When a patient arrives in the emergency room after having a generalized or grand mal seizure, the healthcare provider must obtain as much history as possible. This information includes previous history of seizures, medications, frequency of seizures, and an accurate description of this event including precipitating factors, progression of the seizure, and length of the seizure. A complete assessment of the patient should be done to include airway patency, level of consciousness, pupil reaction, and extremity strength. Cardiac monitoring, vital signs, pulse oximetry, and fingerstick blood glucose should also be done. An intravenous line should be started for medication access. Ativan or Valium should be readily available for recurrent seizure activity. Laboratory tests should be done to include blood level of the anti-convulsant they are currently taking, if applicable. A CT scan of the head may also be done.
A primary focus of nursing care is to provide for the safety of the patient. An open airway is the first priority. When a patient has an altered level of consciousness, the airway may be obstructed by the tongue or he may aspirate gastric contents. The head of the bed should be raised slightly and the patient should be turned on his side. A nasal airway may to be inserted to maintain an adequate airway. Suction should be readily available and oxygen should be given to decrease intracranial pressure. The side rails should be raised and may be padded to prevent injury during a seizure. A nurse should stay at the bedside during a seizure to monitor airway and movements, and prevent the patient from injury. The patient should be reassessed regularly throughout the stay. If the patient remains unresponsive and has repetitive movements, seizures should be suspected - even if the movements are not "classical." If the lab tests indicate that the patient has a less than therapeutic level of anti-convulsant, additional dosages should be given in the emergency room. One of the most common drug used is Dilantin.
Dilantin is a primary drug used for control of grand mal seizures. A "loading dose" is frequently given by intravenous infusion in the emergency room to patients with both new onset seizures and those whose Dilantin level is below therapeutic level. It must be given with caution due to the cardiopulmonary and central nervous system depression it can cause. The recommended rate of administration is no greater than 50 mg/minute. It is diluted in normal saline and infused by pump through a large vein. The patient should be placed on a cardiac and non-invasive blood pressure monitor. Side effects include hypotension, heart blocks and lethal dysrhythmias. Soft tissue irritation and inflammation may occur at the site of injection even without extravasation of the medication. Soft tissue irritation can vary from slight tenderness to extensive necrosis and sloughing. Patients frequently complain of pain on infusion and the medication must be further diluted and/or the rate of infusion must be decreased. Many factors affect the rate of absorption so serum levels of the medication should be monitored regardless of the route of administration.
Chronic myofascial pain syndrome is a commonly used name for a group of symptoms that produce long-term pain. There is an original injury and then pain and inflammation of soft tissue and muscles occur, evidenced by tender, trigger points which can be felt by palpation of those areas, and aching and stiffness. There may be both local and referred pain, that is pain evidenced in other areas along the nerve tract. This injury is often diagnosed as a strain. The muscles involved may shorten causing a taut band which constricts the other tissue causing tender trigger points. If the bands are tight on tendons, the patient may have tendonitis. If the bands are tight on joints, the diagnosis may be facet joint syndrome. These bands and tender trigger points affect flexibility and are aggravated by stress and activity.
Treatment includes limited medication, and physical therapy to include cryotherapy, muscle release, stretching, and strengthening. Steroid and anesthetic injection, as well as biofeedback, may also be used. The goal is to relax the trigger points which will decrease the pain and promote movement. Treatment is aimed at releasing muscle spasms which press on and irritate the nerves. Chronic myofascial pain over time can cause degenerative changes. There also seems to be a psychological component to this syndrome due to fatigue and sleep disturbances related to the syndrome, as well as the extended period of recovery which may last for several years. The frustration, depression, and tension which occur can cause exacerbation of the spasms. Treatment may need to include psychological counseling to assist the patient in developing coping skills.
