Seizure Management After Stroke and SAH Danielle Bajus, MSN, ACNP-BC, CCRN UPMC Presbyterian, Critical Care Medicine Neurovascular ICU
Case Study- Mr. A 72 yo male with PMH: Hypertension COPD Prostate Cancer Right PCA stroke 10/2015 (minimal residual weakness- fully functional)
Mr. A Current Medications: Aspirin Clopidogrel Atorvastatin Amlodipine Lisinopril
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
Mr. A Imaging: HCT negative for bleed Old Right PCA stroke No large vessel occlusion
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
Common Causes of Seizures Neurologic: Ischemic or hemorrhagic stroke Tumors Infection (meningitis, encephalitis) Vasculitis Trauma Primary Epilepsy Craniotomy
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
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
SYMPTOMS??
Diagnosis History Physical exam Neurological exam Diagnostic testing (CT/MRI/LP) EEG
Electroencephalogram 14-21 leads placed on the scalp Amplified electrical activity of the brain is recorded
NORMAL EEG
SEIZURE
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
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
Acute Management Seizures are a medical emergency Goal: stop clinical and electrographic seizures Priorities for 15-60 minutes: 3 rd line AED (refractory status) EEG LP Any additional lab testing
Anti-Epileptic Drugs First Line Treatment Lorazepam Midazolam Diazepam
Anti-Epileptic Drugs Second Line Treatment/Maintenance Phenytoin/fosphenytoin Levetiracetam Phenobarbital Valproate sodium Lacosamide Topiramate
Anti-Epileptic Drugs Refractory seizures- continuous infusions Midazolam Pentobarbital Propofol
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
Nursing Considerations Patient safety ABC s Side effects of treatment Hypotension Drug/drug interactions Skin breakdown from leads
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
Mr. A
Discharged to rehab Lacosamide BID Topiramate BID Valproate Sodium BID ASA Clopidogrel Amlodipine Atorvastatin Mr. A
Seizure After Stroke/SAH Abstract #109 ISC 2016- 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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