Seizures

Seizures are episodes of abnormal motor, sensory,

autonomic, or psychic activity (or a combination of
these) resulting from sudden excessive discharge from
cerebral neurons.

A part or all of the brain may be involved.

Most seizures are sudden and transient.

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 international classification of seizures

1- Generalized seizures
– · Myoclonic seizures
– Petit mal epilepsy
– · Grand mal seizures
– · a tonic (astatic)

2-Partial seizures (focal, local)

– · Simple partial seizures there is no impairment of
consciousness
– · Complex partial seizures -there is impairment of consciousness
– · Partial seizure with secondary generalization e.g. secondarily
generalized

3-Unclassifiable – special epileptic syndrome, Neonatal Seizures

Classification of Seizures
1.Grand mal Seizure/ Tonic-Clonic Seizure

- Has four phases

1. Prodromal subjective phenomena
- for minutes, hours or days
2. Aura: occur seconds to minutes
3. The Seizure: three phases.
o Tonic phase- tonic contraction
o Clonic phase - clonic jerks
o Terminal phase - remain unconscious
4. Post ictal phase - confusion
Complication of grand mal Seizures

a. Burn accidents

b. Injuries - head injury, subdural hematoma,

vertebral fractures etc.

c. Transient neurologic deficit - paralysis of

extremities, aphasia, hemi-anopsia, etc.
 2. Petit mal Epilepsy (Absence seizure)
 Characteristic epilepsy of childhood
 Usually begins in the middle of the first decade of life
(within10 years) .
 Clinical manifestations
1. No aura symptom
2. Sudden interruption of consciousness
- patients become motionless, stop talking, stare
blankly (look at with fixed eyes with out expression), cease to
respond
3. Clonic movements- eye lids, facial muscles, fingers
4. Simple automatism(bodily movements that are not
consciously controlled like breathing or
 Petit mal Epilepsy cont’d

 Duration -Very short in duration – less than 11 seconds

 Frquancy -Occur many times a day – even up to 100
times.
3. Myoclonic epilepsy

 Myoclonic epilepsy of early childhood

o Between 6months - 4 years

4. Focal motor seizure

 Caused by a lesion in the opposite frontal lobe, the motor
cortex.
 Clinical manifestations
1. Turning movements of the head and the eyes to the
opposite side of the lesion
2. Unilateral tonic contraction of the trunk and extremities
3. No loss of consciousness, no falling down
4. No generalized convulsion and no incontinence
A. Complex partial seizure –three phases

1. Aura phase
 Alterations in psychic function
- perceptual distortions , Hallucinations, illusions (mistaken
ideas)

2. Seizure phase
 Impaired consciousness
 Motor disturbance – simple automatism like lip smacking ,
sucking
 Complex automatic behavior – e.g. laughing, running,
picking , undressing, aggressive sexual automatisms
3. Post ictal phase – amnesia (Partial or total loss of memory), deep sleep,
headache
• Can occur in clusters
 Complex partial seizure cont’d

 Not peculiar to any age group

 Past history of febrile seizure present in
~30% of patients
~60% will have additional grand mal seizure
DIAGNOSIS
Questions raised when patient presents with a seizure

Seizure or not?
Focal onset?
Evidence of interictal CNS dysfunction?
Metabolic precipitant?
Seizure type? Syndrome type?
Studies?
 Diagnostic Work-up

 History taking
1. Complete description of the seizure itself
2. Specific precipitant factor
3. Familial predisposition
4. Perinatal and developmental history
5. Past medial history – head injury, CNS infections,etc.
 Physical examination –Neurological, renal,
cardiovascular, etc
 Ancillary investigation – laboratory,EEG, Skull X-ray,
CT-Scan
 Diagnostic Work-up cont'd

