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Spring 2020, Neurology

Seizing the Moment

Julie Ann NettifeeRVT, BS, VTS (Neurology)

For more than 20 years, Julie Ann has been on the staff at North Carolina State University College of Veterinary Medicine. She earned her AAS in Animal Health Technology at the University of Minnesota, Waseca, and a BA degree in Journalism with a minor in Natural Science at the University of Wisconsin-Madison. She holds a Certificate in Nonprofit Management from the Duke Center for Nonprofits. She currently supports clinical research in neurology and nutrition, teaches, and conducts outreach. She has presented locally, nationally, and internationally, and has authored numerous articles on veterinary nursing.

Seizing the Moment
COOL, CALM, AND COLLECTED Veterinary nurses are on the frontlines in communicating with a client who is worried about a pet’s seizure event. Pixel-Shot/shutterstock.com

When a client calls the clinic or hospital and says, “My pet is having a seizure—what should I do?” it’s common for many veterinary professionals answering the phone to become frozen, unable to immediately respond to the crisis. But it is critical that the veterinary team member taking the call asks the right questions quickly, methodically, and with a calm, assertive presence. The entire team will benefit from this calm presence, allowing them to understand the nature of the event the animal is experiencing and to obtain the best and most appropriate level of care as soon as possible.

This article will focus on the questions to ask when faced with uncertain seizure events in pets, as well as tips for keeping the pet owner calm and helping them to maintain a safe environment for their pet. It will also outline the best procedure for bringing a pet to the clinic safely and how to communicate that procedure to a stressed and anxious pet owner.

ASK ABOUT THE FIRST PHASE OF A SEIZURE

If one has never seen a dog having a seizure, it can be a frightening experience. If the client’s pet is truly having a seizure, they will go through 3 notable phases: aura (pre-ictal), seizure, and recovery (post-ictal). Each phase has typical symptoms that are easily noticeable.

The first phase, the pre-ictal (aura), has signs. Ask the client if the patient exhibited any of the following signs:

  • Appeared scared, dazed, nervous, or stressed
  • Sought support from the owner
  • Hid in a quiet, dark environment
  • Paced, salivated, vocalized, or whined
  • Record any observations or signs the owner reports.

WHILE THE PET IS SEIZING

During a seizure, the pet is experiencing an abnormal, uncontrolled burst of electrical activity in the brain. It will usually last for 30 seconds to 2 minutes, although it may seem longer if the pet is being watched by the owner or on the phone with the veterinary practice. It will help calm everyone involved by encouraging the owner to breathe deeply. Communicate the following to the owner:1

  • Time the episode
  • Keep clear of the pet’s mouth to remain safe
  • Keep the pet’s head slightly lower than the body to avoid aspiration
  • Lower the intensity and energy in the room by turning off ceiling fans, fluorescent lights, and televisions
  • Talk soothingly to the pet during a seizure, and touch the patient safely, unless they have fallen into a dangerous area like water
  • Keep the pet away from any areas where they may injure themselves or others
  • Remove all other pets from the area

If the pet is in a safe place, ask the owner if he or she can videotape the pet. Oftentimes these events, seizures, syncope, etc., are transient, and by the time the patient arrives at your practice the animal may be perfectly normal. It is valuable to view what the owners are describing to determine how to most appropriately manage the pet.

ASK ABOUT THE CLINICAL SIGNS OF A SEIZURE

If the pet’s seizure has stopped prior to the call, ask the owner if the animal did any of the following:

  • Fell to their side and became rigid
  • Chomped its jaws
  • Thrashed its limbs or front-leg paddling
  • Salivated
  • Howled or vocalized
  • Urinated and defecated

In addition to recording the signs and symptoms that the owner reports, take note of other characteristics that might not fit the above (BOX 1). While each seizure has its own individual traits, there are other medical conditions that may mimic some of the signs and symptoms described by an owner. These could be manifestations of other medical concerns or conditions.

Be aware that although seizures are the most common neurological concern seen in animals—dogs especially—it is not the only reason that unexplained events take place in companion animals. Other events may be called seizures; however, they could be due to other medical concerns that happen spontaneously.

