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Around fifty million people worldwide suffer from epilepsy, making seizures a common cause for patients to present to emergency departments for treatment (WHO, 2009). They pose for complicated management as the occurrence of further seizures in the ED can result in life threatening complications. A seizure can be defined as “â€¦ a hyperexcitation of neurons in the brain leading to a sudden, violent involuntary series of contractions of a group of musclesâ€¦A seizure may be clonic or tonic: focal, unilateral, or bilateral: generalised or partial” (Anderson (Ed.), 2002, p. 1554). This case study aims to discuss a patient presenting post seizure activity outlining the presenting and foreseen patient problems including a dependant nursing intervention and its role in seizure management. This paper will discuss the presentation of a sixty-one year old Caucasian male, with a complex medical history. His presentation post a witnessed generalised tonic clonic seizure will be explored including the interventions performed by nursing staff. In this case the prescription of Phenytoin was explored as a dependent nursing intervention that aims to provide symptom relief and cessation of seizure activity by binding to inactive sodium channels to prevent neurons firing and therefore prevent muscle contraction (Aschenbrenner & Venable, 2009). Thereafter the paper aims to critically appraise the evidence based literature surrounding its use, discussing its effectiveness in the management of the patient discussed and the evaluation of its use. Any gaps in literature will then be identified outlining suggestions for recommendations to improve current practice.
On arrival to the Emergency Department (ED) via ambulance the patient was triaged as a category one and transferred to the resuscitation cubicle for immediate assessment and intervention. He was witnessed by a friend to have full body shaking with eyes closed and was unresponsive for approximately two minutes. The patient’s history includes alcohol abuse, asthma, epilepsy, heavy smoker and chronic back pain. The patient is generally non-compliant with medications and usually drinks a four litre cask of wine per day of which he has not had for the past three days. The patient was found to be post-ictal following the seizure and remained agitated for some hours after. The patient had multiple problems which include a Glasgow Coma Scale (GCS) of 8-9, agitation, hypertension, and a threatened airway and therefore required a Nasopharygeal airway. He was noted to continue to desaturate on room air.
It can be seen that ensuring the patency of the patients airway is essential in first line management to decrease complications such as tissue hypoxia, hypertension and decreased cerebral blood flow. Thereafter an A,B,C,D assessment approach should be undertaken with interventions aiming to cease seizure activity being a priority (Tesoro & Brophy, 2010). A seizure that lasts longer than thirty minutes can have devastating effects on the patient; initially causing an increase in autonomic activity which can lead to hypertension, tachycardia, hyperglycemia, and sweating. However if the seizure continues on greater than thirty minutes, then further deterioration can occur. As metabolic demand during a seizure is high, the body is no longer able to compensate for this. As a result cerebral autoregulation is lost, cerebral blood flow decreases, intracranial pressure rises and hypotension occurs (Tesoro & Brophy, 2010). Furthermore if the seizure continues on past this time, death and permanent brain damage can transpire (Rabinstein, 2010).
While the management of a patient having a seizure involves multiple interventions, this case study will discuss one dependant intervention being the administration of IV Phenytoin 1gram in 100mls Normal Saline given over thirty minutes. This decision was made by the treating medical officer as the patient was already taking oral Phenytoin, however was likely that a therapeutic dose range was not achieved due to patient non-compliance. The IV route was chosen as the patient could not swallow tablets and therapeutic levels were required immediately for the safety of the patient (Gallop, 2010). While the patient is already on Phenytoin he is therefore assumed not to be allergic to it, however there can be other side effects to this drug when it is given via the IV route. These include local reactions to the IV site, arrhythmias, dizziness and hyponatremia (Gilad, Izkovitz, Dabby, Rapport, Sadeh, Weller & Lampl, 2008). While another study also reports adverse effects of hypotension (Aaronson, Belgado, Spillane & Kunisaki, 2010). For the patient involved these side effects were considered minimal compared to the benefit of stopping the seizure. The nursing implications for this medication include regular cardiac and blood pressure monitoring, both during and after the infusion is completed (Gallop, 2010).
Numerous studies have been conducted on the use of Phenytoin considering adverse effects, efficacy and in comparison to other antiepileptic drugs. While Phenytoin was used in this case study as the patient was already taking it orally, it was shown to work as the seizure activity ceased. However the study by Zeng, Wang, Xi & Yan (2010), illustrate that 39% of patients in their study pulled out due to poor control of seizures. Similar findings were also discovered by Hiba et. al., (2010), who reported less than 40% of patients were seizure free over a twelve month period. Misra, Kalita & Patel (2006) also report findings of reduced efficacy of Phenytoin when compared to Sodium Valporate. Ramsay et al., (2010), further substantiates this with more patients leaving the study due to various reasons when compared to that of Topiramate. However, this study then reports that superiority of Topiramate could not be established, with a p value of 0.366. In comparison Gallop (2010), conducted a review and found it to be moderately effective for Status Epilepticus (SE) patients and could also be used to prevent early post-traumatic seizures. Turnbull, Howel, Rawlins & Chadwick (1985), also report similar findings with efficacy and determined that no statistical difference was found between Phenytoin and Valporate for seizure control, with a p=0.4, both showing similarly good control of seizure activity over a two year period.
