Guidelines for Seizure Management

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1 Guidelines fr Seizure Management Seizure management (Revisin 2010) Rectal diazepam administratin (Revisin 2010) Vagal nerve stimulatin (Revisin 2010)

2 Seizure Management Overview A seizure is an event in which there is a temprary change in behavir resulting frm a sudden, abnrmal burst f electrical activity in the brain. If the electrical disturbance is limited t nly ne area f the brain, then the result is a partial seizure. Fr example, the student may experience cnfusin, lss f awareness, aimless mvements, r uncntrlled bdy mvements. If the electrical disturbance affects the entire brain, the result is a generalized seizure. Epilepsy r a seizure disrder is a chrnic cnditin that is characterized by recurrent seizures. Many students with epilepsy have mre than ne seizure type and may have ther symptms as well. Sme seizures may result frm an acute medical illness (e.g., with a diabetic during a hypglycemic episde) r an acute injury (e.g., head injury) and cease nce the illness is treated. Sme children may have ne seizure withut the cause ever being knwn. Classificatin f Seizures The fllwing table summarizes the classificatin f seizures: Generalized Seizures Tnic-clnic seizures (frmerly knwn as grand mal seizures; affects the entire brain) Onset: any age Absence seizures (frmerly called petit mal seizures, lapses, r staring spells ) Onset: age 4-12 Clinical Manifestatins The eyes rll upward, the student lses cnsciusness, falls t the grund, and becmes rigid as muscles tighten (tnic phase). This is fllwed by jerking mvements f the entire bdy as muscles underg rhythmic tightening and relaxatin (clnic phase). During this phase, the student may becme incntinent f stl and urine as his/her muscles cntract and relax. Breathing may be shallw r even stp briefly, but renews as jerking mvements end. Generalized seizures usually last 1-2 minutes. After the tnic-clnic phase, mvement slws and is fllwed by drwsiness r deep sleep that can last several hurs (pstictal state). These seizures are characterized by a brief lss f cnsciusness with minimal r n alteratin in muscle tne and smetimes g unrecgnized. The seizures can be mistaken fr daydreaming r inattentiveness. Students may: Simply stare blankly fr 5-10 secnds Drp bjects because f lss f muscle tne Have minr mvements such as lip-smacking Experience twitching r slight hand mvements The student will be unable t recall what happened during these brief perids f blankness. If untreated, seizures

3 Generalized Seizures Atnic seizures (als knwn as drp attack) Onset: age 2-5 Myclnic seizures Partial Seizures Simple Partial Seizures (fcal seizures; affects just ne part f the brain) Onset: any age Cmplex Partial Seizures (psychmtr seizures) Onset: age 3and up Clinical Manifestatins may ccur many times a day. Seizures can be precipitated by fatigue, stress, hypglycemia, r hyperventilatin. Manifested as a sudden, mmentary lss f mtr tne. The student may r may nt lse cnsciusness. A mild atnic seizure may cause a sudden, brief head drp. During a mre severe atnic seizure, the student may suddenly fall t the grund, lse cnsciusness briefly, and then get up as if nthing happened. If a student has frequent atnic seizures, a helmet is wrn t prevent injury t the head r face. Characterized by sudden, brief cntractures f a muscle r grup f muscles withut lss f cnsciusness. N pstictal state. Clinical Manifestatins Manifestatins are dependent n the area affected and tend t be lcalized. The student may, r may nt, lse cnsciusness and may be aware f the seizure. Fr example, a student s eyes r eyes and head turn t ne side and the arm n that side may be extended with the fingers clenched. The student may appear t be lking tward the clsed fist. It is imprtant fr an eyewitness t give a clear descriptin f the seizure, especially which bdy parts are initially invlved, t aid in diagnsis and treatment. Als, nting the circumstances that precipitated the episde can help in treatment. Students may als experience a pstictal stage after a partial seizure. Simple partial seizures may spread and becme generalized. Cnsciusness is never impaired. The mst cmmn type f seizures. These seizures ften begin with an aura r warning that the seizure is abut t ccur. Mst cmmnly, the aura is described as a strange feeling in the pit f his/her stmach that rises up t the thrat. Often this sensatin is accmpanied by dd r unpleasant drs r tastes, auditry r visual hallucinatins, r feelings f elatin r strangeness. A student may cry r run fr help. During this time, the student is ften unaware f his/her envirnment and unable t respnd t the envirnment. After the aura, the student may suddenly becme limp r stiff, appear dazed, and cnfused and apathetic. The mst bvius behavirs may be lip smacking, repeating wrds,

