Care Of The Student With Seizures In School

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Care Of The Student With Seizures In School

• Mary Herndon, RN
• Hema Patel, MD
• Pediatric Neurology, Riley Hospital
• September 30, 2008

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Objectives

• Understand basic anatomy of the nervous system
• Identify common causes of seizures
• Evaluation and Investigations
• Describe different types of seizures
• Treatment options
• Seizure First-Aid
• Work with your doctor to manage your childs
  seizures

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Basic Anatomy of the Nervous System

• Brain - housed in skull
• Spinal Cord - supplies nerves to trunk and
  extremities

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Central Nervous System Anatomy
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Cerebrum

• Controls conscious mental process
• Divided in two halves Right and Left
• Each half has four lobes (sections)
• Frontal
• Parietal
• Occipital
• Temporal
• Neurons in the cortex of cerebrum are tiny nerve
  cells that produce seizures

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Definition of Seizures

• A seizure is a sudden, unpredictable burst of
  excessive electrical activity in the brain
• Causes a change in behavior, consciousness,
  movement, perception or sensation

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Other terminology

• Seizures are also referred by other names such
  as
• Fits
• Convulsions
• Spells
• Attacks

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Definition of Epilepsy

• Seizures which occur repeatedly over time or are
  recurrent or chronic
• In the US, about 5 of children and adolescents
  will have a seizure by age 20
• Active cases of epilepsy
• USA 6.8 patients per 1000 lt1

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Causes - seizure can be a symptom of a medical
problem

• Infection/Fever
• Trauma
• Brain Lesions
• Tumors
• Brain Malformations
• Metabolic Problems
• Diabetes
• Nutritional imbalance

• Toxicity
• Hereditary Diseases
• Neurofibromatosis
• Tuberous Sclerosis
• Mitochondrial
• Family Tendencies
• Idiopathic
• (no cause found)

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Diagnosis of Seizures

• Description of event
• Patient and family medical history
• Routine EEG (electroencephalogram) records
  electrical activity of brain
• Video EEG Monitoring - EEG plus video-tapes of
  patient during EEG
• MRI or CT (CAT Scan) - shows structure of the
  brain
• Blood work
• Lumbar puncture
• Urinalysis, Urine genetic screen

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EEG
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Absence Seizures
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Head MRI
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Seizure Classification

• Why do we classify seizures?
• Identify seizure type
• Predict seizure prognosis/course
• Decide treatment
• Identify first aid strategies
• Anticipate life changing concerns

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Seizure Classification

• Generalized - the whole brain cortex has abnormal
  electrical activity
• Partial - abnormal activity in a specific part of
  the brain may spread to whole brain

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Generalized Seizures

• Tonic-Clonic (Grand Mal)
• No warning
• Loss of consciousness
• Body stiffens then jerks or shakes (convulses)
  rhythmically
• Color change dusky or pale
• Incontinent (loss of urine)
• Oral secretions (vomiting, drooling)
• Postictal confusion and sleep

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Generalized tonic-clonic seizure
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Generalized Seizures

• Absence Seizures (Petit Mal)
• Very brief loss of consciousness, lasting seconds
• Staring, sometimes with eye fluttering
• Triggered by hyperventilation (rapid breathing)
• Happens many times a day
• Can affect learning
• Mistaken for daydreaming, ADHD

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Absence seizure
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Generalized Seizures

• Myoclonic Seizures
• Brief jerks of one or more parts of the body
• May be in clusters (one after another)
• Do not lose consciousness

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Myoclonic seizures
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Generalized Seizures

• Atonic Seizures (Drop seizures)
• Sudden loss of muscle tone
• Quick return to normal behavior (baseline)
• Often mistaken for abuse because of injuries

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Atonic seizure
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Partial Seizures

• May have aura (warning, feeling, premonition)
• Focal - Jerking of specific body part
• Postictal confusion or drowsiness
• Simple without a change in consciousness
• motor or sensory symptoms
• Complex with change of consciousness
• Staring, automatisms (lip smacking,
  picking movements, wandering)

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Complex partial seizure
Epilepsy Foundation of America
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Problems Mistaken for Seizures

• Breath holding
• Syncope (fainting)
• Night Terrors/Sleep disorders
• Childhood Migraines
• Rage attacks
• Pseudoseizures

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Status Epilepticus

• Life threatening
• One or more seizures lasting greater than 30
  minutes (However, a single prolonged seizure of
  gt5-10 minutes is concerning)
• Emergency medical attention needed
• Call 911, go to Emergency Room
• Diastat (Rectal Valium/Diazepam) often ordered to
  be given
• IV medicines given in Emergency Room

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Seizure Management

• There is no cure for epilepsy but most (80)
  can be managed with medicine, a healthy life
  style and an accepting attitude

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Risk Factors for Seizures

• Inadequate or improper anticonvulsant medication
• Trauma
• Illness/Fever
• Lack of Sleep
• Fatigue/Stress

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Risk Factors for Seizures

• Poor general health care or nutrition
• Photosensitivity
• Flashing lights, computers/games (nintendo
  epilepsy)
• Hyperventilation
• Medicine, drug or alcohol ingestion or withdrawal
• Menses

