contract and
relax during the clonic phase, which lasts 30-60 seconds. The skin
sometimes acquires a bluish tint and the person may bite his
tongue, lose bowel or bladder control, or have trouble breathing.
A grand mal seizure lasts between two and five minutes, and the
person may be confused or have trouble talking when he regains
consciousness. The period of time immediately following a seizure
is known as the “post-ictal” state.
Primary generalized seizures – This is a primary generalized
seizure that occurs when electrical discharges begin in both halves
(hemispheres) of the brain at the same time. Primary generalized
seizures are more likely to be major motor attacks than to be
absence seizures.
Absence (petit mal) seizures – This type of seizure generally
begin at about the age of four, and usually stops by the time the
child becomes an adolescent. Petit Mal seizures usually begin with
a brief loss of consciousness and last between one and 10 seconds.
A person having a petit mal seizure becomes very quiet and may
blink, stare blankly, roll his eyes, or move his lips. A petit mal
seizure lasts 15-20 seconds. When it ends, the person who had the
seizure resumes whatever he was doing before the seizure began.
He will not remember the seizure and may not realize that
anything unusual has happened. Untreated, petit mal seizures can
recur as many as 100 times a day and may progress to grand mal
seizures.
Myoclonic seizures – This type of seizure is characterized by
brief, involuntary spasms of the tongue or muscles of the face,
arms, or legs. Myoclonic seizures are most likely to occur first thing
in the morning.
Simple Partial seizures – This type of seizure does not spread
from the focal area where they arise. Symptoms are determined by
what part of the brain is affected. The patient usually remains
conscious during the seizure and can later describe it in detail.
Complex Partial seizures – This type of seizures presents with
a distinctive smell, taste, or other unusual sensation (aura) may
signal the start of a complex partial seizure. Complex partial
seizures start as simple partial seizures, but move beyond the focal
area and cause loss of consciousness. Complex partial seizures can
become major motor seizures. Although a person having a complex
partial seizure may not seem to be unconscious, he does not know
what is happening and may behave inappropriately. He will not
remember the seizure, but may seem confused or intoxicated for a
few minutes after it ends.
Causes of Seizures?
Most cases of epilepsy are of unknown origin. Sometimes,
however, a genetic basis is indicated, and other cases may be
traceable to birth trauma, lead poisoning, congenital brain
infection, head injury, alcohol or drug addiction, or the effects of
organ disease. Known causes of Epilepsy and other seizure
disorders can include:
 Brain tumor (Lesions that occupy space)
Cerebral hypoxia (breath holding, carbon monoxide
poisoning, anesthesia)
 Cerebrovascular accident (infarct or hemorrhage)
 Convulsive or toxic agents (lead, alcohol, picrotoxin,
strychnine)
 Alcohol and drug use withdrawal
 Eclampsia
 Hormone changes during pregnancy and menstruation
 Exogenous factors (sound, light, cutaneous stimulation)
 Fever (especially in children
 Head injury (highest incidence is found in young adults)
 Heat stroke
 Infection (acute or chronic)
 Metabolic disturbances (diabetes mellitus, electrolyte
imbalances)
 Withdrawal from, or hereditary intolerance of, alcohol
 Kidney failure (uremia, phenylketonuria)
 Degenerative disorders (senile dementia)
Note: Triggers for the seizures also vary widely. Among the
factors that can bring on seizures are certain chemicals or foods,
sleep deprivation, stress, flashing lights, menstruation, some
prescription and over-the-counter medications, and possibly oral
contraceptives

Diagnosis:
 The first step in diagnosing a seizure disorder is to determine
whether or not the patient “did” or “did not” actually have a
seizure. To do this the following is required:
 Past medial history
 Careful history of clinical presentation and events related to
alleged seizure
 General physical and neurological examination
 Diagnostic testing which include:
 Computed Tomography (CT Scan)
 Magnetic Resonance Imaging (MRI)
 Electroencephalogram (EEG)
 Video EEG (Phase 1 or Phase 2)
 Single Proton Emission Computerized Tomography (SPECT,
can localize not diagnose)
Video EEG Monitoring:
Video EEG Monitoring can be used to determine if a patient is a
candidate for surgical treatment. The purpose of this monitoring is
to capture a seizure on EEG. Video monitoring has two phases;
Phase 1 includes continuous telemetry (waveform) monitoring as
well as video and audio monitoring. If Phase 1 monitoring is
inconclusive, Phase 2 monitoring which is telemetry and video
monitoring with stereotatically implanted depth electrodes or
subdural grid electrodes can be done.
When Phase 2 monitoring is required, MRI is used to select targets
for depth electrodes and to verify the location of these electrodes
within specific anatomical sites in the brain.