4 Partial Seizures Clinical Manifestatins chewing, drling, swallwing, and nausea and abdminal pain fllwed by stiffness, a fall, and sleep. Cmplex partial seizures may spread and becme generalized. Cnsciusness is always impaired. Ptential Settings Many students with a histry f seizures attend a regular classrm and participate in regular schl activities, with mdificatins that are determined by the parents, health care prvider, schl nurse, and schl staff. As with all medical cnditins, every effrt is made t prtect the student s privacy, especially during the ccurrence f a seizure. Schl persnnel having cntact with the student are t be familiar with the student s medicatins and ptential side effects, be able t recgnize signs f seizure-related behavir, knw what t d when signs are bserved, and knw hw t implement the established schl emergency plan. Medicatins Currently Used t Treat Seizures (this list includes nly a sample f medicatins available t treat seizures) Additinal medicatins t treat seizures may becme available fr use in the U.S.A. as apprved by the FDA and prescribed by the medical care prvider. Generic Name Trade Name Seizure Type Adverse Reactins Carbamazepine Tegretl Secndary tnic/clnic Cmplex partial Simple partial Allergic reactins, dizziness, ataxia, muscle incrdinatin, nausea, behaviral changes, blurred r duble visin, aplastic Clnazepam Klnpin Absence Myclnic Tnic/clnic anemia, hepatitis Sedatin, hyperactivity, aggressiveness, slurred speech, duble visin, behavir changes, increased salivatin Ethsuximide Zarntin Absence GI upset, lss f appetite, headache, lethargy, behavir changes, dizziness, dystnia, myelsuppressin, druginduced lupus Felbamate used nly with cautin and infrmed cnsent due t serius adverse reactins Felbatl Partial and generalized (reserved fr severe epilepsy) Gabapentin Neurntin Partial, patients >12 years Aplastic anemia, hepatic failure, anrexia, weight lss, nausea, insmnia, headache, fatigue Smnlence, dizziness, ataxia, fatigue

5 Generic Name Trade Name Seizure Type Adverse Reactins Lacsamide Vimpat Partial Dizziness, headache, nausea, duble visin Lamtigine Lamictal Partial Tnic-clnic Absence Atnic Myclnic Phenbarbital Luminal Tnic-clnic Partial Febrile Phenytin Dilantin Tnic-clnic Cmplex partial Simple partial Smnlence, dizziness, rash, nausea Sedatin, hyperactivity, changes in sleep pattern, inattentin, irritability, cgnitive impairment Gingival hyperplasia, hirsutism, nystagmus, blurred r duble visin, ataxia, rashes, flate deficiency, drug-induced lupus, myelsuppressin Pregabalin Lyrica Partial Blurry visin, dizziness, dry muth, weight gain, sleepiness, swelling f hands and feet, truble cncentrating Primidine Mysline Tnic-clnic Cmplex partial Simple partial Sedatin, hyperactivity, ataxia, behavir changes, rare hematlgical and hypersensitivity reactins Rufinamide Banzel Lennx-Gastaut Syndrme (als knwn as myclnic-astatic epilepsy) Allergic reactins, dizziness, drwsiness, headache, nausea, tiredness, vmiting, appetite changes, sre thrat, blurred visin, tremr, bld in urine; behavir, mental, md changes, truble sleeping, suicidal thughts r attempts Tigabine Gabatril Partial Dizziness, smnlence, Tpiramate Tpamax Partial Tnic-clnic Atnic Myclnic Absence Valprate Valpric acid Depakte Depakene Myclnic Absence Tnic-clnic headache, depressin Smnlence, anrexia, fatigue, difficulty with cncentratin, nervusness Hair lss, tremr, elevated liver enzymes and liver failure, irregular menses,

