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05.04 Seizure Therapeutic Management

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Overview

  1. Seizures diagnosed using EEG brain wave measurement
  2. Medications given to stop or prevent seizures

Nursing Points

Therapeutic Management

  1. EEG Diagnostics
    1. Types of brain waves
    2. Where seizures occurring
    3. How severe
  2. Medications
    1. Antiepileptic drugs
    2. Stop seizures:
      1. Lorazepam (Ativan)
        1. First-line drug
        2. 2 mg IV push during seizure
      2. Diazepam (Valium)
      3. Phenobarbital
    3. Prevent seizures:
      1. Phenytoin (Dilantin)
      2. Fosphenytoin (Cerebyx)
      3. Levetiracetam (Keppra)
      4. Lacosamide (Vimpat)
  3. Procedures
    1. Surgical removal of lesion
    2. Cutting connections in brain
    3. Deep Brain Stimulation

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Video Transcript

So now that we’ve looked at types of seizures and their causes as well as what nursing assessments we need to perform, let’s look at therapeutic management for patients with seizures.

The first thing we’ll see is our diagnostic testing. Seizures are diagnosed and named based on their clinical signs so that we know what type they are. Beyond that we will perform something called an electroencephalogram or EEG. Now this is something that is set up and managed by a technician with special training, but we want you to know what it looks like and what the purpose is. To perform an EEG, dozens of electrodes are placed on the patient’s head like what you see here. These measure brain waves in different parts of the brain. We will get a readout that looks like this and can show us when we begin to have seizure activity. Remember that seizures are overactive nerve impulses, so on the EEG we will see the waves become taller and much more active. An EEG can tell us what types of brain waves there are, where the seizures are occurring, and how severe they are. A lot of times patients will be placed on continuous EEG for 24 hours or more so that we can catch a seizure on the tracing.

Now when we talk about medications for seizures were talking about antiepileptic drugs, or AED’s. There are two sets of drugs that we give to patients who are having seizures, one set to stop seizures when they’re happening, and one set to prevent them and to be maintenance medications for these patients. The first line drugs for seizures are benzodiazepines. Specifically Lorazepam is our most common first-line drug when a patient is having a seizure. We will give 1 to 2 mg of Ativan IV push as soon as possible to try to stop the seizure. We could also use diazepam or Valium which is commonly used rectally for patients without IV access. For patients in status epilepticus that doesn’t break with Ativan, we will give them barbiturates like phenobarbital to try to stop the seizures. Once we stabilize the patient they need to be started on prevention medications, which they will likely take for the rest of their lives. The two most common that you will be tested on are phenytoin and Levetiracetam or Dilantin and Keppra. Two others that you may see are fosphenytoin and lacosamide or Cerebyx and Vimpat. The most important thing to understand is that these medications have very specific half lives so the timing is extremely important. Not only do we need to make sure that we give their medications on time, but the patients need to be taught how important it is to be compliant with their medication instructions. If the patient is on Dilantin, we also need to monitor therapeutic drug levels to prevent toxicity, but honestly Dilantin is not given as commonly these days.

Now there are a few procedural options for patients who have frequent seizures, although it’s very rare to see this happen. Ultimately the goal is to either remove the overactive neurons or redirect the electrical activity. That could mean lesionectomy where they remove the portion of the brain that’s causing the seizures. It could be neurotomies which is where connections between nerves are cut to stop impulses from traveling. Or we could do something called deep brain stimulation where electrodes are placed in the brain to attempt to redirect the electrical activity. Again, these are relatively uncommon, however you may see a patient who has had one or more of these.

So to recap, in order to get effective diagnosis we need to get an EEG. Again the EEG Tech will take care of this but if we notice any of the electrodes have dislodged we will notify the technician. We have our rescue meds like Ativan to administer went the patient has a seizure. If allowed by your facility, it is good practice to have Ativan locked up at the bedside for easy access, instead of having to go get it out of the med room. We will also make sure that the patients get their maintenance medications like Keppra or Dilantin, making sure that we are giving them on time, that the patient’s being compliant, and that we’re monitoring therapeutic levels if applicable. And then, remember these procedures are relatively rare, but they will come with the same post-op precautions as any other brain surgery.

Make sure you check out the nursing care lesson within this module to learn more about specific nursing interventions, and to find a care plan and case study for a patient with seizures. We love you guys, we hope you’re really getting the big picture taking care of a seizure patient. Now, go out and be your best selves today. And, as always, happy nursing!

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