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Epilepsy School Nurses


Title: Epilepsy Nurse s Presentation Author: Carr, Bette L. DPI Last modified by: Laurie Salzman Document presentation format: On-screen Show (4:3) – PowerPoint PPT presentation

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Title: Epilepsy School Nurses

Epilepsy School Nurses Presentation
  • Lucyna Zawadzki, MD
  • Meghan Furstenberg-Knauff, BSN, RN, MSN, FNP-BC,
  • Kamilee Hobbs BSN, RN

Part 2 Treatment Options
What are they?
  • Medications
  • Anti Epileptic Drugs (AEDs)
  • IVIG
  • Epilepsy Surgery
  • Ketogenic Therapy
  • VNS

  • Making the choice as to what medication to use
    for seizure treatment is a difficult decision.
  • Seizures are the result of abnormal electrical
    activity. This is the results of an imbalance
    between the excitation and inhibition.
  • Anti-seizure medications impact the key players
    to prevent seizure activity.

History of Antiepileptic Drug Therapy in the U.S.
  • 1857 bromides
  • 1912 phenobarbital (PB)
  • 1937 phenytoin (PHT)
  • 1944 trimethadione
  • 1954 primidone
  • 1958 ACTH
  • 1960 ethosuximide (ESM)
  • 1963 diazepam
  • 1974 carbamazepine (CBZ)
  • 1975 clonazepam (CZP)
  • 1978 valproate (VPA)
  • 1993 felbamate (FBM), gabapentin (GBP)
  • 1995 lamotrigine (LTG)
  • 1997 topiramate (TPM), tiagabine (TGB)
  • 1999 levetiracetam (LEV)
  • 2000 oxcarbazepine (OXC), zonisamide (ZNS)
  • 2005 - pregabalin (PGB)
  • 2008 lacosamide (LCM), rufinamide (RUF)
  • 2009 vigabatrin (VGB)

American Epilepsy Society 2011
AEDs Molecular and Cellular Mechanisms
  • Phenytoin (Dilantin, Phenytek), carbamazepine
    (Tegretol, Carbatrol)
  • Block voltage-dependent sodium channels

American Epilepsy Society 2011
AEDs Molecular and Cellular Mechanisms
  • barbiturates
  • Prolong GABA-mediated chloride channel openings
  • Phenobarbital
  • benzodiazepines
  • Increase frequency of GABA-mediated chloride
    channel openings
  • Clobazepam
  • Clobazam (Onfi)

American Epilepsy Society 2011
AEDs Molecular and Cellular Mechanisms
  • felbamate (Felbatol)
  • Blocks voltage-dependent sodium channels
  • Modulates NMDA receptor and GABA receptors
  • gabapentin (Neurontin)
  • Blocks calcium channels
  • Suppressed presynaptic vesicle release

American Epilepsy Society 2011
AEDs Molecular and Cellular Mechanisms
  • lamotrigine (Lamictal, Lamictal XR)
  • Blocks voltage-dependent sodium channels

American Epilepsy Society 2011
AEDs Molecular and Cellular Mechanisms
  • Ethosuximide (Zarontin)
  • Blocks low threshold, transient (T-type)
    calcium channels in thalamic neurons
  • Valproate, Divalproex Sodium
  • May enhance GABA transmission in specific
  • Blocks voltage-dependent sodium channels
  • Modulates T-type calcium channels

American Epilepsy Society 2011
AEDs Molecular and Cellular Mechanisms
  • Topiramate (Topamax)
  • Blocks voltage-dependent Na channels
  • Increases frequency at which GABA opens Cl-
  • Antagonizes glutamate action
  • zonisamide (Zonegran)
  • Blocks voltage-dependent sodium channels and
    T-type calcium channels

American Epilepsy Society 2011
AEDs Molecular and Cellular Mechanisms
  • Levetiracetam (Keppra, Keppra XR)
  • Action is unknown, suspect it acts on GABA
  • Oxcarbazepine (Trileptal, Oxtellar XR)
  • Blocks voltage-dependent sodium channels
  • Exerts effect on K channels

American Epilepsy Society 2011
AEDs Molecular and Cellular Mechanisms
  • Lacosamide (Vimpat)
  • Enhances slow inactivation of voltage gated
    sodium channels

American Epilepsy Society 2011
AEDs Molecular and Cellular Mechanisms
  • rufinamide
  • Unclear Possibly stabilization of the sodium
    channel inactive state
  • vigabatrin
  • Irreversibly inhibits GABA-transaminase

American Epilepsy Society 2011
  • For Generalized seizures
  • Levetiracetam (Keppra)
  • Lamotrigine
  • Topiramate
  • Zonegran
  • Valproic Acid
  • Ethosuximidate specifically used for absence
  • For Partial seizures
  • Oxcarbazepine

IVIG Therapy
  • Inflammation is known to cause several
    neurological disorders.
  • Recently, it is being acknowledged to have a role
    in Epilepsy.
  • IVIG Intravenous immunoglobulin contains
    pooled, polyvalent, IgG antibodies that work to
    suppress inflammation.
  • Its on the horizon as an effective treatment for

Medication Alternatives
Epilepsy Surgery
  • Seizure
  • Epilepsy diagnosis
  • Medication trials
  • Imaging for pathology
  • Medical intractability
  • Surgical Consideration
  • Surgical workup
  • Surgery

American Epilepsy Society 2011
Ketogenic Therapy
  • This is a rigid, mathematically calculated,
    doctor-supervised diet.  It can only be attempted
    under close medical and dietary supervision.
  • Who is a candidate?
  • In general, individuals with uncontrolled
    seizures that have failed at least two
    medications for seizure control can be considered
    for this therapy.
  • Research shows that it is more effective for
    certain seizures types.  These include infantile
    spasms, Doose Syndrome, Rett Syndrome, and
    tuberous sclerosis complex.

