Prioritizing Care in the ED: Seizure Management and Support

QUESTION

John is a 12 year old with known generalized tonic-clonic seizures. They were admitted to the ED after experiencing four seizures at home during the last 12 hours. Jackson was diagnosed with generalized tonic-clonic seizures 2 years ago. Upon diagnosis, Jackson’s neurologist started them on oral phenobarbital. Jackson has been seizure-free until this evening. The seizures are of unknown origin.

Jackson’s mother reports that the first three seizures lasted between 3 to 4 minutes, each resolving without intervention. Jackson’s fourth seizure lasted approximately 7 minutes and resolved after the administration of intranasal midazolam. Jackson’s mother called 911 and they were brought the the ED.

Jackson is resting comfortably; they are sleepy but arousable. Jackson is on a cardiorespiratory monitor, and vital signs are stable. They currently have an IV in the left arm with D5 NS infusing at 58 mL/hr. When Jackson arrived in the ED, a CBC with diff, BMP, and a phenobarbital level were drawn and sent to lab stat. Jackson’s mother, Clare, is at the bedside. Clare is very tearful and explains to you that she recently lost her job and has not been able to afford Jackson’s medication. She states that she has been “rationing” out Jackson’s seizure medication and giving it every other day. She asks you if they are going to “take Jackson away from her”.

List in order of priority your initial nursing actions identified for Jackson based on physical findings and family interaction.
What communication techniques should be initiated to decrease anxiety in Jackson’s mother r while simultaneously caring for Jackson?
What are some of the common causes of seizures?
What are two different types of seizures?
Name 3 anti-epileptic drugs? How would you administer each of them? Describe common side effects for the 3 medications.

ANSWER

Prioritizing Care in the ED: Seizure Management and Support

Introduction

When a pediatric patient like Jackson presents in the Emergency Department (ED) with a history of generalized tonic-clonic seizures, it requires careful assessment, prioritization, and effective communication, especially in cases of medication non-compliance. This essay will discuss the initial nursing actions, communication techniques to decrease anxiety in Jackson’s mother, common causes of seizures, different types of seizures, and three anti-epileptic drugs, including their administration and common side effects.

Initial Nursing Actions for Jackson

Ensure Patient Safety: The first priority is to assess and ensure Jackson’s safety. He should be positioned to prevent injury during any potential seizure activity, and an emergency seizure kit should be readily available.

Assess Airway and Breathing: Given the duration of the last seizure, monitoring for potential respiratory distress and airway compromise is essential. The use of intranasal midazolam may affect Jackson’s respiratory status.

Assess Medication Adherence: In collaboration with the healthcare team, determine the extent of medication non-compliance. Understanding the reasons for non-compliance can help tailor interventions.

Stabilize Vital Signs: Ensure that vital signs remain stable and that the IV infusion of D5 NS is maintained to prevent hypoglycemia, which can trigger seizures.

Evaluate Lab Results: Once the lab results are available, assess Jackson’s CBC, BMP, and phenobarbital level to gauge his current health status and medication levels.

Communication Techniques for Jackson’s Mother

Active Listening: Listen to Clare’s concerns without interruption to show empathy and validate her emotions. This can reduce anxiety by providing an outlet for her distress.

Provide Information: Explain the importance of consistent medication compliance and the potential consequences of medication lapses. Educate Clare about available resources for obtaining medication assistance, such as patient assistance programs.

Involve in Care: Encourage Clare to participate in Jackson’s care. This can empower her, reduce her fears about losing custody, and strengthen the bond between her and her son.

Common Causes of Seizures

Seizures can be caused by various factors, including epilepsy, brain injury, stroke, infections like meningitis, high fever (febrile seizures in children), drug or alcohol withdrawal, metabolic disorders, and brain tumors.

Different Types of Seizures

Generalized Tonic-Clonic Seizures: These involve loss of consciousness, stiffening (tonic phase), followed by rhythmic jerking (clonic phase) of the limbs. This is the type Jackson experiences.

Partial Seizures: These seizures affect only a specific region of the brain and may not involve loss of consciousness. They can be simple (without altered awareness) or complex (with altered awareness).

Three Anti-Epileptic Drugs and Their Administration

Phenobarbital: Typically administered orally or intravenously. Common side effects include drowsiness, dizziness, and cognitive impairment.

Midazolam: Administered intranasally, intravenously, or intramuscularly. Side effects may include drowsiness, confusion, and respiratory depression.

Levetiracetam: Given orally or intravenously. Side effects may include dizziness, mood changes, and fatigue.

Conclusion

Managing seizures in the ED involves a systematic approach that prioritizes patient safety, addresses medication compliance, and provides support to the patient and their family. Effective communication with the caregiver, along with education and reassurance, can help reduce anxiety and enhance cooperation. Understanding the causes and types of seizures, as well as anti-epileptic drugs and their side effects, is crucial for comprehensive care and intervention.