6 Generic Name Trade Name Seizure Type Adverse Reactins Mixed seizures types increased appetite, nausea and vmiting, pancreatitis thrmbcytpenia Diet Therapy In specific cases, students with seizures may be prescribed a ketgenic diet fr treatment and cntrl f seizures. Usually this diet is prescribed fr students with prly cntrlled seizures wh cannt tlerate the side effects f anticnvulsants. The ketgenic diet is designed t induce and maintain a state f ketsis which has been fund t metablically imprve seizure cntrl in certain cases. The diet is high in fat (80-90%) and lw in carbhydrates and prteins. It is a carefully calculated diet and requires daily mnitring t maintain ketsis. A student n a ketgenic diet is fllwed by a registered dietitian and has a prescribed meal plan t fllw daily. Crdinatin between the student s neurlgist, dietitian, family, and schl is recmmended fr the develpment f a successful individualized health care plan (IHCP). Mnitring The purpse f seizure mnitring is t prtect the student frm injury during a seizure, t carefully bserve the seizure in rder t prvide infrmatin fr the management f the seizure disrder, and t distinguish between behavirs related t a seizure and thse behavirs nt related t it. Mnitring prvides the health care prvider with the infrmatin needed t better manage the student s medicatin. An increase in the number f seizures may indicate that the student needs a change in medicatin r that he/she is nt receiving the prescribed medicatin. A change in medicatin may be needed because f a change in the student s metablism. In additin, antiepileptic medicatin may be txic. Therefre, any side effects frm the medicatin shuld be dcumented and reprted t the schl nurse, family, and/r health care prvider. Careful mnitring f the student can imprve the management f seizures. Signs f an Emergency A series f cnsecutive seizures in which the student des nt regain cnsciusness is called status epilepticus, which is a medical emergency. Immediate medical care is required. Seizures that last lnger than 5 minutes require emergency medical services. Seizures lasting lnger than 30 minutes can cause brain damage. Status epilepticus can lead t respiratry failure, brain damage, and death. Therefre, it is critical that the student receive immediate medical attentin. Managing a Seizure Managing a seizure in schl cnsists f prtecting the student, bserving the student, and getting medical assistance when needed. The prcedures n the fllwing pages are guidelines fr managing a student having a seizure and what t d after the student has a seizure. Included in the guidelines is the First Aid Flw Chart fr Seizures algrithm (see page 165).

7 Cmpnents f the Individualized Health Care Plan (IHCP) Each student s IHCP must be tailred t the individual s needs. The fllwing sectin cvers the prcedure fr managing a seizure and pssible prblems and emergencies that may arise. It is essential t review it befre writing the IHCP. Nte: Equipment, medicatin, and supplies are prvided by the parents/guardians. A sample seizure actin plan and seizure bservatin recrd (r seizure lg) are available frm Fr a student with seizures, the fllwing items shuld receive particular attentin: Student s underlying cnditin and pssible prblems assciated with the cnditin r treatment. Type f seizures student experiences and typical curse f seizure. Student s baseline r nrmal behavirs. Whether student experiences auras, r can anticipate when seizures may ccur. Behavirs that indicate a seizure may be abut t ccur. Actins t take if the student has a seizure. Medicatins the student is taking, including rescue treatments, and signs f adverse reactins r txicity. Determining the need fr seizure precautins, and what these precautins will be. Latex allergy alert. Standard precautins. Additinal resurces and supplementary materials fr managing students with seizures are available at Surces: Drugs.cm. ( ). Banzel. Available nline at Epilepsy Fundatin f America. Available nline at Epilepsy Fundatin f America. (2008) Seizure Training fr Schl Persnnel. Available at Hckenberry, M.J. & Wilsn, D. (2007). Wng s Nursing Care f Infants and Children. (8 th ed.). St. Luis: Msby, pp Physician Desk Reference Cnsumer Drug Infrmatin. ( ). Available nline at Vimpat.cm. (2009). Vimpat. Available nline at

