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Overcoming the fear of tonic-clonic seizures

Do you remember the first time you saw a patient having a seizure? If your experience was anything like mine, you won’t soon forget. For nurses, physicians, and even neurologists working in acute care, a seizure can be a frightening experience. Of all seizure types, the tonic-clonic (formerly known as grand mal) is the most common and most unsettling.

What is a tonic-clonic seizure?            
A tonic-clonic seizure is a type of generalized seizure that involves abnormal electrical firing of the entire outer covering of the brain, known as the cerebral cortex. Although a tonic-clonic seizure seems as though it goes on forever, typically it lasts 3 to 5 minutes.

During the seizure, a patient usually emits a forced expiration that may sound like a cry. In the tonic phase, the patient loses consciousness, and his voluntary muscles contract, causing his arms and legs to extend for 30 to 60 seconds. He may be apneic, and his skin may appear dusky or cyanotic.

Next, he enters the clonic phase, during which he experiences aggressive, rhythmic muscular contractions. The patient’s pupils dilate. He may be incontinent and bite his tongue or cheek.

During the postictal (postseizure) phase, the patient may have numbness or weakness and may experience confusion, fatigue, amnesia, or coma.

What triggers a tonic-clonic seizure?
The seizure occurs when conditions in the central nervous system reach a particular level of imbalance, but the specific cause of about 70% of tonic-clonic seizures isn’t known. When assessing your patient’s risk of seizures, focus on his neurologic history, including any family history of seizures, alcohol use, illicit drug use, recent medication history including recently discontinued drugs, and current electrolyte levels.

If your patient was admitted for evaluation of seizures or is at high risk for seizures, implement seizure precautions. In most institutions, seizure precautions include keeping the bed in the low position at all times, padding the side rails, keeping the head-of-bed side rails up, and having suction set up and ready for use at the bedside.

What should I do during a seizure?
First of all, stay with your patient! Although the urge to run for help may be strong, you need to stay with the patient. Call for help from your patient’s room. Your primary job is to protect the patient from injury. If he is sitting or standing, ease him to the floor. Remove his eyeglasses and loosen any restrictive clothing.

You can guide the patient’s movements to prevent injury but don’t try to restrict his movements. Also, don’t attempt to force anything into the patient’s mouth. Do try to protect his head and I.V. site.

After the seizure, place your patient on his side to promote the drainage of any secretions, and suction him, if necessary. Assess the patient’s blood glucose level, vital signs, and oxygen saturation. Give supplemental oxygen, if needed. If your patient is awake, assess his motor strength, orientation, memory, and speech. After your assessment, allow your patient to sleep.

What should I observe during a patient’s seizure?
Time the seizure, using your watch or a clock, and observe the patient’s activity. Your assessment should answer these questions:

  • In which part of the body did seizure activity begin and how did it progress?
  • What types of movements did the seizure cause?
  • Which parts of the body were affected?
  • Did the size of the patient’s pupils change?
  • Did the patient gaze to one side?
  • How long did the seizure last?
  • Was the patient unconscious during the seizure?
  • Was the patient incontinent?
  • Did the patient suffer trauma—for example, did he bite his tongue?
  • Was the patient weak after the seizure? Did he fall asleep?

If you didn’t answer all these questions during the seizure, ask a colleague or other witness what they noted. After the seizure, obtain information about the events just before the seizure. Ask the patient these questions:

  • Did you have a warning sign or aura?
  • What were you doing just before the seizure?

How do I recognize status epilepticus?
If the seizure lasts longer than 5 minutes, if your patient has another seizure before fully regaining consciousness, or if your patient doesn’t begin breathing after the seizure, activate the Code Blue team immediately.

Status epilepticus (SE) is defined as recurrent seizures without complete recovery of consciousness or continuous seizure activity lasting at least 30 minutes. SE is associated with several types of seizures. Tonic-clonic status epilepticus is the most common.

SE is a medical emergency. Mortality may be as high as 30%. One of the most common causes of SE is the abrupt discontinuation of anticonvulsant drugs.

The Code Blue team should perform these interventions:

  • Establish an airway and provide oxygen.
  • Monitor vital signs.
  • Establish I.V. access, preferably in the forearm.
  • Draw blood for lab work, including chemistry, hematology, and glucose, blood urea nitrogen, and anticonvulsant drug levels.
  • Correct hypoglycemia with glucose and give thiamine.
  • Administer an I.V. benzodiazepine, such as lorazepam (Ativan) or diazepam (Valium).
  • If the seizure activity continues, administer I.V. phenytoin (Dilantin) or fosphenytoin (Cerebyx), while monitoring the patient’s blood pressure for hypotension and ECG for arrhythmias. Refer to your hospital’s policy on phenytoin use to avoid infusion-related complications.
  • If the seizure activity continues, intubate the patient and place him in a barbiturate coma.

What is the most effective way to inform the physician of a seizure? 
The most effective way is to use the Situation, Background, Assessment, Recommendation format, known as SBAR.

Situation: Identify the patient and state that the patient had a seizure.
Background: Summarize why the patient is in the hospital. Then, describe the seizure in detail and the patient’s postictal condition, including vital signs.
Assessment: State the type of seizure you think the patient had. Note whether the patient has a history of seizures.
Recommendations: Report that you have implemented seizure precautions and recommend appropriate tests and medications.

What can I do to reduce my fear factor?
Unless you routinely care for patients who have seizures, witnessing a seizure may always be a bit frightening. But you can take certain steps to reduce your anxiety and boost your confidence.

First, identify which of your patients are at high risk for seizures, and implement seizure precautions for them. Then, plan what you will do if your patient has a seizure. Make sure you know how to report a seizure. And finally, familiarize yourself with the policy for administering commonly used anticonvulsants.

Selected references
Bader MK, Littlejohns LR, eds. AANN Core Curriculum for Neuroscience Nursing. 4th ed. St. Louis, Mo: Saunders; 2004.

Fisher R, Long L, White I. Guide to the Care of the Patient with Seizures: AANN Reference Series for Clinical Practice. Glenview, Ill: AANN; 2004.

Hickey JV. The Clinical Practice of Neurological and Neurosurgical Nursing. 5th ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2003.

Markand ON. Epilepsy in adults. In: Biller J, ed. Practical Neurology. 2nd ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2002.

Susan Blackmer Tocco, MSN, RN, CNRN, is a Neuroscience Clinical Nurse Specialist at Orlando Regional Medical Center in Orlando, Florida.

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