If an isolated epileptogenic region can be identified, a resective
surgery to remove that particular portion of the brain can be
performed. Most patients undergo a standard anterior temporal
lobectomy, but an increasing number are receiving extratemporal
cortical resections.
According to the UCLA Seizure Disorder Center, 70% –80% of
patients can expect to become free from disabling seizures
following temporal lobe surgery, while all but 3%-5% percent
experience a worthwhile improvement in seizure frequency, with
marked improvement in the quality of their daily lives.
How are seizure disorders treated?
Once a seizure disorder of Epilepsy has been diagnosed the first
line of treatment is usually medication therapy that focuses on
reducing the frequency and severity of the seizures. The goal is to
find a medication that will control the seizures but not produce
side effects. Because many people will continue on medication for
many years, selection of a good first drug is extremely important.
Anticonvulsants and other prescription agents are usually
prescribed based on the type of seizures that the patient is
experiencing. The following medications are frequently
prescribed:
 Benzodiazepines – which are a family of drugs, used to treat
insomnia, anxiety, panic attacks, muscle spasms, and seizure
disorders. Examples include:
o Clonazepam (Klonipin)
Clorazepate (Tranxene)
o Diazepam (Valium)
 Phenytoin (Dilantin) – a synthetic drug that is classified as a
hydantoin. It is used for the treatment of simple partial,
complex partial and generalized tonic-clonic seizures.
Phenytoin blocks post-tetanic potentiation by influencing
synaptic transmission through voltage sensitive sodium
channels.
 Carbamazepine (Tegretol) – used as a first line agent for the
treatment of simple partial, complex partial and generalized
tonic-clonic seizures. The mechanism of action is depression
of transmission via the nucleus ventralis anterior thalamus,
which acts to decrease the spread of seizure discharge.
 Lamotrigine (Lamictal) – used when seizures are focal in
onset, tonic-clonic, atypical absence and/or myoclonic in
nature.
 Valproate (Depakote) – used for the management of
myoclonic, tonic, atonic, absence and generalized tonicclonic seizures especially with patients with one or more type
of generalized seizure.
 Phenobarbital (Luminal) – Once a mainstay in the treatment
of seizures (especially status epilepticus), Phenobarbital is
now being replaced by other anticonvulsants but can still be
used for the treatment of generalized seizures except for
absence and partial seizures.
Side Effects of Anticonvulsants:
The following are mild side effects that are experienced while
taking anticonvulsants. Often, these side effects will go away as the
patient gets used to the medication or can be resolved by adjusting
the medication dose.
 Visual disturbances
 Lightheadedness
 Balance problems
 Confusion
 Mild gastrointestinal dysfunction
 Headaches
 More serious side effects that may require the
discontinuation of the drug include:
 Rash
 Easy bleeding (bruising)
 Jaundice (and other symptoms of blood or liver problems)
o
Note: Some antiepileptic drugs will require routine monitoring of
blood counts and liver function, so that any problems caused by
the drugs, however rare, can be caught early.
Diet:
In addition to anticonvulsant medication, a ketogenic diet is a
dietary approach based on the observation that ketosis (increased
blood levels of ketones) is associated with the reduction of seizures.
Ketosis can be produced by a diet high in fat and very low in
carbohydrates and protein.
Surgical Intervention:
If Video EEG has isolated the origin of seizure activity, surgery can
be pursued (if all other medical management has proven
ineffective). Surgical options for treatment of seizures include
cortical excision (lobectomy) or if scar tissue or other focal
epileptogenic areas exist a lesionectomy can be done. The most
common surgical areas include:
 Temporal Lobectomy (the most common site of seizure focus
localization with a mortality rate of less then 1%)
 Frontal Lobectomy (removal of part of the frontal lobe)
 Hemispherectomy (removal of ½ of the brain)
 Corpus Callostomy (splitting of the two hemispheres of the
brain)
Complications of Surgical intervention include:
 Infection
 Hydrocephalus
 Cerebral edema
 Cerebral ischemia
 Hematoma
 Hemiparesis/Hemiplegia
 Aphasia
 Visual field deficits
 Higher level functioning disturbances (cognition, memory,
concentration)
 Psychosocial impairment (family interpersonal dynamics,
self-esteem)
Placement of a Vagus Nerve Stimulator (VNS):
A VNS is an implantable device that is used to decrease seizure
frequency. In some cases it eliminates seizure activity altogether. It
is a surgically implanted device that is placed in the chest wall
(similar to a pacemaker), with a wire that is threaded to the Vagus
nerve in the neck. Once in place the Vagus Nerve Stimulator is
programmed (using a magnet), to stimulate the Vagus nerve at
pre-set intervals. Patients are sent home with a magnet as well to
trigger the device at the onset of a seizure.