8 Prcedure fr Managing a Seizure If the student has a seizure: 1. Remain calm. N ne can stp a seizure nce it starts. 2. Time the seizure. Dcument all f the student s activity during a seizure: the time seizure began, the time seizure ended, area f bdy where the seizure began, any mvement f the seizure frm ne area f the bdy t anther, type f mvements f the head, face, and/r arms. 3. Check fr medical alert I.D. and fllw the student s individualized health care plan (IHCP). If applicable, prvide seizure rescue treatment. 4. Have an adult stay with the student during the seizure t mnitr his/her prgress. 5. Put n glves, if available. 6. Place student n side. If pssible, put smething flat and sft (like a flded blanket r jacket) under student s head s the student cannt bang against the flr. This psitining prevents the tngue frm blcking airway and helps the student nt t chke n secretins. 7. D nt place anything in the student s muth. Padded tngue blades and airways are nt accepted practice because they may induce vmiting, cause ptential damage t teeth, and may be aspirated. 8. Lsen tight clthing, especially arund the student s neck. 9. If student is standing r sitting, gently lwer student t the grund t avid a fall. Clear the area f anything that culd hurt the student. D nt attempt t restrain student r use frce. D nt remve student frm a wheelchair unless necessary. 10. D nt give the student any ral medicatins, fd r drink during a seizure. 11. Prvide emtinal supprt. 12. Call (911) Emergency Medical Services if: Student stps breathing. Seizure lasts lnger than 5 minutes. This is student s first seizure. Repeated seizures withut regaining cnsciusness. Student cannt be awakened and is unrespnsive t pain after seizure ends. Pupils are nt equal in size after seizure. There is evidence f student injury. Student has diabetes r is pregnant. Seizure ccurs in water. Parents request emergency evaluatin. Prepare schl envirnment t be as safe as pssible fr the student wh has a histry f seizures.

9 Be aware f the ptential fr head injuries with uncntrlled seizures. The student may require a lightweight helmet fr head prtectin, especially fr seizures that prduce sudden changes in muscle tne (atnic, myclnic, akinetic). Prepare fr ptential prblems assciated with seizures. Fr example, if the student has cpius secretins with a seizure, a bulb syringe r suctin machine will need t be available. Pathways and envirnments shuld be free f unnecessary bjects. Fr example, unused tys, wheelchairs, strage bxes, etc. shuld be remved frm the envirnment. Supervisin during use f hazardus machinery r equipment (such as that fund in a shp class) shuld be available. After a Student Has a Seizure: 1. After the seizure is ver, clear secretins frm the student s muth with a bulb syringe r suctin catheter. Keep child n his/her side. D nt try t clear the student s muth until the seizure has ended. 2. Mnitr student s breathing. Check psitin f head and tngue. Repsitin if head is hyperextended. If student is nt breathing, activate the schl emergency plan and begin rescue breathing. 3. Talk with student t determine student s level f awareness. Nte if the student is alert, cnfused, drwsy, etc. and dcument findings. If student remains uncnscius after seizure is ver, maintain pen airway and assess breathing. If necessary, begin rescue breathing r CPR. 4. Determine and dcument whether r nt the student is able t mve arms and legs, r if there is change in the student s ability t mve. 5. Check fr injuries and prvide care, if needed. 6. Check fr lss f cntrl f urine and stl. Prvide privacy. Lss f cntrl is very embarrassing t the student. Clean the student t make him/her mre cmfrtable. 7. Remain with the student until they have regained full awareness f their surrundings. Make the student cmfrtable; allw him/her t sleep as needed. D nt give fd r liquids until fully alert and swallwing reflex has returned. After the seizure, the student may sleep fr 30 minutes up t a number f hurs (pstictal perid). Refer t the First Aid Flw Chart fr Seizures (see page 165) t determine the dispsitin f the student pst seizure. 8. Dcument the length f seizure, what happened during and after the seizure. Ntify schl nurse, family, and/r health care prvider as per the individualized health care plan (IHCP). Surces: Epilepsy Fundatin f America. (2008). Seizure Training fr Schl Persnnel. Available at Hckenberry, M.J. & Wilsn, D. (2007). Wng s Nursing Care f Infants and Children. (8 th ed.). St. Luis: Msby, pp

