• sudden and involuntary contraction of muscles, often with loss of consciousness

• from known causes, eg high fevers, elec imbalances, hypoglycemia, brain tumors, etc; best to treat underlying condition

• = most common, from local brain area with specific symptoms; can cause a simple seizure (consciousness impaired/changed), motor seizure, or somatosensory seizure, etc. Depends on area of brain.  There is not a loss of consciousness.

• loss of consciousness with or without convulsions. 
• tonic-clonic or myoclonic

§         Tonic-clonic = alternating bt tonic (contraction) and clonic (relaxation) and abnormal behavior

§         Myoclonic = sudden forceful contractions

1.        ethotoin

2.        fosphenytoin

3.        phenytoin (Dilantin)

1.        valproic acid (Depakote)

1.        ethosuximide

2.        methsuximide

1.        clonazepam (Klonipin)

2.        clorazepate

3.        diazepam (Valium, Diastat)

4.        lorazepam (Ativan)

1.        acetazolamide

2.        carbamazepine (Tegretol)

3.        felbamate

4.        gabapentin (Neurontin)

5.        lamotrigine (Lamictal)

6.        levetiracetam

7.        magnesium

8.        oxcarbazepine

9.        pregabalin (Lyrica)

10.     primidone

11.     tiagabine

12.     topiramate (Topamax)

13.     zonisamide

stabilize hyperexcitability postsynaptically in motor cortex

depress motor cortex, making higher threshold for nerve reaction to convulsive stimuli

elevate seizure threshold by decreasing post synaptic excitability

a.        Prevention of seizures after trauma, neurosurgery, or brain tumors

b.       seizure disorders

c.        neuropathic pain

d.       bipolar

e.        anxiety disorder

f.         lorazepam is drug of choice for status epilepticus – though lasts only about an hour, so must give with longer lasting anticonvulsant like phenytoin

                                                               i.      drowsiness, somnolence

                                                              ii.      weakness

                                                            iii.      dizziness

                                                            iv.      headache

                                                             v.      nystagmus

                                                            vi.      ataxia

                                                          vii.      slurred speech

                                                               i.      N/V

                                                              ii.      anorexia

                                                            iii.      C/D

                                                            iv.      gingival hyperplasia (overgrowth of gums)

                                                               i.      rash, pruritus, urticaria

                                                              ii.      urinary frequency

                                                            iii.      serious skin reactions like Steven-Johnsons syndrome assoc with lamogrigine (Lamictal)

                                                            iv.      Some assoc with hematologic changes like pancytopenia, leucopenia, aplastic anemia, thrombocytopenia (carbamezepine, felbamate, trimethadione)

                                                               i.      sinus bradycardia

                                                              ii.      sinoatrial block

                                                            iii.      Adams-Stokes syndrome

                                                            iv.      2^nd and 3^rd degree AV block

                                                             v.      pregnancy and lactation (cat D)

Contraindications of ethoin (Peganone)

What type of drug is ethoin?

                                                               i.      hepatic abnormalities

A HYDANTOIN

                                                               i.      associated with serious adverse reactions and fetal malformations

                                                              ii.      Only used when less toxic drugs are not effective

                                                               i.      bone marrow depression

                                                              ii.      hepatic or renal impairment

                                                            iii.      associated with higher rate of lupus

                                                               i.      do not give within 14 days of MAOI

                                                              ii.      bone marrow depression

                                                            iii.      hepatic or renal impairment

                                                            iv.      pregnancy (cat D)

                                                               i.      renal impairment

                                                              ii.      pregnancy (cat D) – increased risk for birth defects

                                                               i.      kidney disease

                                                              ii.      neuro disorders

                                                            iii.      pulmonary disease

                                                            iv.      hyperactive children

                                                               i.      kidney disease

                                                              ii.      neuro disorders

                                                            iii.      pregnancy (cat D)

                                                            iv.      psychoses

                                                             v.      acute narrow glaucoma

                                                            vi.      elderly

                                                          vii.      debilitated

                                                               i.      kidney disease

                                                              ii.      neuro disorders

                                                            iii.      hypotension

                                                            iv.      severe myocardial insufficiency

                                                             v.      hepatic impaiment

phenytoin can also cuase hemo changes, leading to increased risk of infetions, increased bleeding, etc; signs of infection and bleeding, etc must be reported immediately

