Seizures
P: Sudden excessive, uncontrolled discharge of neurons in the brain
• Potential causes: idiopathic, PTSD, hypoglycemia, drug withdrawal, febrile, tumor, electrolyte
imbalances, state of alkalosis, possibly family history; triggers (bright flashing lights, loud noises,
stress)
• Several types that are classified by where they occur in the brain
A: **need to monitor “ABCs” during seizure as can lead to hypoxia; LOC; VS, labs
o Respirations are affected; airway has risk of being obstructed due to tongue, or even saliva
o Increased demand of O2 during seizure
o Acidosis possible due to increased CO2 and lactic acid in the body
T: EEG, MRI (to detect structural abnormalities)
T: maintaining seizure precautions, provide a quiet, dim room, assess vital signs and electrolytes;
during seizure- roll pt on their side, do NOT put anything in their mouth, administer ordered
medications, TIME THE SEIZURE and note how the pt is presenting/what type of seizure they are
having; if seizures are persisting, contact MD ASAP
• Benzodiazepines (module 10) can be used for seizures as well
• Anticonvulsant (aka antiepileptic) meds: Phenytoin, Phenobarbital, Levetiracetam, Pregabalin,
Valproic acid, etc.
E: Educate on seizure precautions (see picture); educate on compliance with medications; educate
on identifying possible triggers and how to avoid them; educate to keep a journal on seizure activity;
safety!
Generalized: multiple origins in deep structures
of both cerebral hemispheres and the brain
stem; causes loss of consciousness
• Partial: single origin, often in the cerebral
cortex; may or may not involve altered
consciousness
Types of Seizures
Myoclonic
Generalized
• Muscle jerking movements that last about 1-2 seconds
Tonic-Clonic
(grand-mal)
Generalized
• Tonic: strong muscle contraction and flexion, followed by limb extension and
rigidity
• Clonic: repetitive muscle jerking movements of whole body lasting about 1-2
minutes
• Prodromal, aura, post ictal phases
Atonic
Generalized
• Sudden stiffness of limbs leading patient to fall
Absence (Petit mal)
Generalized
• Brief loss of awareness; “spacing out”, “staring into space” usually do not
realize it; may have facial twitching
Simple partial
(focal)
• Repeated motor activity
o Jerking, turning head; tingling in a limb
• Remain conscious, reduced awareness
• May experience auditory/visual experiences (tinnitus)
Complex partial • Bizarre behavior that may be repetitive
o Clapping or waving hands
o Hallucinating
▪ May have “déjà vu” sensations
• Unresponsive to people/activities and usually amnesic/drowsy postictal
Epilepsy
• Chronic disorder of recurrent pattern of seizures
o Syndrome of CNS dysfunction
• Most common chronic neurologic illness
• Results from excessive electrical activity of neurons located in superficial area of brain (gray
matter)
• Therapy goals: controlling seizures, avoid side effects from medication, maintain or restore
quality of life
Antiepileptic meds (anticonvulsants)
• Ex: Phenytoin, phenobarbital, carbamazepine, primidone, valproic acid, ethosuximide,
levetiracetam, lamotrigine, topiramate, etc.