10 First Aid Flw Chart fr Seizures At nset f seizure, begin first aid immediately: Place student gently n the flr Keep airway clear by placing student n their side Time the seizure Prtect student frm injury by remving any bjects that culd cause injury Prtect head by placing smething sft (i.e., rlled up cat r sweater) under head DO NOT RESTRAIN STUDENT DO NOT PLACE ANYTHING IN MOUTH **Refer t Individualized Health Care (IHCP) Plan fr student-specific instructins Is this the first time the student has had a seizure? Is the student a diabetic? Is the student pregnant? Is the student injured? Yes N Perfrm first aid and bserve student fr details f the seizure Swipe Vagal Nerve Stimulatr (VNS) with magnet, if applicable CALL 911 IMMEDIATELY Des the seizure stp within 2 minutes? N Yes Allw student t rest fr 15 t 30 minutes Keep airway clear Cntact parent/guardian Aruse student every 5 minutes Prepare t administer seizure rescue medicatin, if student-specific rder n file Cntinue t mnitr Can the student be arused? Des the seizure stp within 5 minutes? Yes N Yes Return student t class r send hme. Refer t IHCP. N CALL 911 Administer seizure rescue medicatin per trained staff, if student-specific rder n file Ntify parent/guardian and schl nurse Stay with student until EMS arrive CALL 911 if: Student stps breathing. Seizure lasts lnger than 5 minutes. This is student s first seizure. Repeated seizures withut regaining cnsciusness. Student cannt be awakened and is unrespnsive t pain after seizure ends. Pupils are nt equal in size after seizure. There is evidence f student injury. Student has diabetes r is pregnant. Seizure ccurs in water. Parents request emergency evaluatin. Dcument event n Student Treatment Recrd (STR) Seizures may be any f the fllwing: Episdes f staring with lss f eye cntact. Staring invlving twitching f the arm and leg muscles. Generalized jerking mvements r stiffening f the arms and legs. Unusual behavir fr that persn (e.g. running, belligerence, making strange sunds, etc.) Altered mental status Mdified frm Guidelines fr Managing Seizures in the Schl Setting, Schl District f Escambia Cunty, Flrida. Guidelines%20Final% % pdf

11 Rectal Diazepam fr Seizures A seizure disrder r epilepsy is a chrnic cnditin that is characterized by recurrent seizures. A seizure is an event in which there is a temprary change in behavir resulting frm a sudden, abnrmal burst f electrical activity in the brain. Many students with epilepsy have mre than ne seizure type and may have ther symptms as well. Sme students cntinue t experience seizures despite medical treatment. Acute prlnged r repetitive seizures are detrimental t a student s health. Studies shw that rectal diazepam can be a safe and effective treatment fr acute repetitive r prlnged seizures. Althugh intravenus diazepam can prduce serius respiratry depressin, published studies f rectal diazepam have fund n instances f serius respiratry depressin. Hwever, sme anecdtal stries f respiratry depressin exist. The mst cmmn side effect f rectal diazepam is sleepiness. Other side effects that have been reprted include dizziness, headache, pr crdinatin, pain, nervusness, slwed speech, diarrhea, and rash. The greatest incidence f side effects is when mre than ne dse is given. Rectal diazepam is available as a rectal gel. The mst cmmnly prescribed frm is Diastat, a rectal gel that cmes pre-packaged as a quick delivery set in a syringe with a flexible, mlded tip. Diastat Acudial 10 mg r 20 mg syringes are dialed and lcked t the prescribed dse. A 2.5 mg Diastat syringe is als available. It can be stred fr three years at rm temperature. Ptential Settings The need t give rectal diazepam can ccur anywhere. Measures shuld be taken t prtect the privacy f the student as much as pssible. Students wh may require rectal diazepam n the bus shuld have an adult aid available n the bus. Guidelines regarding where and hw diazepam can be administered shuld be cvered in the student s individualized health care plan. Staff Preparatin Rectal diazepam can be administered by a registered schl nurse, licensed practical nurse, r ther adult with specialized training in apprpriate techniques and prblem management. Guidelines regarding wh can administer rectal diazepam shuld be included in the student s individualized health care plan. These persns shuld als have training in cardipulmnary resuscitatin. Any schl persnnel wh has regular cntact with a student wh requires rectal diazepam shuld receive general training cvering the student s specific needs, ptential prblems and implementatin f the established emergency plan. Cmpnents f the Individualized Health Care Plan Each student s IHCP must be tailred t the individual s needs. The fllwing sectin cvers the prcedure fr the administratin f rectal diazepam and pssible prblems and emergencies that may arise. It is essential t review it befre writing the IHCP.

