CASE PRESENTATION ON SEIZURES

2. By-
Syanthika Dutta
MCH

3. Case scenario
History of the patient
Identification data-
Name Sk. Saleha Begum
Age 37
Sex Female, MUSLIM
Bed no 418
Ward Green 4th floor (f)
Regd no MCHK/RG2100172261
Address Panch para, Howrah
Date of Admission 30/03/2021
Name of doctor Prof. Sandip Pal (unit-1)
Diagnosis SEIZURES

4. History of the patient
Chief complaint-
2 episodes of GTCS – 6months ago(1st) and 2months(2nd) ago
Weakness in both lower limbs for last 6 months.
Involuntary jerky movements in both the lower limbs for 6months.
Nausea and vomiting for the last 3 months. Inability to take food
properly.
Past medical history
History of hypothyroidism with therapy of drugs.

5. Physical Examination
System Details
Central nervous system WNL
Respiratory system WNL
Cardiovascular system WNL
GI system WNL
Integumentary system WNL
Musculoskeletal system Joints are movable; movement
restricted due to weakness
Excretory system WNL
GCS 15

6. Neurological Examination
Within normal limits

7. Overview
Seizure—transient involuntary alteration of
consciousness, behaviour, motor activity, sensation and/or
autonomic function due to abnormal discharge of cortical
neurons; an episodic event, may have provoking factors,
e.g. anoxia, alcohol, drugs
Convulsion– seizure with prominent alteration of motor
activity
Epilepsy—a disorder with recurrent seizures(2 or more),
unprovoked by a specific event such as fever, trauma,
infection, or chemical change, stereotypic

8. Seizures are episodes of series of involuntary
contractions of voluntary muscles occurring due
to disturbances(i.e. Paroxysmal electricity activity)
in brain function resulting from abnormal
excessive electrical discharge from brain
manifested by involuntary, motor, sensory,
autonomic or psychic phenomenon, alone or in
combination.
DEFINITION

9. Familial history of epilepsy
Abnormal brain structures
Abnormal blood vessels in the brain
Presence of brain tumors
Intracranial hemorrhage
Serious brain injuries
Less amount of oxygen in the brain
CNS infections
Stroke
Use of illegal drugs and abuse
RISK FACTORS

10. Aetiology
Idiopathic causes-
--Genetic causes *
Acquired causes-
--Birth asphyxia
--Hypoxia
--Congenital malformations
--Kernicterus
--Intrauterine infections[STORCH]
--CNS infections- Meningitis, Encephalitis, Tetanus
--Space occupying lesions in brain- Brain tumor, Brain abscess,
Tuberculoma, Cysticercosis.
Neonatal
period
* Found in patient

11. --Vascular malformations- Hypertension, arteriovenous
malformations, DIC
--Metabolic disturbances- dyselectrolytemia, hypoglycemia,
hypocalcemia, inborn errors of metabolism, glycogen storage
disease.
--Trauma- accidental and non- accidental injury.
--Drugs and poisoning- Phenytoin, Lead poisoning.
--Others- Heat stroke, cerebral anoxia, acute cerebral edema,
alcohol and drug abuse .

12. PATHOPHYSIOLOGY
Contribution of etiological factors
Alteration of the integrity of the neuronal
membrane
Production of disturbed electrical
activities by the nerve cells of a specific
part of brain
Emits abnormal, recurring, uncontrolled
electrical discharges
Seizure activities

13. Stages of SEIZURE

14. Classification
of
Convulsions
Seizures
Generalized
seizures
Tonic-clonic seizures
Tonic seizures
Clonic seizures
Absence seizures
Atonic seizures
Myoclonic seizures
Partial seizures
Simple partial seizures
Complex partial seizures

15. Generalised
Seizures
In Primary generalized seizure the
abnormal electrical discharges originate
from the diencephalic activating system
and spread simultaneously to all areas
of brain

16. 1. TONIC-CLONIC SEIZURE/ GRAND MAL
TYPE/MAJOR MOTOR SEIZURE
> lasts for about 30sec
> Often manifestated by 4 phases
Clinical features-
 Loss of consciousness*
 Up rolling of eyeballs*
 Frothing from mouth*
 Tongue bite
 Perioral cyanosis
 Epileptic cry*
 Incontinence of stool and urine
* Found in patient

17. 2. ATONIC SEIZURE/ DROP ATTACKS
-- Rare
--Clinical features-
 Brief relapse of muscle tone
 Loss of muscle strength
 Patient may fall.

18. 3. ABSENCE SEIZURE/PETIT MAL
SEIZURE/ LAPSE SEIZURE
-- lasts for about 30-60 secs
-- Occurs multiple times a day
-- Clinical features-
Sudden lapse of consciousness
Brief abrupt period of discontinuation of movement
Sudden discontinuation in eye movement with staring
spell
No muscular movement but with little bilateral jerking

19. 4. MYOCLONIC SEIZURES
-- It has a periodic rate of occurrence between 3-8 months.
-- Clinical features-
 No loss of consciousness.
 Shock like momentary contraction involving the whole body.
 Sudden forceful myoclonic contractions involving
muscles of trunk, neck and extremities.
 Non- rhythmic jerks.