In our set up- EEG, CT scan, MRI – required if

Acute onset 3-6 months
First onset after age 40
Interval sign and symptom of neurologic or
medical condition
 Organic causes of epilepsy
Brain tumor- primary/secondary
Intracranial bleeding
Thrombotic/hypertensive stroke
Rupture of aneurysm
Post head injury
Intracranial inflammation
Abscess/mass – TB, meningitis, syphilis
Cyst- neurocysticercosis
HIV AIDS – toxoplasmosis, sarcoma
Common clinical features
Apart from the epileptic seizures, they have interval
symptoms, most commonly

1. Focalizing neurologic symptoms

 Paralysis of one part of the body
 Aphasia, double vision
 Sensory loss e.g. anesthesia, analgesia
 Common clinical features cont’d

2. Sign of increased intracranial pressure

Blurred vision
Persistent headache; vomiting - projectile
Neck stiffness
3. Cognitive abnormalities
Memory impairment,…dementia
4. Psychiatric symptoms
Delusion, hallucination, disorganized behavior
Depression, anxiety, personality change
TREATMENT
Major Components of Treatment

A) Non-drug measures
B) Drug treatment
C) Surgery
 General non-drug measures

1. Physical and mental hygiene

 Regular hours of sleep
 Avoid substances – alcohol, hashish, cigarettes
 Avoid dangerous situations
 Moderate physical exercise
2. Removal of precipitating factors-e.g.. TV watching
3. Supportive psychotherapy – education about the illness,
avoid overprotection in children
 Management during acute grand mal seizure

SHOULD DO
1. Move patient away from water, fire, traffic,
2. Take away any object that could harm the patient
3. Loosen tight cloths, remove eye-glasses
4. Put something soft under the head
5. Turn patient to his side
6. Remain with the patient until he/she regains
consciousness
Management during acute grand mal attack cont’d

SHOULD NOT DO
1. Donot put anything( e.g. tongue plate) into the mouth
2. Donot light matches
3. Donot give anything to drink
4. Donot try to stop the convulsion
5. Donot give diazepam - except during status
epilepticus or series of seizure attacks
Drug Treatment

.
 Principles of drug treatment

A. General remark
ANTIEPILEPTIC DRUGS - AEDs
 Decrease the frequency/severity of seizures in
patients with epilepsy
 Treat the symptoms, not the underlying condition
 Goal: maximize quality of life by minimizing
seizures and adverse drug effects
Principles of drug treatment cont’d

B. Steps of drug treatment

1. Start drug treatment with one drug
2. Select the appropriate drug
3. Start drug treatment with a small dose
4. Gradually increase dosage until complete control of
seizure
5. Aim to achieve lowest maintenance dose
 Principles of drug treatment cont’d

6. Watch for presence of marked side effects

7. If initial drug is not well tolerated, substitute with
another
8. If initial drug cannot control seizure, substitute with
another
9.Gradually withdraw first drug while gradually
introducing the new drug
Tab. 3 Drug of choice
Type of seizure Drugs

Simple partial epilepsy, Carbamazepine, phenytoin,

complex partial epilepsy Phenobarbital

Grandmal epilepsy Carbamazepine, phenytoin,

Phenobarbital, sodium
valproate

Petit mal epilepsy Sodium valproate,

ethosuximide
Myoclonic epilepsy Clonazepam, Valproate
 Tab. 4 Drug dosage and side effects
Childhood Adult Common side effects
Drugs dosage, dosage
mg/kg/day mg/day

Phenobarbital 2-3 60-200 Mental dullness, sedation, drowsiness, skin

rash, hyperactivity in children

Phenytoin 4-7 100-400 Gum hypertrophy, skin rash, hirsutism,

neuropathy, ataxia, slurred speech

Carbamazepine 10-20 400-1600 Skin rash, leucopenia, elevated liver

enzymes

Sodium valproate 20-40 600-1200 Liver toxicity, alopecia

Ethosuximide 20-30 750-1500 Drowsiness, hyperactivity, sleep

disturbance
Duration of drug treatment

 Grand mal epilepsy, partial epilepsy

→ 4 (2-5) years
 Petit mal epilepsy→ 2 years
 Juvenile myoclonic epilepsy →for life
 Indications for surgery
1. Intractable to medical therapy
2. Partial or secondarily generalized seizure
3. Absence of progressive diffuse cerebral disease
4. Good surgical risk
 Nursing Management During a Seizure

