Seizure Management After Stroke and SAH

Transcription

1 Seizure Management After Stroke and SAH Danielle Bajus, MSN, ACNP-BC, CCRN UPMC Presbyterian, Critical Care Medicine Neurovascular ICU

2 Case Study- Mr. A 72 yo male with PMH: Hypertension COPD Prostate Cancer Right PCA stroke 10/2015 (minimal residual weakness- fully functional)

3 Mr. A Current Medications: Aspirin Clopidogrel Atorvastatin Amlodipine Lisinopril

4 Mr. A March 2016 Riding in the car with his son Sudden onset confusion, talking gibberish Could not repeat words or follow commands Question of left sided weakness ED

5 Mr. A Imaging: HCT negative for bleed Old Right PCA stroke No large vessel occlusion

6 What is a seizure? Transient episode of abrupt and temporary alteration of cerebral function Imbalance between excitation and inhibition within the CNS Often accompanied by altered consciousness or other neurological manifestations

7 Common Causes of Seizures Neurologic: Ischemic or hemorrhagic stroke Tumors Infection (meningitis, encephalitis) Vasculitis Trauma Primary Epilepsy Craniotomy

8 Common Causes of Seizures Complications of critical illness: Hypoxia Drug/substance toxicity Drug/substance withdrawal Fever (Febrile seizures) Renal/hepatic dysfunction Metabolic abnormalities Hyponatremia, hypoglycemia

9 Types Partial seizures Simple partial- no change in consciousness Complex partial- impaired consciousness Generalized seizures Tonic-Clonic Acute LOC, muscular contractions, post-ictal Status epilepticus Continuous seizure lasting >5 minutes

10 SYMPTOMS??

11 Diagnosis History Physical exam Neurological exam Diagnostic testing (CT/MRI/LP) EEG

12 Electroencephalogram leads placed on the scalp Amplified electrical activity of the brain is recorded

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14 NORMAL EEG

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16 SEIZURE

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18 Acute Management Seizures are a medical emergency Goal: Stop clinical and electrographic seizures Within the first 5 minutes: Evaluate airway Check vital signs Neurologic exam Administer benzodiazepine (1 st line AED) Fluid resuscitation

19 Acute Management Seizures are a medical emergency Goal: Stop clinical and electrographic seizures Within the first 15 minutes: Intubation/oxygenation support Administer 2 nd line AED IV Vasopressor support if hypotensive Laboratory tests EKG

20 Acute Management Seizures are a medical emergency Goal: stop clinical and electrographic seizures Priorities for minutes: 3 rd line AED (refractory status) EEG LP Any additional lab testing

21 Anti-Epileptic Drugs First Line Treatment Lorazepam Midazolam Diazepam

22 Anti-Epileptic Drugs Second Line Treatment/Maintenance Phenytoin/fosphenytoin Levetiracetam Phenobarbital Valproate sodium Lacosamide Topiramate

23 Anti-Epileptic Drugs Refractory seizures- continuous infusions Midazolam Pentobarbital Propofol

24 Status Epilepticus Convulsive or non-convulsive Continuous EEG monitoring Continuous infusion 3 rd line agent Burst suppression 24-48h Intensive nursing care Stop clinical and electrographic seizures

25 Nursing Considerations Patient safety ABC s Side effects of treatment Hypotension Drug/drug interactions Skin breakdown from leads

26 Mr. A While in ED Discussion regarding tpa administration Extension and rhythmic activity of LUE Progression to generalized seizure Lorazepam/phenytoin given IV Admit to the ICU

27 Mr. A

28 Discharged to rehab Lacosamide BID Topiramate BID Valproate Sodium BID ASA Clopidogrel Amlodipine Atorvastatin Mr. A

29 Seizure After Stroke/SAH Abstract #109 ISC Cornell Long term seizure risk in patients with ischemic stroke or SAH vs. TBI patients (3.5 year F/U) 15.3% stroke/sah patients with seizures 5.7% TBI patients

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31 References Lawson T, Yeager S. Status Epilepticus in adults: A review of diagnosis and treatment. Critical Care Nurse. 2016;36(2): Zipfel G, Diringer MN, Bleck TP, et al. Reference tools. Neurocritical Care. 2011;15(2): Connolly ES, Rabinstein AA, Carhuapoma JR, et al. Guidelines for the management of Aneurysmal Subarachnoid hemorrhage: A guideline for healthcare professionals from the American heart association/american stroke association. Stroke. 2012;43(6): Neshige S, Ota BAC, Hospital M, et al. Seizures after intracerebral hemorrhage; risk factor, recurrence, efficacy of antiepileptic drug - journal of the neurological sciences. Journal of the Neurological Sciences. 2015;359(1): Bryndziar T, Sedova P, Kramer NM, et al. Seizures following Ischemic stroke: Frequency of occurrence and impact on outcome in a long-term population-based study. Journal of Stroke and Cerebrovascular Diseases. 2016;25(1): Hickey J. The Clinical Practice of Neurological and Neurosurgical Nursing. 5th ed. Philadelphia: Lippincott Williams & Wilkins; 2003.