20. Partial
Seizures
Partial seizure originates from a
paroxysmal discharge in a focal
area of cerebral cortex (temporal
lobe).

21. 1. SIMPLE PARTIAL SEIZURE
-- No loss of consciousness
-- Often starts from the thumb and progresses upwards towards the arm
--Clinical features-
Tingling sensation
Pain
Sensation of cold and burning
Visual, auditory, tactile hallucinations
eg. Jacksonian seizure

22. 2. COMPLEX PARTIAL SEIZURES
-- Originates from parietal or the temporal lobe.
-- Clinical features-
-Often begins with aura with warning signs anxiety, thirst and flashing
lights
-Impaired loss of consciousness
-Automatism
-Inappropriate laughing
-Lip smacking
-Cry
-Tonic jerks of face and limbs
-Visual hallucinations

23. DIAGNOSTICS AND INVESTIGATIONS
1. History
2. Physical Examination
3. Neurological Examination
4. Diagnostic examinations-
Biochemical Studies
Hematological Studies
Serological Studies
5. MRI
6. EEG
7.SPECT

24. MANAGEMENT
MEDICAL
MANAGEMENT
SURGICAL
MANAGEMENT
NURSING
MANAGEMENT

25. IMMEDIATE MANAGEMENT of SEIZURES
Move patients away from danger.
Providing in recovery position- the semi prone
position.
Don’t insert anything into mouth.
Seek for urgent attention towards –
Patency of AIRWAY
Maintenance of BREATHING pattern
Proper CIRCULATION and TISSUE PERFUSION
status.
Seek for administration of anticonvulsant drugs.
Patient should not be left alone after recovery.

26. FIRST AID MANAGEMENT FOR SEIZURE
Stay with the person until the seizure ends and he or she is fully awake.
After it ends, help the person sit in a safe place. Once they are alert and
able to communicate, tell them what happened in very simple terms.
Comfort the person and speak calmly.
Check to see if the person is wearing a medical bracelet or other
emergency information.
Keep yourself and other people calm.
Ease the person to the floor.
Turn the person gently onto one side. This will help the person breathe.
Clear the area around the person of anything hard or sharp. This can
prevent injury.
Put something soft and flat, like a folded jacket, under his or her head.
Remove eyeglasses.
Loosen ties or anything around the neck that may make it hard to
breathe.

27. Do not hold the person down or try to stop his or her movements.
Do not put anything in the person’s mouth. This can injure teeth or the
jaw. A person having a seizure cannot swallow his or her tongue.
Do not try to give mouth-to-mouth breaths (like CPR). People usually
start breathing again on their own after a seizure.
Do not offer the person water or food until he or she is fully alert.
DON’TS -

28. MEDICAL MANAGEMENT
PHARMACOLOGICAL MANAGEMENT
Barbiturate- Phenobarbitone
Deoxybarbiturate- Primidone
Hydantoin- Phenytoin, Fosphenytoin
Iminostilbene- Carbamazepine Oxcarbazepine
Succinimide Ethosuximide
Aliphatic carboxylic acid- Valproic acid (sodium valproate), Divalproex
Benzodiazepines- Clonazepam Diazepam, Lorazepam
Cyclic GABA analogues- Gabapentin, Pregabalin
 Phenyltriazine- Lamotrigine
Newer drugs- Topiramate, Zonisamide, Levetiracetam

29. NON-PHARMACOLOGICAL MANAGEMENT
DIET Management- KETOGENIC DIET/ Atkins diet
(diet low in carbohydrates and high in proteins
and fats).
MECHANISM
Reduces the amount
of Glutamate in brain
Enhances the synthesis
of GABA
Reduces the frequency of
SEIZURES
Ketogenic diet

30. VNS (VAGUS NERVE STIMULATION)
It is a palliative techniques that involves surgical implantation of a
stimulating device.
Currently indicated for patient older than 12 yrs with medically partial
seizure that are not treated surgically
It has improved efficacy in the recent times.

31. SURGICAL MANAGEMENT
Indications-
Drug resistant epilepsy
Intolerable to side-effects of anti-convulsants drugs.
If the surgery proves safe and is effectively resected.
If the patient is willing to undergo operation and a well-informed
consent.
Localized seizures
To improve quality of life.
Benefits of surgery should outweighs the risks.

32. Common surgical procedures-
Lobectomy-
the most common operation for seizure discorders. It involves the
removal of the portion of the temporal lobe( responsible for partial
seizures), carried out under general anaesthesia and requires a recovery
time of 24 hrs.

33. Lesionectomy-
the operation that removes the lesion, a damaged or abnormally
functioning area of brain. It generally includes tumors, hematomas.