BOX 1 Ask the Right Questions
Once an event becomes categorized as a seizure, information gathered during the initial call gets placed into communications and medical documentation. It is critically important that veterinary personnel communicate, listen, and ask the questions to discern whether the event is a seizure caused by the “misfiring” in the brain or whether it is another type of medical event that may be characterized by abnormal episodes. These are some medical concerns and conditions that can sometimes be categorized incorrectly as a seizure, including:

  • Atlantoaxial subluxation
  • Breed and drug-induced dyskinesia/movement disorders
  • Cataplexy, narcolepsy, rapid eye movement (REM) sleep disorder
  • Cervical muscle spasm
  • Chiari malformation/syringomyelia-associated episodes
  • Encephalitis
  • Episodes of neuromuscular disease
  • Exercise-induced collapse
  • Extreme agitation
  • Head bobbing/tremor syndromes
  • Intermittent decerebrate/decerebellate rigidity
  • Metabolic/toxic event
  • Myoclonus
  • Syncope
  • Vestibular episode

ASK ABOUT THE RECOVERY PHASE

A companion animal experiencing seizures may immediately recover from the event, or it may take hours to improve. Ask the client if the pet showed any of these signs during the recovery phase:

  • Wandered aimlessly, paced, or turned in circles
  • Appeared disoriented, dazed, confused, or acted as
    if blind
  • Was hungry and/or thirsty

Record any post-ictal events the owner reports.

DISTINGUISH BETWEEN SEIZURES AND FAINTING SPELLS

Some signs of seizures are also symptoms of other conditions. One of the most commonly mistaken symptoms is syncope. With syncope, a dog’s blood pressure quickly drops, causing the pet to lose consciousness temporarily. In this case, fainting is not a symptom of a seizure, but could be caused by other problems or disorders, such as anemia or respiratory problems. Other differences include the following:

  • The eyes will not dilate with syncope; during a seizure, the eyes will dilate.
  • Heart rate and temperature will be normal with syncope, but will elevate during a seizure.
  • With syncope, the mouth or tongue will turn blue because oxygen is cut off; this typically will not happen during a seizure.

DISTINGUISHING BETWEEN SEIZURES AND BAD DREAMS

Pet owners may also notice a dog that starts barking during sleep and fear the pet is having a seizure. To distinguish between a seizure and bad dream, have the owner try to wake the dog. If it’s a dream, the dog will wake, but the owner won’t be able to rouse the pet if it is having a seizure.

When talking to the client, ask if the pet showed any of these signs:

  • Urination and defecation
  • Thrashing about
  • “Clingy” behavior upon awakening

These are all signs of seizure, not a bad dream, and should be recorded if the pet owner has observed them.

TRANSPORTING THE PATIENT TO THE CLINIC

If an owner notices a single seizure, they will likely call to obtain an examination appointment. Typically, single seizure events are not emergencies as long as the seizure has ceased and there are no known signs of toxins, trauma, infections, or other concerns. The pet should be evaluated; you can schedule an appointment as a routine status and instruct the owner that should the pet have additional episodes, to contact you as soon as possible or to take the pet to the nearest emergency clinic.

However, if the pet is having repeated sustained seizures (status epilepticus) that don’t stop, emergency treatment is required. Any seizure that lasts longer than 5 minutes can be life threatening. If the pet owner notices a pet experiencing a sustained seizure, instruct them to immediately take the pet to an emergency veterinary clinic for treatment.

To help the client safely transport this type of patient into the clinic, follow these steps:

  1. Calmly ask the pet owner if they have another person to help them transport. Ask how far away they are from the clinic, and alert personnel to the status of the incoming emergency.
  2. Tell the owners to carefully lay the patient on a blanket, and to carry the pet in a sling-type fashion and place it in the vehicle. Ideally, they will have assistance, so that one person can monitor the patient and another can drive. Instruct the owner that if at any point the animal begins to regurgitate, to hold the head lower than the body to prevent aspiration.
  3. If the patient has been seizing for several minutes, instruct the owner to place cool towels around the pads of the pet’s feet. Ensure that they do not try to administer anything orally during this time.
  4. Make sure they know the most efficient route to the closest emergency clinic. Reassure the owner that you are available via phone while they are transporting their pet.
  5. Ensure that the pet owner understands that these nonstop seizures can kill a pet if not treated promptly. It’s essential that you help the owner to remain calm, while at the same time conveying this is an emergency situation.

In the event of a mild seizure occurrence, the patient will still require a medical examination. When the patient and owner arrive, thoroughly check the pet. Gather a detailed medical history, particularly crucial details that were not asked during the initial phone query, including questions about past head injuries, ear infections, teeth problems, or exposure to toxic substances. Vaccination status and proof of vaccination can help to protect not only the patient, but the entire veterinary team in these settings.

Fortunately, most seizure activity is not that severe in the early stages of the disorder process. Your examination should:

Determine the likelihood of primary and secondary epilepsy.2 Advanced diagnostics are needed to distinguish between primary and secondary epilepsy. If the concerns related to the diagnoses with your patient is secondary epilepsy, this means a neurological condition (such as a stroke, infection, or brain tumor) is causing the seizures and needs to be treated. However, if the patient is diagnosed with primary epilepsy, which is a genetic disorder that can start while the patient is young, treatment is started typically when seizures happen more than once a month. Each seizure could potentially cause brain damage, increasing the severity and number of seizures. There are several treatment options (e.g., antiepileptic medications) available that will typically have to be given to the patient for their whole lives.