• Before and during a seizure, the following are assessed and

documented:
- circumstances before the seizure (visual, auditory, or olfactory
stimuli, tactile stimuli, emotional or psychological disturbances,
sleep, hyperventilation)
- occurrence of an aura (visual, auditory, or olfactory)
- first thing the patient does in a seizure—where the movements or
the stiffness starts, conjugate gaze position, and the position of the
head at the beginning of the seizure.
- areas of the body involved (turn back bedding to expose patient)
- size of both pupils. Are the eyes open? Did the eyes or head turn
to one side?
- presence or absence of automatisms (involuntary motor activity,
such as lip smacking or repeated swallowing)
- Incontinence of urine or stool
- Duration of each phase of the seizure
- Unconsciousness, if present, and its duration
- Any obvious paralysis or weakness of arms or legs after
the seizure
- Inability to speak after the seizure
- Movements at the end of the seizure
- Whether or not the patient sleeps afterward
- Cognitive status (confused or not confused) after the
seizure
Nursing Management After a Seizure
• document the events leading to and occurring
during the seizure
- to prevent complications (eg, aspiration, injury).
- to prevent complications, the patient is placed in
the side-lying position to facilitate drainage of
oral secretions and is suctioned
 EPILEPSIES

• Epilepsy
- It is a group of syndromes characterized by recurring
seizures.
- Epileptic syndromes are classified by specific
patterns of clinical features, including age of onset,
family history, and seizure type
• Epilepsy can be:
- primary (idiopathic) or
- secondary, when the cause is known and the epilepsy
is a symptom of another underlying condition such as a
brain tumor.
 Causes

• Genetic susceptibility
• Unknown
-----------------------------------------------------------
• Epilepsy can follow
- birth trauma
- asphyxia neonatorum,
- head injuries, some infectious diseases (bacterial, viral,
parasitic)
- toxicity (carbon monoxide and lead poisoning)
- circulatory problems, fever
- metabolic and nutritional disorders, and drug or alcohol
intoxication .
 Possible causes of epilepsy

1. Perinatal brain damage

2. Head injuries
3. Cerebrovascular diseases
4. Neoplasm
5. Central nervous system infections
6. Congenital or metabolic disorders
7. Degenerative neurologic disorders
8. Chronic alcohol abuse
9. Genetics
 Aggravating & precipitating
• Sleep deprivation
• Starvation or hypoglycemia
• Emotional disturbance
• Drugs – psychotropic medications
• Alcohol
 Medical illness with seizure

1). Bacterial meningitis

2) Uremia
3) Hyponatremia, hypoglycemia
4) Thyrotoxicosis
5) Cardiac arrest- hypoxic encephalopathy
6) Lead, mercury, and CO poisoning
7) Alcohol withdrawal
8) Pyridoxine deficiency
 Pathophysiology

• Messages from the body are carried by the neurons (nerve

cells) of the brain by means of discharges of
electrochemical energy that sweep along them.
• These impulses occur in bursts whenever a nerve cell has
a task to perform.
• Sometimes, these cells or groups of cells continue firing
after a task is finished.
• During the period of unwanted discharges, parts of the
body controlled by the errant cells may perform
erratically(unpredictably).
• When these uncontrolled, abnormal discharges occur
repeatedly, a person is said to have an epileptic
syndrome
 General truth

• Epilepsy is not associated with intellectual level.