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Effect of Medicine

• Changes the chemistry in the brain
• Normalizes electrical activity stops or slows
  the spread of the abnormal electrical impulses
• Increases the seizure threshold

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Goal of Medicine Therapy

• THE LEAST NUMBER OF DRUGS
• AT THE LOWEST THERAPEUTIC DOSE to control
  seizures
• WITH MINIMUM SIDE EFFECTS

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Choice of Medicine

• By seizure type
• Some medicines best for certain types of seizures
• Some medicines can make certain types of seizures
  worse
• Sex, age, child bearing risk
• Financial factors
• Ease of use (Given twice a day versus three times
  a day)

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Starting Medicine in Children

• Dose is decided by childs body weight (mg/kg)
  and is different for every medicine
• Increased to therapeutic range or level of
  medicine in blood
• Takes time after an increase of dose, for effect
  to be seen (to reach a steady state)

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Seizure Medicines
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Blood Monitoring

• Drug levels in the blood help decide dose of
  medicine
• Shows toxicity or compliance
• Shows side effects liver toxicity, decreased
  blood cell production, kidney stones,
  pancreatitis
• Usually blood is drawn before AM dose

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Medicine Side Effects - Call doctor

• Allergic reaction (rash)
• Sleepiness less active, lethargy
• Dizziness, poor coordination
• Blurred Vision
• Behavior or cognitive changes
• Interference with other medicines
• (blood thinners, birth control)
• Birth Defects
• GI disturbance (stomach upset, nausea, vomiting)

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Important Things to Remember

• Stopping seizure medicine quickly can cause
  serious seizures
• Plan ahead for refills
• Missing doses drops the blood level which can
  cause seizures
• Illness (unable to take, vomiting)
• Non compliance

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Other Treatments

• These are only used for patients with refractory
  seizures
• Refractory means the seizures are not responding
  to the usual therapy
• Ketogenic Diet
• Vagal Nerve Stimulation (VNS)
• Surgery

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First Aid for Seizures

• The main goal of care during a
• seizure is to protect the child
• from injury

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Generalized Tonic Clonic(Grand Mal) Seizures

• Remove objects in the way.
• Position child on his side to keep airway open
  (saliva and vomit cannot get into the lungs).
• Put something soft under the childs head.
• Do NOT restrain let seizure run its course.

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Generalized Tonic Clonic(Grand Mal) Seizures

• Do NOT put anything in the mouth.
• Stay with child estimate the length of the
  seizure
• Let child rest until alert enough to be moved
  and/or return to normal activity
• Call 911 if seizure does not stop in 5-10 minutes

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Complex Partial Seizures

• Do NOT restrain but stay close to the child and
  protect him from harm
• may wander unaware
• Let seizure run its course
• Let child rest until able to return to normal
  activity

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Seizure Observations/Records

• Keep a diary of
• Seizure frequency (how often)
• Description of event Motor activity and level of
  responsiveness
• What happens before
• What happens during
• What happens after
• Length of seizure

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Activity Restrictions

• Dangerous if the child loses consciousness during
  activity (child could be hurt)
• No tub baths unless supervised or watched.
• No swimming unless supervised.
• Biking, skateboards/scooters with helmet on
  non-busy streets
• No above ground activity rope and tree
  climbing, jungle gyms
• No contact sports unless OK with doctor
• No driving unless OK with doctor

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Other Safety Precautions

• Wear a medical identification bracelet
• Tell important people about history of seizures
  (teachers, babysitters, etc.)
• Educate these important people about seizure
  first aid.

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Helpful Resources

• Your doctor or nurse
• Epilepsy Foundation of America
• www.epilepsyfoundation.org
• 1-800-332-1000 or 1-800-efa-1000
• Indiana Epilepsy Services
• www.indianaepilepsy.org
• Books on Epilepsy for Parents and Children (see
  handout)
• www.medlineplus.gov
• Medical Alert www.medids.com, www.americanmedical
  -id.com

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Important Phone Numbers

• 911 (access to your local emergency services)
• Pediatric Neurology
• 317-278-5450
• Riley Hospital Emergency or After Hours Phone
  317-274-5000

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A person with epilepsy is a person who just
happens to have epilepsy.

• Epilepsy Poster 1985

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Questions?
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Febrile Seizures

• Happens in otherwise healthy children between 6
  months and 5 years of age
• Average age 12-18 months
• Fever over 101o F
• Infection not involving central nervous system
  (ear infections, upper respiratory infection)
• 1st seizure usually not treated unless
  complicated presentation
• Medicines of choice Phenobarbital, Rectal
  Diazepam and Valproic Acid

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Infantile Spasms/West Syndrome

• Children under 12 months of age
• Peak onset is 4-6 months
• EEG pattern hypsarrhythmia
• Cluster of head dropping down arms extended then
  coming in like a hug, may have leg extension

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Infantile Spasms/West Syndrome

• Can have poor developmental prognosis
• Most have some form of brain damage
• Small number idiopathic (no cause)
• Treatment of Choice
• ACTH injections
• Vigabatrin not approved in US
• Oral prednisone
• Other oral Antiepileptic Drugs (AEDs)