Distinguish between generalized and focal seizures.2 Generalized seizures may cause dogs to have convulsions and lose consciousness. Focal seizures aren’t as dramatic as generalized seizures. The only sign may be staring off into the distance, snapping at imaginary things, or other signs such as a single limb twitching or facial movements localized to only one side of the body. Generalized seizures are more typical of canine epilepsy and have specific stages of the seizure process.

ANTIEPILEPTIC MEDICATIONS

The veterinary nurse will assist the veterinarian with diagnostics leading to a treatment plan established by the veterinarian. The veterinary nurse can then help support the client in teaching them how to medicate, monitor, and support their pet and in being sure they understand the prescribed dosage and schedule. Common treatment options include:3

Phenobarbital: This drug suppresses seizure activity in the brain and is one of the most common treatment options for epilepsy as it is an effective treatment and still a relatively economical option for many pets. Monitor the dog’s diet because they may be hungrier or thirstier while on this medication. It is important to monitor chemistry panels and evaluate liver enzymes, as it can affect liver function.

Levetiracetam: This anticonvulsant is one of the newer anticonvulsants, and is metabolized by the kidneys. It is also a product that is available in an extended-release formulation, allowing it to be administered twice daily in dogs instead of three times daily. It has a wide margin of safety, and is often tolerated well.3

Potassium Bromide: If a dog has liver problems while taking phenobarbital, potassium bromide is another option to consider. It also decreases seizure activity in the brain.

Zonisamide: Zonisamide is an anticonvulsant medication that is unrelated to the other anticonvulsants routinely used for treating dogs. It can be used alone or in combination with phenobarbital and/or potassium bromide for treating seizures.

Diazepam or Midazolam: These drugs have anticonvulsant effects but are also a sedative and rather short-acting. Often administered intranasally, rectally, or intramuscularly, they are used if a dog is experiencing nonstop seizures or cluster seizures.

Other items to consider would be diets high in medium-chain triglycerides, which have shown promising results in some epileptic pets. 4 Alternative therapies such as acupuncture have also demonstrated benefits in some animals experiencing seizures.1

AFTER THE DIAGNOSIS

Veterinary professionals are on the frontline of communications to help the client monitor a pet over the short- and long-term. Ask the pet owner to observe and record the patient’s eating, drinking, urination, and defecation while on medication. Advise them about the side effects of medication, which can range from mild (occasional vomiting, increased eating and drinking, sedation) to severe (liver damage, pancreatitis). Explain to the client that the pet will most likely experience some side effects, but that without treatment the epilepsy will progress and cause serious problems. Follow-up care by the entire team is critical to the successful management of epileptic pets. Schedule follow-up calls and visits to check the patient’s overall health, which is especially important if drugs are combined to keep the patient as seizure-free as possible.Finally, share resources so that the pet owner can access support networks and resources. This support makes a huge difference for the client when caring for a pet facing long-term care needs.

References

1. Companion Animal Epilepsy. go.ncsu.edu/epilepsyresearch. Accessed November 11, 2019.

2. Understanding Canine Epilepsy. akcchf.org/canine-health/top-health-concerns/epilepsy/understanding-canine-epilepsy.html. Accessed February 4, 2020.

3. de Lahunta A, Glass E, Kent M. Veterinary Neuroanatomy and Clinical Neurology. 4th ed. Philadelphia: Saunders; 2014.

4. Berk BA, Packer RMA, Law TH, et al. A double-blinded randomised dietary supplement crossover trial design to investigate the short-term influence of medium chain fatty acid (MCT) supplement on canine idiopathic epilepsy: study protocol. BMC Vet Res 2019;15(1):181.

Suggested Readings

De Risio L, Bhatti S, Muñana KR, et al. International veterinary epilepsy task force consensus proposal: diagnostic approach to epilepsy in dogs. BMC Vet Res 2015;11:148.

Muñana KR, Thomas WB, Inzana KD, et al. Evaluation of levetiracetam as adjunctive treatment for refractory canine epilepsy: a randomized, placebo-controlled, cross-over trial. J Vet Intern Med 2012;26:341-348.

Muñana KR. Newer options for medically managing refractory canine epilepsy. veterinarymedicine.dvm360.com/newer-options-medically-managing-refractory-canine-epilepsy. Accessed Nov. 11, 2019.

Nettifee JA, Muñana KR, Griffith EH. Evaluation of the impacts of epilepsy in dogs on their caregivers. JAAHA 2017;53(3):143-149.

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