o Sub-classes
▪ Barbiturates, Hydantoins, Iminostilbenes, Valproate, Second- and third-generation
antiepileptics
• Goal is to control or prevent seizures
• Not recommended after only one seizure episode
• May also be used for migraines, psychiatric disorders, neuropathy
• Start with one medication until max dose before adding additional
• Maintain serum drug levels (not indicated for levetiracetam or lamotrigine)
• Primidone gets metabolized into phenobarbital in the liver
• Common adverse effects: suicidal thoughts
o Phenytoin- gingival hyperplasia
• Precautions for IV Phenytoin administration
o Very irritating to veins, Slow IV directly into a large vein through a large-gauge (20-gauge or
larger) venous catheter, diluted in normal saline (NS) for IV infusion, Filter must be used,
Saline flush, Numerous IV incompatibilities
• Interventions: head-to-toe, VS, weight, labs (liver function, CBC), drug allergies, do not
crush/chew/open ER meds
Phenobarbital- Barbiturate
MOA Uses Adverse effects Contraindications Notes
• Potentiates
effects of GABA*
• Seizure
prophylaxis
• Epilepsy
• Sedation, sleep
promotion
• PO and IV
• Therapeutic
effects seen at
serum drug
levels of 10-
40mcg/mL
• Long half-life
• 20-320mg/day
• Sedation
• Paradoxical
restlessness
• GI upset
• Learning
impairments
• Potential birth
defects
(regardless of if
mother was
taking med
during
pregnancy)
• Physical
dependence
• Allergy
• Porphyria
• Pregnancy
• Liver or renal
impairment
• Respiratory
infection
• Interacts with
alcohol by
enhancing CNS
suppression
• Altered CYP450
enzyme
metabolism in liver
and decrease
effects of beta
blockers, steroids,
calcium channel
blockers,
metronidazole
• Can interact with
Ca and Vitamin D
Phenytoin- Hydantoins
MOA Uses Adverse effects Contraindications Notes
• Selective
inhibition of
sodium
channels and
suppresses
impulses
• Partial seizures
• Tonic-clonic
seizures
• Potential use for
arrythmias
• IV, PO
(chewable, oral
suspension,
extended
release)
• Therapeutic
level of 10-20
mcg/mL
• 300-400mg/day
• Mild sedation
• Nystagmus
• Cardiac
arrythmias and
hypotension with
IV admin (inject
SLOW)
• Suicidal thoughts
• Thrombocytopenia
• Purple hand
syndrome (rare)
• Gingival
hyperplasia
• Stevens-
Johnson
syndrome
• Pregnancy
• Heart blocks
• Interacts with
amiodarone,
benzodiazepines,
PPIs,
sulfonamide
antibiotics
• Interacts with
alcohol
• Interacts with St
John’s wort
• Most prescribed
drug for
seizures
• May increase
glucose levels
(inhibits insulin
release)
• Monitor oral
health closely
• Regular lab
work to monitor
drug levels
• Long term use
can cause acne,
hirsutism,
osteoporosis
Valproic Acid- Valproate
MOA Uses Adverse effects Contraindications Notes
• Selective
inhibition of
sodium channels
and suppresses
impulses
• Suppresses Ca
influx through T-
type Ca channels
• Augments the
inhibitory
influence of GABA
• Epilepsy
• Generalized
seizures
• Bipolar disorder
• Migraines
• PO
• IV
• Dizziness
• Drowsiness
• GI upset
• Weight gain
• Hepatotoxicity
• Pancreatitis
• Hepatic
impairment
• Pregnancy
• Pancreatitis
• NOT to be
given with milk
or carbonated
drinks (may
cause drug to
be dissolved too
quickly)
Levetiracetam- Pyrrolidine
MOA Uses Adverse effects Contraindications Notes
• Unknown? • Partial seizures
• PO, IV
• Rapid PO onset
• Half-life 12-
59hrs
• 500 mg BID to
3000 mg/day
• Therapeutic
level 12-
46mcg/mL
• Dizziness
• Drowsiness
• Hyperactivity
• Hostility
• Suicidal ideation
• Anxiety
• Potential for
excessive CNS
depression with
use of other
sedating drugs
• Do not need
routine serum
level monitoring
Pregabalin- GABA analogue
MOA Uses Adverse effects Contraindications Notes
• Binds to
alpha2-delta
receptor sites
which affects
Ca channels in
CNS
• Partial seizures
• Neuropathic
pain
• Postherpetic
neuralgia
• Fibromyalgia
• PO
• Dizziness
• Drowsiness
• Peripheral
edema
• Blurred vision
• Drug allergy • Schedule V
controlled
substance
• Do not need
routine serum
level monitoring
Diazepam- Benzodiazepine
MOA Uses Adverse effects Contraindications Notes
• inhibits
stimulation of
the brain
• Anxiety
• Sedation
• Anticonvulsant
• Skeletal muscle
relaxation
• PO, IV, rectal
• Headache
• Drowsiness
• Paradoxical
excitement or
nervousness
• Dizziness or
vertigo
• Cognitive
impairment
• Lethargy
• Drug allergy
• Narrow-angle
glaucoma
• Pregnancy
• Do NOT take
with ETOH, CNS
depressants
• Interacts with
herbal
supplements
kava, valerian
• Interacts with
grapefruit
• High risk for
falls, confusion
• Rebound
insomnia with
withdrawal
• Reversal agent:
Flumazenil
Benzodiazepines
• Ex: Diazepam, Lorazepam, Midazolam, Clonazepam, Alprazolam, Zolpidem, etc.