                                                               i.      kidney disease

                                                              ii.      neuro disorders

                                                            iii.      eye disorders like retinal or optic nerve disease (can cause vidual disturbances)

                                                               i.      kidney disease

                                                              ii.      neuro disorders

                                                            iii.      glaucoma or increased IOP

                                                            iv.      Hx of cardiac, renal, or liver dysfunction

                                                             v.      psychiatric disorders

                                                               i.      kidney disease - increased risk for failure

                                                              ii.      neuro disorders

                                                            iv.      increased risk for pancreatitis

à may increase seizures

a.        increases depressant effect

 increased blood glucose levels

a.        Thorough history, including hx of head trauma

b.       Observations of friends/family – description, frequency, length, LOC, triggers and presence of aura (feeling that precedes a seizure)

c.        Family history of seizures

d.       recent drug tx

e.        Vitals for baseline

f.         Review lab orders e.g. EECG, MRI, CBC, hep/renal fnx etc

a.        Dosage/drug type may frequently changes initially based on therapeutic response and adverse reactions

b.       Blood tested for toxicity

c.        If hospitalized, watch seizures closely and document descriptions as much as possible to help PCP dx type of seizures and tx effect

• constant seizure activity lasting longer than 5 minutes
• can be caused by missing a dose, even pt on a small dose

Implementation

Admin of hydantoins

                                                               i.      Phenytoin is most common (Dilantin) bc relatively less toxic

                                                              ii.      However, some can’t metab phenytoin, so pts must be monitored for toxicity

                                                            iii.      Signs of phenytoin toxicity are slurred speech, ataxia (uncoordinated muscle movements), lethargy, dizziness, N/V

                                                            iv.      When oral, give with food to avoid GI upset

                                                             v.      When parenteral, IV preferred over IM bc can harm/hurt muscle

                                                            vi.      NURSING ALERT – when admin phenytoin, closely monitor for signs of toxicity (slurred speech, ataxia, lethargy, dizziness, N/V, nystagmus, mental changes).  Phenytoin bt 10-20 mcg/mL is optimal, greater than 20 associated with toxicity.

                                                               i.      causes CNS depression

                                                              ii.      in ELDERLY, can cause marked excitement, depression and confusion.  Monitor elderly closely for unusual reactions

                                                               i.      dose individualized

                                                              ii.      IV lorazepam can quickly control seizures, but effect is short

                                                            iii.      diazepam can precipitate when mixed with other drugs, don’t do this

                                                            iv.      LIFESPAN ALERT – apnea and cardiac arrest can occur when diazepam given to older adults, very ill and those with limited pulm capacity.  Watch these pts closely for oversedation.  May need lower dose.

“Risk for Injury rt seizure disorder, drowsiness and ataxia”

a.        drowsiness common adverse reactions, esp. early in tx

b.       Assis pt until stable

c.        Careful with oral admin, bc drowsi pt could choke; assess swallowing first with water; if unable to swallow, notify PCP ASAP for different route    

“Risk for Impaired Skin Integrity rt adverse reaction to drug”

a.        phenytoin, lamotrigine and the barbiturates can produce a severe and potentially fatal hypersensitivity rash

b.       notify PCP immediately

c.        Closely examine areas and describe

d.       If itchy, keep nails short and give antiseptic cream (may open skin); avoid use of soap (drying)

e.        NURSING ALERT – tell PCP immediately; Certain types of rashes necessitate permanent DC. 

“Risk for Infection rt immunosupression secondary to drug therapy”

a.        Be alert for pancytopenia signs: sore throat, fever, malaise, bleeding from mucos membranes, epistaxis (nose bleeding) and easy bruising

b.       carbamazepine can cause aplastic anemia and agranulocytosis

c.        succinimides also toxic

d.       Should be routine labs taken like CBC and differentials

e.        Looking for bone marrow suppression (resulting in pancytopenia); if apparent, probably DCed

f.         Protect pt from injury and trauma (bleeding) bc of low platelets.

g.       Also protect from infection

h.       NURSING ALERT – phyenytoin can cause hemo changes like aplastic anemia, leucopenia, thrombocytopenia; immediately report to PCP signs of thrombocytopenia (low platelets) which means more bleeding or leucopenia (signs of infection)