- People with epilepsy without other brain or nervous
system disabilities fall within the same intelligence ranges
as the overall population.
• Epilepsy is not synonymous with mental retardation or
illness.
- Many who are developmentally disabled because of
serious neurologic damage, however, have epilepsy as
well.
 Clinical Manifestations

• Depending on the location of the discharging neurons,

seizures may range from a simple staring episode to
prolonged convulsive movements with loss of
consciousness.
 Partial seizures are focal in origin and affect only part of
the brain.
• In complex partial seizures:
- person either remains motionless or moves automatically
but inappropriately for time and place, or
- may experience excessive emotions of fear, anger, elation,
or irritability.
 Generalized seizures
• Generalized seizures,, involve both hemispheres of the
brain, causing both sides of the body to react .
 STATUS EPILEPTICUS

• A condition characterized by continuous or repetitive

discrete seizure with impairment of consciousness during
inter-ictal period, which lasts for more than 30 minutes.
It can be caused or precipitated by
– CNS infections, Metabolic derangement, Tumors
– Trauma and Stroke

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Medical Management
 The goals of treatment are to stop the seizures
as quickly as possible, to ensure adequate
cerebral oxygenation, and to maintain the
patient in a seizure-free state.
 If the patient remains unconscious and
unresponsive, a cuffed endotracheal tube is
inserted.
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 Cont,….
 The goals of treatment are to stop the seizures as
quickly as possible, to ensure adequate cerebral
oxygenation, and to maintain the patient in a
seizure-free state.
 If the patient remains unconscious and
unresponsive, a cuffed endotracheal tube is
inserted.

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 Cont,…..

Control the seizure with anticonvulsant

1st step: Lorazepam 0.1 mg/kg IC at a rate of 2mg/min or
Give diazepam IV 5- 10 mg IV
2nd step: Phenytoin 20 mg/kg IV at a rate of 50 mg /min if
seizure continues
3rd step: Phenobarbital 20 mg/kg IV at a rate of 50 -75
mg/min, if seizure still continues
4th Step: General anesthesia with Medazolam,
pentobarbitol, if seizure becomes refractory
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Cont,….
 In resource limited setting Diazepam 5-10 mg IV is
given 2-3 times, and if the seizure is not controlled
Phenytion 1000 mg PO is given through NG tube.
Phenobarbitone can also be used.
 Give maintenance antiepileptic drug: after the acute
condition is controlled.
 An intravenous infusion of dextrose is given if the
seizure is due to hypoglycemia.
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 MANAGEMENT OF
PATIENTS
WITH NEUROLOGIC
TRAUMA

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Head Injuries

Head injury is a broad classification that includes injury to

the scalp, skull, or brain.

A head injury may lead to conditions ranging from mild

concussion to coma and death; the most serious form is
known as a traumatic brain injury (TBI).

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Cont,….

The most common causes of TBIs are falls

(28%), motor vehicle crashes (20%), being
struck by objects (19%), and assaults (11%).
People at highest risk for TBI are those in the
15-19-year age group.
Males are twice as likely as females to sustain
a TBI.
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 Cont,…
 Damage to the brain from traumatic injury takes two

forms: primary injury and secondary injury.

Primary injury is the initial damage to the brain that

results from the traumatic event.
 This may include contusions, lacerations, and torn

blood vessels due to impact,

acceleration/deceleration, or foreign object
penetration.
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 Cont,….

• Secondary injury evolves over the ensuing hours

and days after the initial injury and results from
inadequate delivery of nutrients and oxygen to the
cells

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 Skull Fractures

 A skull fracture is a break in the continuity of

the skull caused by forceful trauma.
 It may occur with or without damage to the
brain.
 Can be classified as simple, comminuted,
depressed, or basilar.
 A simple (linear) fracture is a break in the
continuity of the bone.

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Cont,…..
• A comminuted skull fracture refers to a
splintered or multiple fracture line.
• Depressed skull fractures occur when the
bones of the skull are forcefully displaced
downward and can vary from a slight
depression to bones of the skull being
splintered and embedded within brain tissue.
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Cont,…

A fracture of the base of the skull is called a

basilar skull fracture .
A fracture may be open, indicating a scalp
laceration or tear in the dura (eg, from a bullet ),
or closed, in which case the dura is intact.