12 A sample plan is included in Appendix A. Fr a student wh requires rectal diazepam, the fllwing items shuld receive particular attentin: Details f events which wuld necessitate the administratin f rectal diazepam. Need t call 911 and activate the schl emergency plan when rectal diazepam is given. Student s underlying cnditin and pssible prblems assciated with the cnditin r treatment. Type f seizures student experiences and typical curse f seizure. Actins t take when the student has a seizure. Side effects t mnitr. What t d if respiratry depressin is nted. Student s baseline r nrmal behavirs. Whether student experiences auras, r can anticipate when seizures may ccur. Behavirs that indicate a seizure may be abut t ccur. Other medicatins the student is taking and signs f adverse reactins r txicity. Latex glve allergy alert if applicable. Standard precautins. Surces: Dreifuss, FE, et al. (1998). A Cmparisn f Rectal Diazepam Gel and Placeb fr Acute Repetitive Seizures. The New England Jurnal f Medicine 338 (26): Epilepsy.cm. Diastat. Available nline at Epilepsy Fundatin f America. (2005). Diastat Acudial. Available nline at Hckenberry, M.J. & Wilsn, D. (2007). Wng s Nursing Care f Infants and Children. (8 th ed.). St. Luis: Msby, pp Natinal Assciatin f Schl Nurses. (2003). Psitin Statement: The rle f the Schl Nurse Caring fr a Student Requiring a Rectal Medicatin fr Seizures. Available nline at Natinal Institute f Neurlgical Disrders and Strkes. (2009). Safe and Effective Treatment fr Acute Repetitive Seizures Available fr At-Hme Use. Originally released June Available nline at Physician Desk Reference (PDR). ( ). Cnsumer Drug Infrmatin. Diastat Acudial Gel. Available nline at

13 Prcedure fr Administering Rectal Diazepam Nte: Equipment, medicatin and supplies prvided by parents. 1. Review prcedure prir t having t implement it. 2. Verify the medicatin rder and medicatin administratin parental permissin frm. 3. Dn glves. 4. Obtain assistance f anther adult, if pssible. 5. Remve prtective cver frm the medicatin syringe and lubricate the rectal tip with lubricating jelly (cmes with syringe). 6. Turn the student n his r her side (left side preferable) facing yu. Bend the upper leg frward and separate the buttcks t expse the rectum. 7. Gently insert the syringe tip int the rectum. The rim shuld be snug against the rectal pening. Slwly cunt t three while gently pushing in the plunger. Cunt t three again befre remving the syringe. Hld the buttcks tgether while cunting t three ne mre time. 8. Keep the student n their side facing yu and nte the time the medicatin was given. 9. Call 911 and activate the emergency plan. 911 must be called and the emergency plan activated whenever rectal diazepam is given by schl persnnel. 10. Observe the student fr side effects. Mnitr respiratry status thrughut the seizures and afterwards. Respiratry depressin can be a cnsequence f a seizure and/r f seizure medicatins. 11. Remve glves and wash hands when apprpriate. 12. Dcument the administratin f diazepam, student s respnse, and implementatin f the emergency plan. Surces: Dreifuss, FE, et al. (1998). A Cmparisn f Rectal Diazepam Gel and Placeb fr Acute Repetitive Seizures. The New England Jurnal f Medicine 338 (26): Epilepsy.cm. Diastat. Available nline at Epilepsy Fundatin f America. (2005). Diastat Acudial. Available nline at Hckenberry, M.J. & Wilsn, D. (2007). Wng s Nursing Care f Infants and Children. (8 th ed.). St. Luis: Msby, Natinal Assciatin f Schl Nurses. (2003). Psitin Statement: The rle f the Schl Nurse Caring fr a Student Requiring a Rectal Medicatin fr Seizures. Available nline at Natinal Institute f Neurlgical Disrders and Strkes. (2009). Safe and Effective Treatment fr Acute Repetitive Seizures Available fr At-Hme Use. Originally released June Available nline at Physician Desk Reference (PDR). ( ). Cnsumer Drug Infrmatin. Diastat Acudial Gel. Available nline at