Note: The actual mechanism of action with a Vagus Nerve
Stimulator for preventing seizures is actually uncertain
Nursing care and management of seizures in the acute
setting:
Before (and During) Seizure Care:
 If the patient is seated when a major seizure occurs, ease
them to the floor
 Provide privacy if possible
 If patient experiences an aura, have them lie down to prevent
injury
 Remove eyeglasses and loosen restrictive clothing
 Do not try to force anything into the mouth
 Guide the movements to prevent injuries (do not restrain
patient)
 Stay with the patient throughout the seizure to ensure safety
 Time the seizure (seizure events often seem much longer
then they really are)
 Verbalize events as they happen to assist with more accurate
recall later
 If not already available have someone retrieve O2 and
suction
Post Seizure Care:
 Position patient on their side to facilitate drainage of
secretions
 Provide adequate ventilation by maintaining a patent airway
 Suction secretions if necessary to prevent aspiration
 Allow the patient to sleep post seizure
 On awakening, orient patient to what has occurred
Nursing Assessment/Documentation Post Seizure
(consider the following when organizing information and
documentation regarding a seizure):
 Was the seizure witnessed from the start?
 Were there any warning signs?
 Where did the seizure begin and how did it proceed?
 What type of body movement was noted?
 Where their pupil changes or was there conjugate gaze
deviation?
Was the patient unconscious throughout the seizure?
 Was there urinary incontinence?
 What was the person’s behavior before and after the seizure?
 Was there any weakness or paralysis of the extremities post
seizure?
 Were there any injuries noted?
 Did the patient sleep (post-ictal) after the seizure and for
how long?
Note: These observations should be noted in narrative fashion in
the nurse’s notes or placed on a separate seizure activity sheet if
one is available at your facility. All nursing interventions such as
positioning , suction, O2 and physician notification must also be
documented.

Nursing care and management for Status Epilepticus in
the acute setting (defined as seizures lasting at least
5minutes or two or more seizures in a row without
complete recovery in between)
Initial Nursing Management:
 ABC’s of life support
 Position patient to avoid aspiration or inadequate
oxygenation
 If possible as soft oral airway can be placed (again do not
force teeth apart)
 Suction and O2 must be available
 Monitor respiratory function with ongoing pulse oximetry
 IV access should be secured
 Frequent monitoring of neuro exam and vital signs
 Monitor ABG’s (profound metabolic acidosis can occur
during seizures)
 Monitor Glucose (hyperglycemia followed by hypoglycemia is
common)
 Treat hyperthermia (occurs often with status epilepticus)
aggressively
Anticonvulsant therapy for management of Status
Epilipticus:
The following drug therapy regimen assumes that the previous
administered drug was not successful in terminating the seizures.
 Time 0-3 minutes: Lorazepam (Ativan) 4mg-8mg IVP
(2mg/min)
 Time 4-23 minutes: Phenytoin (Dilantin) 20mg/kg (about 1
gm) in NS at (50mg/min)
Time 22-33 minutes: Phenytoin (Dilantin) additional dose 510mg/kg
 Time 37-58 minutes: Phenobarbital 20mg/kg IV (5075mg/min)
 Time 58-68 minutes: Phenobarbital additional dose 510mg/kg
Note: If patient remains in Status Epilepticus despite the above
drug therapy regimen, consider anesthesia with Midazolam or
Propofol.

Patient/Family Education for Seizures/Epilepsy:
General Health:
 Trigger signs (patient specific if possible)
 Regular exercise
 Regular sleep patterns
 Showers vs. Baths (for safety)
 Good oral hygiene (some anticonvulsant can cause gingival
hyperplasia)
Diet/Nutrition/Beverages:
 Eat well rounded meals at routine times
 Avoid excess sugar, caffeine or other trigger foods
Fever and Illness:
 Fever can trigger seizures treat immediately
 Any prescription or over the counter drugs should be reviewed for
interaction
Environmental/Occupational/Recreational Risk Factors:
 Noisy environments should be avoided
 Avoid bright flashing or fluorescent lights
 Use a screen filter on the computer screen to avoid glare
 Do not use recreational or street drugs
 Avoid work/recreation that could cause injury if a seizure was to occur
 Swim with a “buddy”
 Avoid contact sports
 Advise patient to carry disease process information at all times
Stress/Anxiety/Depression:
 Avoid emotional stress (often a trigger)
 Counseling for stress reduction or depression may be warranted
Woman’s Health:
 Seizures may increase at time of menses (careful control of other
triggers during menses is recommended)
 Anticonvulsant drugs decrease the effectiveness of oral contraceptives
 Seizure patterns often change during pregnancy
 Some Anticonvulsants can cause birth defects