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Cont,….
 Basal skull fractures can occur at different
sites (anterior, middle or posterior fossa). They
often result in CSF leak.
 Anterior fossa fractures present with
subconjuctival hematoma, anosmia, epistaxis
and CSF rhinorrhoea.
 Middle fossa fracture presents with CSF
rhinorrhea or otorrhea, and ecchymosis
(bruising) may be seen over the
mastoid(Battle’s sign).
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 Brain injuries
Mechanisms of brain injury
 Abrupt deceleration of a moving head results in
minor injury at site of impact (coup injury) or
contusion of the brain opposite the point of impact
(contra coup injury).
 From clinical point of view, brain injuries could be
primary (occurring at the time of impact) or
secondary (develops subsequently).
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 Medical Management

 Non depressed skull fractures generally do not

require surgical treatment; however, close
observation of the patient is essential.
 Depressed skull fractures usually require surgery
with elevation of the skull and débridement,
usually within 24 hours of injury.

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 Primary brain injury
Cerebral concussion
 A cerebral concussion after head injury is a
temporary loss of neurologic function with no
apparent structural damage.
 A concussion generally involves a period of
unconsciousness lasting from a few seconds to a
few minutes.

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 Cont,….

 This is a clinical diagnosis characterized by

temporary dysfunction.
 It is most severe immediately after injury and
resolves after variable period of time.

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 Cont,…..
There are two types of concussion: mild and classic.
 A mild concussion may lead to a period of observed or
self reported transient confusion, disorientation, or
impaired consciousness.
 Commonly, there is a memory lapse at the time of injury
and a loss of consciousness lasting less than 30 minutes.
 Other signs and symptoms may include seizures,
headache, dizziness, irritability, fatigue, or poor
concentration.
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 Cont,…..
 A classic concussion is an injury that results
in a loss of consciousness; characteristically,
this usually lasts less than 6 hours.
 This loss of consciousness is always
accompanied by some degree of
posttraumatic amnesia.

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 Cont,……

Cerebral contusion and Laceration

 Cerebral contusion is a more severe injury in
which the brain is bruised, with possible surface
hemorrhage.
 The patient is unconscious for more than a few
seconds or minute
 Pia and arachnoid tearing and intracerebral
bleeding characterize these conditions.
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Cont,….
It usually produces focal neurologic
deficits that persist for more than 24 hours.
Blood brain barrier defects and cerebral
edema are common.
Contusions may resolve spontaneously or
persist.

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 .0Intracranial hematomas
Extradural hematoma: this condition usually
follows temporal bone fracture with tearing of
middle meningeal artery leading to hematoma
collection.
 Patients may present in coma after a lucid
interval.
 Urgent evacuation of the hematoma is required.
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 Cont,….

Acute Subdural hematoma: this state is the

most common intracranial mass lesion
following head injury.
Mostly, it results from tearing of bridging
veins.
The lesion is rapidly evolving and early
evacuation is mandatory.
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Cont,…….
Chronic subdural hematoma: this is most common
in infants and adults over 60 years of age.
 Patients usually present with progressive
neurological deficit more than 2 weeks after the
trauma.
Intracerebral hematoma: results from areas of
contusion coalescing into contusion hematoma.

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 Cont,…
Cerebral swelling (Brain edema)
 This results from vascular engorgement, due to loss of

auto regulation and increased extra and intracellular fluid.

 If not corrected early, it results in cerebral ischemia.

Infections
 Compound depressed fractures or basal skull fractures

can lead to meningitis or cerebral abscess.

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 MENINGITI
S

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MENINGITIS
Is an inflammation of the meninges, the protective
membranes that surround the brain and spinal cord.
Is classified as aseptic or septic
Aseptic meningitis, bacteria are not the cause of the
inflammation; the cause is viral or secondary to
lymphoma, leukemia, or human immunodeficiency virus
(HIV).

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 Cont,…….
• The bacteria streptococcus pneumoniae and
neisseria meningitides are responsible for 80%
of cases of meningitis in adults.

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 Cont,…..
 Septic meningitis refers to meningitis caused by bacteria,
most commonly Neisseria meningitidis, although
Haemophilus influenzae and Streptococcus pneumoniae.