Ketogenic Therapy
  • The Basics
  • The ketogenic diet is a medical treatment for
    controlling seizures by switching the body's
    primary energy source to fat-based (ketones)
    verses sugar-based (glucose).
  • We are not sure why this diet is successful.
  • The diet can be adapted using table foods or
    given formula based.
  • There are potential side effects associated with
    the diet, however, all are treatable and
    reversible without having to stop the diet.
  • They include, lack of weight gain, slightly
    decreased growth, somewhat high cholesterol,
    constipation, kidney stones, and acidosis.
  • There are a number of common misunderstandings
    about this therapy.
  • Additional Resources
  • On the Web - The Charlie Foundation -

Vagus Nerve Stimulation
  • The Basics
  • The vagus nerve is one of the primary
    communication pathways between the body and the
  • This is not drug therapy!  VNS Therapy is
    delivered by a surgically implanted generator and
    lead.  It's best to think of it as similar to a
  • Side Effects
  • Cough
  • Hoarseness
  • Paraesthesia
  • Shortness of Breath
  • Vocal Cord Paralysis/weakness
  • Infection
  • Increased/Improved Mood
  • Increased Alertness
  • Improved Memory

Part 3 Safety
During a Seizure
  • Caring for a child during a seizure is all about
    safety. The following is needed of you
  • Keep calm.
  • Time the seizure.
  • Don't hold the child down or try to stop any
  • Clear the area of any hard or sharp objects and
    loosen ties or anything around the neck that may
    make breathing difficult.
  • Place something flat and soft under the head.
  • Turn the child gently onto one side. This will
    help keep the airway clear.
  • Do not try to force the mouth open with any hard
    objects or with fingers. A person having a
    seizure CANNOT swallow their tongue. Efforts to
    hold the tongue down can injure teeth or the jaw.
  • Remain with child the entire time.
  • The child may be disoriented and confused as they
    wake from the seizure, be reassuring during this
  • Assess for injury and respiratory status.
  • If the child is sleepy following the seizure,
    allow them to rest.
  • Nothing to eat or drink until able to swallow.

When to Call 911
  • When seizures approach 5 minutes in duration or
    per patient's seizure action plan (administering
    rescue med for the first time).
  • If the child has seizures back to back
  • If it's the child's first seizure
  • If injury is suspected
  • If child is pregnant or diabetic
  • If child does not return to baseline in an
    expected amount of time post seizure activity

Potential Injuries from Seizures
  • Immediate lacerations, bruises, burns, head
    trauma, fractures, and drowning/near drowning.
  • Delayed fever, aspiration pneumonia, subdural
    hematomas, and fractures.

Tips for Seizure Observation and Documentation
  • What happened before, during, and after the event
  • Be detailed
  • Include lots of information from the start to the

Seizure Safety
  • There are some restrictions that must be in place
    for a period of time following a seizure in order
    to keep the child safe. These restrictions are
    in place for 90 days, they include
  • No driving a motor vehicle or operating heavy
    machinery (this is mandated by the State of
    Wisconsin Department of Transportation).
  • No high climbing, this means nothing higher then
    2 steps off the ground or the childs height.
  • No swimming in lakes or rivers due to concerns
    with currents and the worry that if a seizure
    occurred the child could be swept away or under.
  • If swimming in a pool or soaking in a hot tub,
    must have an adult in the water at all times
    within an arms reach.
  • No tub baths. Children should only shower during
    this period.
  • Any individual who is being treated for seizures
    should avoid sports where a moments inattention
    could lead to injury these include such
    activities as skydiving, bungee-jumping,
    scuba-diving, or motor racing.
  • We strongly encourage Medical Alert use.

Home Rescue Medications
  • We typically prescribe a specific medication to
    be used when a child has a prolonged seizure or a
    cluster of seizure activity (a series of seizures
    in a short amount of time) that can be used at
    home. This medication is a rescue medication.
  • These medications can be administered in a
    variety of ways. We typically used two routes,
    buccal or rectal.
  • The medication that is prescribed depends on the
    type of seizure a child has and the age of the
  • We prescribed either rectal Diastat or buccal

  • Diastat is a rectal form of diazepam that is used
    to stop a seizure.
  • It is effective, well tolerated, and side effects
    such as changes in breathing are not common.
  • Dosing of this medication is dependent on a
    childs age and weight.
  • The biggest advantage of giving a medication
    rectally during a seizure is that it can be given
    and absorbed quickly.
  • Education on Diastat administration should be
    preformed while inpatient. The drug company
    provides a DVD as well as teaching sheets.

  • Midazolam is a short acting benzodiazepine.
  • It can be administered in two ways for rescue
    with a single prolonged seizure or cluster,
    buccal or intranasal.
  • The most common side effects are drowsiness,
    tiredness, weakness, and nausea. There is a
    chance that a child may experience breathing
    problems following this medication. We advise
    families that the first time they use this, they
    call 911 to ensure it is well tolerated.
  • To administer buccally, simply divide the
    prescribed dose in half, giving on each side
    between the cheek and gum.

Communication and Collaboration with Healthcare
  • Medication Administration Forms
  • Any concerns about medication compliance or
    safety risks.
  • Any letters for special privileges (water
    bottles, activity restrictions, etc.)
  • Any general questions about medications
  • Any general questions about plan of care
  • We encourage you to fax us updates or concerns.
    This is recommended as we know we will likely
    recieve this correspondence.
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