• Used for sedation, anxiety, seizure, agitation, anesthesia, ETOH withdrawal
• BBW: risk for abuse, physical dependence
• MOA: inhibits stimulation of the brain
o Works in hypothalamus, the thalamic and limbic systems
• Reversal agent: Flumazenil
Parkinson’s Disease
P: Chronic, progressive, neurodegenerative disorder
• 2nd most common neuro disease after Alzheimer’s
• Caused by an imbalance of two neurotransmitters: Dopamine and Acetylcholine (ACh)
o Balance of these are necessary
• Affects dopamine-producing neurons in the brain
o Ultimately affects Extrapyramidal system (made up from substantia nigra, basal ganglia,
globus pallidus)
▪ This system involves motor function, posture, muscle tone, smooth muscle activity
L: bradykinesia, postural instability, rigidity, tremors, shuffled gait
T: symptom assessment; r/o of other conditions
T: PT/OT/ST; *physical activity*; drug therapy
Carbidopa-Levodopa- Dopaminergic
MOA Uses Adverse effects Contraindications Notes
• Carbidopa:
inhibits
decarboxylation
of levodopa in
the intestine and
tissues to make
levodopa more
available in CNS
• Stimulate
presynaptic
dopamine
receptors to
increase levels
• Parkinson’s
Disease
• PO (do NOT
crush)
• Immediate
release,
extended
capsule,
extended
suspension
• Cardiac
arrhythmias
• Hypotension
• Chorea
• Muscle cramps
• GI upset
• Angle-closure
glaucoma and
open-angle
glaucoma
• Undiagnosed
skin condition
(due to potential
activation of
malignant
melanoma)
• Interferes with
pyridoxine and
dietary protein;
tricyclic
antidepressants
• Carbidopa
cannot cross
BBB
• Levodopa is
precursor to
Dopamine
• Large levels of
Levodopa are
required to
obtain
therapeutic
effect (which
leads to more
adverse effects)
“Carbidopa is the car that drops off levodopa in the brain”
Amantadine- Dopamine Agonist (also an Antiviral)
MOA Uses Adverse effects Contraindications Notes
• Releases
dopamine and
catecholamines
from presynaptic
fiber storage in
basal ganglia
• Blocks reuptake
of dopamine into
nerve fibers
• Influenza
• Mild-moderate
Parkinson’s
• PO
• Dizziness
• Insomnia
• nausea
• Drug allergy
• Interacts with
anticholinergics
• Monitor for s/s
infection
• May need to
monitor CBC
Pramipexole- Dopamine Agonist
MOA Uses Adverse effects Contraindications Notes
• Stimulates
dopamine
receptors at
striatum of brain
• Parkinson’s
• Restless leg
syndrome
• Dizziness
• Hallucinations
• Weakness
• Hypotension
• Abnormal
dreams
• Constipation
• Extrapyramidal
syndrome
• Pregnancy
• Renal
impairment
• Breastfeeding
• Monitor for
patient safety
due to risk of
weakness,
hallucinations
• Monitor for
orthostatic
hypotension
Entacapone- Catechol Ortho-Methyltransferase Inhibitor
MOA Uses Adverse effects Contraindications Notes
• Block COMT,
the enzyme that
catalyzes the
breakdown of
the body’s
catecholamines,
presynaptically
• Parkinson’s
• Helps to
decrease
wearing off
effects from
Levodopa
• PO
• Quick onset
• GI upset
• Urine
discoloration
• Can worsen
dyskinesia
• Hallucinations
• Somnolence
• Do NOT take
with MAOIs
(increases
cardiac event
risk)
• Taken with
Levodopa
Selegiline- Monoamine Oxidase Inhibitors (MAOI)
MOA Uses Adverse effects Contraindications Notes
• Inhibits
monoamine
oxidase type B
to keep
dopamine
present in brain
• Parkinson’s
• May be used
with depression
• Insomnia
• Hypertensive
crises in higher
doses
• Increased
suicidal thoughts
• Drug allergy
• Interacts with
Meperidine,
Abatacept
• Avoid foods with
tyramine if dose
is >10mg/day
• Used as
monotherapy or
used as adjuncts
with levodopa