34. Amygdalohippocampectomy-
It is the removal of the amygdala and hippocampus.
Hemispherectomy/multilobar resection-
It is the removal of the hemisphere associated with abnormalities;
proves beneficial for severe seizures.
Corpus callostomy

35. NURSING MANAGEMENT
Assessment
History of the patient-
It includes details about prenatal, birth and developmental history,
family history, age of seizure onset, precipitating factors for seizures and
associated history of associated illness and traumas.
Physical Examination
Neurological Examination

36. Nursing Diagnosis-
Ineffective breathing pattern related to neuromuscular
impairment secondary to prolonged tonic phase of seizure or
during post ictal period as evidenced by abnormal respiratory
rate, rhythm and depth.
Interventions-
--Maintain a semi prone position of the patient.
--Arrange for a flat surface for the patient.
--Loosen clothing from neck or chest and abdominal areas.
--Provide supplemental oxygen therapy.
--Provide suction, if needed.

37. Ineffective coping related to perceived loss of control and
denial of diagnosis and stress as evidenced by
verbalization and non compliant behaviour.
INTERVENTIONS-
--Assess for social, physiological and behavioural problems in
the patient.
--Assess for fears and stress present.
--Encourage and reinforce the prevention of alcohol intoxication.
--Encourage patient to ventilate out grievings and concerns.
--Encourage the family in treatment and care.
--Educating the patient and family members of the prior
symptoms of seizures, care before and after seizure.

38. Fear related to the possibility of seizures as evidenced by
insomnia, increased apprehension and facial grimacing and
anxious expressions.
INTERVENTIONS-
--Encourage the importance of adherence of medications in order
to prevent episodes of seizures.
--Periodic monitoring of the associated side effects of the drugs.
--Identification of factors that precipitate seizures.
--Encourage the patient to adopt a healthy lifestyle diet, exercise
and adequate sleep.
--Wearing of sunglasses/ dark glasses.
--Encourage to avoid alcoholic beverages and alcohol.

39. Ineffective therapeutic regimen management related to
lack of knowledge about management of seizure disorder as
evidenced by verbalization of lack of knowledge ,inaccurate
perception of health status.
INTERVENTIONS-
--Assess for the knowledge deficit areas.
--Clarification of any doubts and concerns related to seizures and
treatment process.
--Encourage the family in treatment and care.
--Educating the patient and family members of the prior
symptoms of seizures, care before and after seizure.
--Reinforce the importance for the adherence to medications.

40. Risk for injury related to seizure activity and subsequent
impaired physical mobility secondary to postictal
weakness.
INTERVENTIONS-
a) During seizure-
--Provide privacy and protect the patient from curios on-lookers, Ease
the patient to the floor, if possible.
--Protect the head with a pad to prevent injury (from striking a hard
surface.
--Loosen constrictive clothing
--Push aside any furniture that may injure the patient during the
seizure
--If the patient is on bed, remove the pillows and raise side rails
--If an aura precedes the seizure, insert an oral airway to reduce the
possibility of the tongue or cheek being bitten

41. Do not attempt to open jaws that are clenched in a spasm
to insert anything.
Broken teeth and injury to the lips and tongue may result
from such an action.
No attempt should be made to restrain the patient during
the seizure; place the patient on one side with head flexed
forward, which allows the tongue to fall forward and facilitates
drainage of saliva and mucus.
If suction is available, use it if necessary to clear
secretions

42. b)After the Seizure-
Keep the patient on one side to prevent aspiration.
Once the patient awakes, reorient the patient to environment.
If the patient is confused, guide the patient gently on bed and
chair.
If the patient is agitated, keep distance from patient, but close
enough to prevent injury unless the patient is fully aware.

43. HEALTH EDUCATION
Take anticonvulsant medications daily as prescribed to keep the drug
level constant to prevent seizures. Never discontinue medications, even if
there is no seizure activity
Keep a medication and seizure record (in electronic or paper format),
nothing when medications are taken and any seizures activity.
Notify the primary provider if unable to take medications due to illness
Have anticonvulsant medication serum levels checked regularly. When
testing is prescribed, report to the laboratory for blood sampling before
taking the morning medication.
Avoid the activities that require alertness and coordination (driving
operating machinery) until after the effects of the medication have been
evaluated.
Report signs of toxicity so that dosage cab be adjusted.

44. Avoid OTC medications unless approved by the primary care
provider.
Carry a medical alert bracelet or identification card containing
the details of the patient.
Avoid seizure triggering agents.
Take showers baths in order to avoid drowning if seizures
occurs suddenly.
Never spare the patient to swim alone.
Exercise should be done in moderation in a temperature-
controlled environment.
Develop regular sleep patterns.

45. PROGNOSIS
Up to 71% of those with first seizure will go on to
have a second.
65% manage to stay in remission, requires
follow-up
Poor prognostic factors: multiple seizure types,
failure of treatment response, focal seizures with
structural abnormalities