Before I became a nurse, I thought seizures were rare events that only occurred in people with epilepsy. However, seizures are relatively common, have multiple causes and can present in a variety of ways. In this post we’ll talk about the basics of seizures, how they’re treated, and seizure nursing interventions to keep our patients safe.

What is a seizure?

Seizures are sudden and uncontrolled electrical disturbances in the brain that can range from mild to life-threatening. When a patient has recurrent seizures (at least two or more), then they are considered to have epilepsy. 

What causes seizures?

A seizure can occur for a variety of reasons. In addition to epilepsy, seizures can occur in the presence of:

  • Brain injury secondary to trauma
  • Ischemic or hemorrhagic stroke
  • Hyponatremia (a low sodium level)
  • Alcohol withdrawal
  • Methamphetamine use
  • Hypoxia
  • Brain tumors, also known as “space-occupying lesions”
  • Medications that lower the seizure threshold (antidepressants are a great example).

What are the different types of seizures?

There are two main types of seizures, generalized and focal. Generalized seizures have several subtypes: 

  • Tonic-clonic seizures, also known as Grand Mal seizures: This is most likely what you think of when you imagine a patient having a seizure. In tonic-clonic seizures, the patient abruptly loses consciousness, with their whole body  stiffening and shaking. The patient may lose control of their bladder, bite their tongue, and thrash about uncontrollably. It is very important to keep the patient SAFE during a tonic-clonic seizure as injury is a very real concern. Safety will definitely be a key component of any seizure care plan (hint hint!)
  • Tonic seizures: This type of seizure causes the muscles to stiffen, usually the muscles of the back, legs and arms. Patients having a tonic seizure are at high risk for falls if the seizure occurs while standing or even sitting. Again, think SAFETY!
  • Clonic seizures: In a clonic seizure the patient will exhibit repeated or rhythmic jerking of the muscles. You’ll often see these in the face, neck and arms. 
  • Myoclonic seizures: These seizures typically have a sudden onset of brief twitches or jerks of the legs and arms.
  • Atonic seizures: You may also hear these called “drop seizures.” They involve a loss of muscle control, causing the patient to suddenly fall down or collapse.
  • Absence seizures, also known as “petit mal seizures”: This type of seizure occurs most commonly in children and exhibits as staring off into space with or without subtle body movements. These movements typically include blinking eyes or lip smacking. 

There are two types of focal seizures…those with impaired awareness and those without. 

  • Focal seizure with impaired awareness: In this type of seizure, the patient either has a change in awareness or a total loss of consciousness. S/he may stare off into space and have abnormal, repetitive body movements such as swallowing, walking in circles, rubbing their hands or chewing.
  • Focal seizure without impaired awareness: These seizures often cause the individual to experience a change in their emotions or in the way things look, smell, taste or feel; patients may feel tingling, see flashing lights, and even get dizzy (THINK SAFETY!). They can occur with or without involuntary body movements as well. 

Seizure nursing interventions

It can be very scary when your patient has a seizure. Here’s what you’re going to do:

  • First of all, stay with your patient! You need additional people in the room, but do not leave the patient to go grab someone. YELL for help…someone will hear you and they’ll come running.
  • Protect their airway! If your patient is having a seizure, you want to be sure their airway is protected, especially with those tonic-clonic seizures. During a seizure, patients are at high risk for aspiration of their saliva (or whatever happens to be in their mouth at the time). As well as you are able, position the patient onto their side so the secretions run out of their mouth instead of down their throat. Do not attempt to insert a suction catheter into the patient’s mouth during the seizure, but do have suction READY so that as soon as you can safely insert the catheter you can clear their oral cavity. Another option, depending on how much the patient is thrashing about, is to place a nasal-pharyngeal airway (also called a nasal trumpet) and insert a thin flexible suction catheter through the NPA down into the pharynx to suction any secretions. 
  • Provide supplemental oxygen. Hypoxia can not only be the cause of the seizure, but it can occur during the seizure as well. Oxygen may be provided via a face mask or with the Ambu-Bag if the patient needs help ventilating.
  • Safety is a key component of seizure nursing interventions, so if you don’t know what to do during this very stressful event, think along the lines of “what can I do to keep this patient safe?” For example, if the patient is on a hard surface such as the floor, place something soft under their head to prevent serious injury. You’ll also want to move any nearby objects out of the way to prevent them from hitting their arms and legs against them. If you’re in a tight space, such as a bathroom, you can place pillows against the walls and other surfaces that can’t be moved. If your patient is at risk for seizures, make sure that seizure precautions are in place. This is typically a bundle of elements that, when performed together, can help keep your patients safe. Seizure precautions usually refers to placing pads against the side rails of the bed (these are usually just called “seizure pads”), ensuring oxygen is functional, ensuring suction is set up and working at the bedside, and maintaining the bed in its lowest position.
  • Medication may be given in an attempt to stop the seizure. This is typically a benzodiazepine of some kind…lorazepam (Ativan), midazolam (Versed) or diazepam (Valium). 