Several studies have shown a number of adverse effects post the IV administration of Phenytoin in the patient having a seizure. Gallop (2010) and Earnest, Marx & Drury (1983), report studies showing burning and pain to the IV site during administration. Tesoro & Brophy (2010) also report an adverse effect of pain and oedema to the IV site, however all studies reported pain ceased when the infusion was slowed or diluted further. Other adverse effects were noted by Gilad, et. al., (2008), reporting 12% of patients in the study showed cardiac arrhythmia, vertigo and hyponatremia, however noting a p value 0.035. Further studies show similar findings; Gallop (2010) reports hypotension, bradyarrhythmias and arrest; Aaronson et. al., (2010) shows only hypotension with no statistical difference noted between Phenytoin and Fosphenytoin in terms of adverse reactions. Turnbull et.al., (1985), report on the oral form of Phenytoin and note reactions of rashes, nystagmus, tremor and ataxia. Zeng et. al., (2010), report similar findings with most common reactions being loss of appetite, nystagmus, nausea, fatigue and tremor.
Phenytoin was used for the patient to control his seizures as he was already taking its oral form and it was assumed that Phenytoin provided him with good efficacy. However based on the research conducted for this case study, there is no definitive antiepileptic drug that provides excellent efficacy for every patient. A number of studies show several adverse effects relating to Phenytoin and some studies suggest Sodium Valporate as a substitute, which has a limited number of documented adverse reactions. Gilad et. al., (2008) make this suggestion, with 87.8% of patients receiving good seizure control with Sodium Valporate with no recorded side effects, however 88% of patients on Phenytoin also report good efficacy. However other studies, for example Gallop (2010), show good seizure control when administered to patients suffering SE and in post-traumatic seizures. While another study suggests that no superiority was found between Phenytoin and Topiramate in terms of efficacy, however would recommend Topiramate for its reduced number of adverse effects (Ramsay et. al., 2010).
While no medication is ever risk free, all adverse effects should be considered and consultation made of whether the risks outweigh the benefits. In this case study the intervention of Phenytoin was decided to be of benefit to the patient, to stop him from having life threatening seizures. While the evidence shows Phenytoin to be of risk to the patient in terms of adverse effects it did stop this patient from seizing while recording no adverse reactions, which suggests good efficacy.
The use of Phenytoin, as previously stated, does have its risks, however these can be minimised with recommendations for best practice. Gallop (2010), and Tesoro & Brophy (2010), suggest an infusion rate for IV Phenytoin no greater than 50mg/min and monitoring of blood pressure and ECG during and post infusion. Earnest et. al., (1983), make similar recommendations with suggestions of a dilution down to 6.7mg/mL with an infusion rate 40mg/min, with a total dose of 10-15mg/kg, also suggesting regular observations both during and after the infusion is completed. Other studies then suggest a combination of medications. Rabinstein (2010), suggests administration of an antiepileptic drug and also the use of Benzodiazepine. Tesoro & Brophy make this same suggestion; stating that Benzodiazepines should be first line and then treat with anticonvulsants. While most studies are able to provide evidence from research carried out, all make the suggestion for further, larger studies, to provide further substantiation prior to change of clinical practice.
The patient was loaded with IV Phenytoin 1 gram, diluted in 100mls Normal Saline and given over thirty minutes, giving a dilution of 10mg/mL; a slightly higher rate than that suggested by Earnest et. al., (1983), however a slower infusion of 33mg/min, than the suggested 50mg/mL by Gallop (2010), and Tesoro & Brophy (2010). The patient was also given Midazolam 3mg in increments for agitation post the seizure, with good effect. The patient at no time became hypotensive or bradycardiac with nil rash, nausea or nystagmus. The patient eventually returned to a GCS 15 and was admitted to the ward for observation.
In summary this case study discusses the dependant intervention of Phenytoin administration to a patient that presents to the ED while having a seizure. Various studies report hypotension and bradycardia as life threatening adverse reactions to Phenytoin, however these can be minimised with slow IV infusion. Best practice suggests an infusion rate of 50mg/min with a dilution of 6.7mg/ml. While Phenytoin had good efficacy for this patient, some studies report Sodium Valporate as most efficient, however no antiepileptic drug is found to be superior over all. More research and larger scale studies are recommended prior to application of intervention to clinical practice from the research discussed.
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