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Rout of infection
 Droplet infection through the upper airways: E.g.
Meningococcus meningitis, with possibly epidemic
spread
 Haematogenous spread: e.g. in Pneumococcus
pneumonia
 Contagious spread from adjacent sites : e.g. in otitis
media , sinusitis.
 Direct: e.g. in open head injury
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 Pathophysiology
 Once the causative organism enters the
bloodstream, it crosses the BBB and proliferates
in the CSF.
 The host immune response stimulates the
release of cell wall fragments and
lipopolysaccharides, facilitating inflammation
of the subarachnoid and pia mater.

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Cont,……

 Because the cranial vault contains little room for

expansion, the inflammation may cause increased
intracranial pressure (ICP).
 CSF circulates through the subarachnoid space,
where inflammatory cellular materials from the
affected meningeal tissue enter and accumulate.

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 Clinical Manifestations

 Headache and fever are frequently the initial symptoms.

 Neck mobility: A stiff and painful neck (nuchal rigidity) can
be an early sign and any attempts at flexion of the head are
difficult because of spasms in the muscles of the neck.

 Positive Kernig’s sign: When the patient is lying with the

thigh flexed on the abdomen, the leg cannot be completely
extended.

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Cont,…
Positive Brudzinski’s sign: When the patient’s
neck is flexed , flexion of the knees and hips is
produced; when the lower extremity of one side is
passively flexed, a similar movement is seen in
the opposite extremity.
Photophobia (extreme sensitivity to light): This
finding is common, although the cause is unclear.

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 Assessment and Diagnostic Findings
History, physical examination,
Search for possible source of
infection(pneumonia , otitis media , sinusitis ,
head injury)
CSF analysis
Identify the organism from CSF and blood
(culture, PCR etc.)
Serologic antibody test : latex agglutination test
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 Management
Empirical antibiotic therapy:
 Bacterial meningitis is a medical emergency and
antibiotics should be initiated immediately before the
results of the CSF gram stain and culture are known.
Antibiotics should be given intravenously, at higher
doses.
 Ceftriaxone 2 gm IV BID plus Ampicilline 2 gm IV
QID for 2 weeks.
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Cont,…..

 Crystalline Penicillin 3-4 million IU, IV every

4 hours plus Choramphnicole 1gm IV QID are
alternative antibiotics for a resource limited
setting
 Patients with ENT infection or head injury:
Ceftriaxone 2 gm IV BID and Vancomycin 1gm
IV BID + treatment of the underlying cause.
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Cont,….
 If suspected hospital-acquired infection: Ceftriaxone
2 gm IV BID plus Vancomycin 1 gm IV BID plus
Gentamycin (80 mg TID)
 In immunodeficient patients: Ceftriaxone 2 gm IV
BID plus Vancomycin 1 gm IV BID plus Ampicillin
(2g IV QID).

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 Specific antibiotic therapy
 Is given when the specific etiologic agent is identified through
gram stain or culture
 N. Meningitidis : even though ceftriaxone or cefotaxim provide
adequate empirical coverage , penicillin G remains the drug of
choice for N. Meningitides
 Crystalline penicillin 3-4 million IU, IV every 4 hours for 7 -10
days may be adequate.

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 Cont,….

Pneumococcal meningitis:
Ceftriaxone 2 gm IV BID and Vancomycin 1 gm IV BID
for 2 weeks
H. influenza: Ceftriaxone 2 gm IV BID for 1- 14 days
Choramphnicole 1gm IV QID may be an alternative
antibiotic, for patients who may not afford Ceftriaxone.

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 Symptomatic and adjunctive Therapy

Steroids:
Dexamethason10 mg IV 15-20 minutes before the first dose of
antibiotics and 4 mg IV QID for 4 days
Dehydration and shock are treated with fluid volume
expanders.
Seizures, which may occur in the early course of the disease,
are controlled with phenytoin (Dilantin).

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 Treat increased intracranial pressure

Elevation of the patients head to 30-45

Intubation and hyperventilation ( till PaCO2 is
lowered to 25-30 mmHg )
Mannitol IV infusion

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