What happens after the seizure?

The period after the seizure is called the “postictal state” and it persists until the patient has returned to his or her baseline. The length of time varies, and the name of the game during this period continues to be patient safety. Most patients are hypoactive in the postictal state, but be aware that the patient may be hyperactive as well (when this occurs, it is sometimes referred to as postictal delirium or postictal psychosis).  

If the patient is hypoactive, you want to make sure the patient can protect his or her airway. Keeping them lying on their side is an easy intervention to prevent secretions from running down their throat and to help prevent the tongue from occluding the airway. The patient may be withdrawn and subdued during this period, showing signs of lethargy, detachment and extreme sleepiness.

A hyperactive postictal state can present as either delirium (defined as sudden onset of confusion) or psychosis. Again, patient safety is key. Be aware that patients can be agitated and even violent during this period. Unfortunately, the best treatments for postictal psychosis remain undefined and many medications typically used to treat psychosis can lower the seizure threshold (meaning the brain can more easily go into a seizure state). The patient may need frequent reorientation during the delirious state and, if a danger to himself, may require a sitter at the bedside.

Common seizure medications

Seizure medications work by raising the seizure threshold. We could go through a whole blog post about this topic, and there are a lot of medications used in the treatment of seizures. Here are some common meds you’ll see in the clinical setting: 

  • Levetiracetam (Keppra): Available IV and PO. Patients will typically start on this IV and then transitioned to PO when the can safely swallow medications. Keppra can cause dizziness, fatigue and weakness. 
  • Phenytoin (Dilantin): Used for treatment of tonic-clonic seizures and complex partial seizures. Phenytoin will enter breast milk and cross the placenta. Common side effects include ataxia, hypotension, diplopia, nausea and gingival hyperplasia. This last one is a very common side effect, which can cause patients to lose their teeth (it’s also a very common exam question!). Be aware that phenytoin can cause a severe dermatologic condition called Stevens-Johnson syndrome.
  • Fosphenytoin (Cerebyx): This drug is used for short-term control of generalized seizures if the patient is not able to tolerate phenytoin. Common side effects are similar to those of phenytoin, including the potentially life-threatening Stevens-Johnson syndrome. 
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What’s the difference between a seizure and a pseudoseizure?

You may hear someone refer to your patient’s seizure activity as a “pseudoseizure.” This DOES NOT mean that the seizure was faked. It simply means that the seizure was caused by a psychological problem, not a neurological problem. The nonepileptic seizure is just as real, but the treatments will vary. Rather than utilizing drugs to raise the seizure threshold, patients with pseudoseizure may benefit from therapy, antidepressants and medications aimed at treating the underlying disorder.

What’s it like living with a seizure disorder?

Though we’ve been talking about seizures in a general term, a wonderful book about childhood epilepsy is The Spirit Catches You and You Fall Down by Anne Fadiman (#ad). It was required reading in my pediatrics course and was incredibly eye-opening on several fronts. Fadiman’s book explores the cultural barriers that make managing a complex illness extremely difficult, so you’ll learn about epilepsy management but also how health care workers can strive for cultural competency. It’s a great book and I highly recommend it!

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References

Abood, W., & Bandyopadhyay, S. (2019). Seizure, Postictal State. In StatPearls. Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK526004/

Deglin, J. H., & Vallerand, A. H. (2007). Daviss drug guide for nurses (11th ed.). Philadelphia, PA: F. A. Davis Company.

Fire Engineering. (2008, May 1). Status Seizures: A BLS Approach. Retrieved from Fire Engineering website: https://www.fireengineering.com/2008/05/01/237184/status-seizures-a-bls-approach/

Johnson, J. (2018, June 1). Pseudoseizure: Definition, symptoms, causes, treatment. Retrieved from Medical News Today website: https://www.medicalnewstoday.com/articles/322016.php

Krauss, G., & Theodore, W. H. (2010). Treatment strategies in the postictal state. Epilepsy & Behavior: E&B, 19(2), 188–190. https://doi.org/10.1016/j.yebeh.2010.06.030

Mayo Clinic. (n.d.). Seizures—Symptoms and causes—Mayo Clinic. Retrieved from https://www.mayoclinic.org/diseases-conditions/seizure/symptoms-causes/syc-20365711