14 Vagal Nerve Stimulatin fr Seizures A seizure disrder r epilepsy is a chrnic cnditin that is characterized by recurrent seizures. A seizure is an event in which there is a temprary change in behavir resulting frm a sudden, abnrmal burst f electrical activity in the brain. Many students with epilepsy have mre than ne seizure type and may have ther symptms as well. Sme students cntinue t experience seizures despite medical treatment. Acute prlnged r repetitive seizures are detrimental t a student s health. Vagal nerve stimulatin (VNS) has been fund t reduce the frequency and intensity f sme seizures. It invlves the insertin f a device similar t a pacemaker under the skin n the left side f the chest. This vagal nerve stimulatr can send intermittent electrical signals t the brain by stimulating the left vagus nerve in the neck. The vagus nerve is ne f the cranial nerves that cntrls the muscles respnsible fr swallwing, cughing and vice sunds. It is nt fully understd hw VNS wrks, but the thery is that the stimulatin alters nerve pathways that lead t a seizure. Benefits f VNS are nt always apparent immediately. Seizure activity may imprve immediately, r it may imprve ver a tw-year time perid The vagal nerve stimulatr wrks in tw ways. It is autmatically prgrammed t deliver stimulatin thrughut the day. Typically, the stimulatr activates n fr 30 secnds nce every 5 minutes. It can als be activated t give extra stimulatins manually between preprgrammed stimulatins by placing a magnet ver the stimulatr and then remving the magnet. The VNS system cnsists f a pulse generatr which is battery-perated and lks much like a pacemaker implanted under the skin f the chest. Prgramming f the generatr is accmplished with a wand attached t a cmputer at the physician s ffice. A strng magnet can als be used t activate the VNS n demand if the student senses that a seizure is abut t ccur r has just started. In additin, the magnet can temprarily suspend activity f the VNS if activatin f the VNS affects nrmal eating, speaking, r singing. The mst cmmn side effects f VNS are harseness and tingling r pain in the thrat r neck. Cugh, headache, and ear pain have als been reprted. Side effects tend t diminish ver time. Equipment that culd interfere with the stimulatr shuld be avided. This includes strng magnets, MRI scanners, hair clippers, and ludspeaker magnets. Areas which display pacemaker warning signs shuld als be avided. The additinal handheld magnets supplied fr manual stimulatin f the system can damage credit cards, cell phnes, and cmputer disks.