“Impaired Oral Mucous Membranes rt gum overgrowth secondary to hydantoins”

a.        long-term hydantoins can cause gingivitis and gingival hyperplasia

b.       periodically inspect mouth, teeth, gums and report changes to PCP

c.        Oral care very important

“Disturbed Sensory Perception: Visual rt adverse drug reactions”

a.        Assist pt with ambulation

b.       ensure safe environment

c.        May want dimmer light if sensitive to light

d.       May be photosensitive, so wear protection until know

a.        Some pts, when under contoll, may start missing doses; explain that pt must never miss dose

b.       Blood levels of anticonvulsant will be monitored

c.        Don’t put anything into mouth of person having a seizure

d.       Do not do anything hazardous while drowsy

e.        Driving privileges can be reinstated once controlled

f.         Avoid alcohol unless approved

g.       Med ID

h.       Do not use OTC without approval

i.         Keep record of seizures and take with to appointments

                                                               i.      inform dentist and other PCPs

                                                              ii.      good oral care necessary

                                                            iii.      Take with food to lessen GI upset

                                                            iv.      Thoroughly shake suspension form just before use

                                                             v.      Do not take discolored capsules

                                                            vi.      Notify if:

1.        rash

2.        bleeding

3.        swollen or tender gums

4.        yellow skin or eyes

5.        fever

6.        sore throat

7.        unusual bleeding/bruising

8.        persistant headache

9.        malaise

10.     pregnancy

                                                               i.      Take with food or milk if GI upset

                                                              ii.      Notify PCP if:

1.        rash

2.        joint pain

3.        fever

4.        sore throat

5.        unusual bleeding/bruising

6.        drowsiness

7.        dizziness

8.        blurred vision

9.        pregnancy

• "You can take with food/milk, but you might die with a full stomach"

• can cause photosensitivity.  Protective measures needed until tolerance determined
• Do not become pregnant with trimethadione bc or risk of serious birth defects
• Notify PCP if:

1.        visual disturbances

2.        excesss drowsiness or dizziness

3.        sore throat

4.        fever

5.        rash

6.        malaise

7.        easy bruising

8.        epitaxis or bleeding tendencies

9.        pregnancy

10.     trimethadione can cause serious birth defects

slurred speech, ataxia, lethargy, dizziness, N/V

20 mcg/mL

Tx levels are 10-20 although below 10 can be effective

hydantoins

carboxylic acid derivative

oxazolidinediones

succinimides

bezodiazepines

miscellaneous

barbituate

Having convulsions or seizures breaks my brain

                                                               i.      Phenytoin is most common (Dilantin) bc relatively less toxic

                                                              ii.      However, some can’t metab phenytoin, so pts must be monitored for toxicity

                                                            iii.      Signs of phenytoin toxicity are slurred speech, ataxia (uncoordinated muscle movements), lethargy, dizziness, N/V

Describe

Frequency

Length

Aura?

LOC

Triggers

lorazepam

short term control, so must be given with another longer lasting anti-convulsant

• They are particularly toxic 
• Are contraindicated in those with bone marrow depression (and hepatic/renal impoairment)
• Associated with greater risk of lupus erythematosis

phyenytoin can hemo changes like aplastic anemia, leucopenia, thrombocytopenia

Must be reported immediatey: signs of infection (leucopenia) and excess bleeding (thrombocytopenia)

An oxazolidinedione

Can cuase serious birth defects

visual disturbances

excess drowsiness/dizziness/malaise

Signs indicating hemotologic changes

Signs of infection

sore throat

fever

skin rash

Signs of bleeding

easy bruising

epistaxis

bleeding tendencies

phenytoin (Dilantin)

lamotrigine (Lamictal)

barbituate (Phenobarbitol)

valproic acid - diplopia

oxcarbazepine (Trileptal) - diplopia

benzodiazepines

Diamox (a misc = acetazolamide)

trimethodione

Kidney disease

Neurological disorders

IV

IM hurts muscle

phenytoin

lamotringine (Lamictal) also used for bipolar?

phenobarbitol

can cause apnea and cardiac arrest

monitor for over sedation and report