15 Ptential Settings The VNS system delivers stimulatin n a regular, nging basis. The need fr additinal VNS t prevent a seizure can ccur anywhere. Measures shuld be taken t prtect the privacy f the student. Staff Preparatin VNS can be administered by the student r by an adult with training in apprpriate VNS techniques and prblem management. Any schl persnnel wh has regular cntact with a student wh requires VNS shuld receive general training cvering the student s specific needs, ptential prblems and implementatin f the established emergency plan. This training shuld include what t d when a seizure ccurs and hw and when t activate VNS. Cmpnents f the Individualized Health Care Plan Each student s IHCP must be tailred t the individual s needs. The fllwing sectin cvers the prcedure fr the vagal nerve stimulatin and pssible prblems and emergencies that may arise. It is essential t review it befre writing the IHCP. A sample plan is included in Appendix A. Fr a student wh requires vagal nerve stimulatin, the fllwing items shuld receive particular attentin: Student s underlying cnditin and pssible prblems assciated with the cnditin r treatment. Type f seizures student experiences and typical curse f seizure. Whether student experiences auras, r can anticipate when seizures are abut t ccur. Behavirs that indicate a seizure may be abut t ccur. Actins t take when the student has a seizure. When and hw t use VNS magnets. Side effects t mnitr. Student s baseline r nrmal behavirs. Other medicatins the student is taking and signs f adverse reactins r txicity. Standard precautins. Surces: Cybernics, Inc. (2008). Epilepsy Patient s Manual fr Vagus Nerve Stimulatin with the VNS Therapy System. Hustn, TX: Cybernics, Inc. Available nline at Cybernics, Inc. ( ). VNS Therapy. Available nline at Kennedy PA & Schallert G. (2001). Practical Issues and Cncepts in Vagus Nerve Stimulatin: A Nursing Review. Jurnal f Neurscience Nursing 33(2): Zalvan, C et al. (2003). Laryngpharyngeal Dysfunctin Frm the Implant Vagal Nerve Stimulatr. Laryngscpe 113(2):

16 Prcedure fr Activating Vagal Nerve Stimulatin Nte: Equipment and supplies prvided by parents. 1. Review literature that cmes with the vagal nerve stimulatr. 2. Student r trained caregiver shuld keep magnet with student at all times. The watchstyle magnet attaches t the wrist with a wristband. The pager-style magnet cmes with a belt clip s that the magnet and clip can be remved as a unit frm the belt withut cming apart. Always keep magnets at least 10 inches away frm credit cards, televisins, cmputers, cmputer disks, micrwave vens, watches, r ther magnets. 3. If student senses a seizure is abut t ccur, place the magnet ver the Pulse Generatr site fr ne secnd and then mve it away. This will cause the VNS system t deliver extra stimulatin. This can be dne by the student r by any adult trained in using VNS. T use the pager-style magnet, remve the belt clip and magnet frm the belt and place the label against the Pulse Generatr. T use the watch-style magnet, psitin the wrist s that the label can be placed ver the generatr. 4. T temprarily stp stimulatin (turn ff the Pulse Generatr) when student needs t sing r speak in public, while eating, r if stimulatin is ever painful, put the magnet ver the Pulse Generatr and leave it there. The Pulse Generatr will nt stimulate while the magnet is in place ver tp f it, but it will start when the magnet is remved. The magnet shuld nt be used fr mre than fur hurs in a rw because it can decrease the Pulse Generatr battery. 5. Check the pulse generatr battery n a regular basis. Pass the magnet ver the Pulse Generatr fr ne secnd t see if it causes stimulatin and is wrking. 6. If stimulatin ever hurts, hld the magnet in place t stp stimulatin and cntact schl nurse and health care prvider immediately. 7. If student cmplains, f sre thrat, harseness, r any ther prblems with the VNS, dcument in student lg and ntify the schl nurse and family. Surces: Cybernics, Inc. (2008). Epilepsy Patient s Manual fr Vagus Nerve Stimulatin with the VNS Therapy System. Hustn, TX: Cybernics, Inc. Available nline at Cybernics, Inc. ( ). VNS Therapy. Available nline at Kennedy PA & Schallert G. (2001). Practical Issues and Cncepts in Vagus Nerve Stimulatin: A Nursing Review. Jurnal f Neurscience Nursing 33(2): Zalvan, C et al. (2003). Laryngpharyngeal Dysfunctin Frm the Implant Vagal Nerve Stimulatr. Laryngscpe 113(2): Illustratin Surce: Cybernics, Inc. (2008). Epilepsy Patient s Manual fr Vagus Nerve Stimulatin with the VNS Therapy System. Hustn, TX: Cybernics, Inc. Available nline at

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