epilepsy emergencies and how the prevent them
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Epilepsy emergencies and how the prevent them. Marcelo Lancman , MD Medical Director, Northeast Regional Epilepsy Group. Epilepsy emergencies. Breakthrough seizures Seizure clusters Prolonged seizures (status epilepticus) Sudden unexpected death in epilepsy (SUDEP) - PowerPoint PPT PresentationTRANSCRIPT
Epilepsy emergencies and how the prevent them
Marcelo Lancman, MDMedical Director,
Northeast Regional Epilepsy Group
Breakthrough seizures Seizure clusters Prolonged seizures (status epilepticus) Sudden unexpected death in epilepsy
(SUDEP) Seizure-related injuries Preparedness plans
Epilepsy emergencies
Perspectives◦ Person with epilepsy (PWE)◦ Caregiver◦ Healthcare provider (nurse, MD)
How to recognize them? What to do ? How to prevent them? How to prepare?
Epilepsy emergencies
The severity and urgency depends on seizure type, seizure duration and external circumstances
Some seizures are more dangerous than others
Most seizures are self limited and there is no need for urgent intervention
Only a few need urgent care…and we need to be prepared for those
Breakthrough seizures
Simple partial (lower risk)◦ Sensory, motor, auditory, visual, psychic,
autonomic
Complex partial (moderate risk)
Breakthrough Partial Seizures
Absence (lower risk) Atonic (higher risk) Tonic (higher risk) Clonic/myoclonic (moderate risk) Tonic-clonic (higher risk)
Breakthrough Generalized Seizures
Safety measures When to worry? When to call 911? When to go to the hospital? When to call your doctor? When to use rescue medications?
Breakthrough seizures
Clear the way: keep other people out of the way Move objects that could injure PWE Important to keep calm and track the time and
characteristics of the seizure Check if there is any information regarding
seizure or epilepsy type on bracelet or necklace Turn PWE on his/her side to keep airway clear Cushion head Loosen any tight neckwear
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Safety measures
Do not try to stop movements related to the seizure or hold down PWE
Do not put anything in the PWE’s mouth during a seizure
After the seizure, remain with PWE until awareness of surroundings is fully regained
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Safety measures
First time seizure (since you do not know this behavior)
Seizures lasting more than a few minutes (5?)
Repeated seizures without regaining consciousness
Increase in frequency of seizures Different seizure types occur PWE is injured, pregnant or with known
associated medical condition Seizure occurs in water Difficulty breathing
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When to worry
When to call 911? (when you have any of the “worry” signs)
When to go to the hospital? (It is better to call 911 and have EMT trained personnel take care of the PWE)
When to call your doctor? (whenever you do not know what to do. However, if it an emergency call 911 first)
What to do
What are rescue medications? What are the side effects and possible
complications? Routes of administration:
◦ Oral medications◦ Buccal◦ Sublingual◦ Rectal◦ Intranasal◦ Intramuscular◦ Intravenous
Breakthrough seizure-Rescue medications
What are rescue medications?◦ Medications that act very fast and can break
seizures◦ They are usually not effective as routine
antiepileptic treatment◦ It needs to be possible to administer them safely
(oral, sublingual, rectal, nasal, intramuscular, intravenous)
◦ They need to be available all the time to PWE and caregivers
Breakthrough seizure-Rescue medications
What are side effects◦ Sleepiness
May facilitate aspiration◦ Respiratory depression
May cause breathing problems
Breakthrough seizure-Rescue medications
Ativan, Valium, Klonopin May be difficult to administer during a
seizure Very useful if there is an aura Risk of injury by trying to put medication in
mouth Risk of aspiration Never give liquids with medication during a
seizure
Oral rescue medications
Between gums and cheek
Problems: gagging, coughing and aspiration
Buccal rescue medications
Buccal route
Klonopin wafers◦ Get absorbed faster than oral medications◦ May be difficult to administer during a seizure◦ Very useful if there is an aura◦ Risk of injury by trying to put medication in mouth◦ Risk of aspiration◦ Never give liquids with medication during a
seizure
Sublingual rescue medications
Sublingual route
Used in acute or emergency situations to stop a seizure that will not stop on its own
Approved by FDA for use by parents and non-medical caregivers
State/school district regulations often govern use in schools
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Diazepam Rectal Gel
Rectal Diastat
◦ Clinically proven
◦ Hard to give
◦ Adults don’t like it
◦ Can’t self administer
Emergency Treatment
Easy to administer
Increases production of nasal mucous and congestion
Intranasal route
Easy to give
Preferred route
Can be self-administered or given by caretaker
Under study
Intranasal Midazolam
Valium, Ativan, Midazolam (Versed)◦ Rapid effect◦ Needs caregiver to be trained◦ Only in rare occasions
◦ Midazolam IM
Rescue medications-Intramuscular and Intravenous
The seizure threshold◦What is the seizure threshold? The amount of activity necessary to
bring a seizure on. We all have a seizure threshold It is lower in PWE
◦What can change it?◦The importance of knowing
How to prevent them
Seizure triggers:◦ Missing medication doses (pill organizers, alarms)◦ Alcohol and drugs◦ Stress◦ Environmental temperature◦ Lights◦ Fever/illness
How to prevent them
Seizure triggers:◦ Hormonal changes◦ Hyperventilation◦ Sleep deprivation◦ Medications and supplements (very important to
discuss with your doctor every time you take any new medication for any reason or any supplements—many can provoke seizures)
◦ Travel across time zones
How to prevent them
What are seizure clusters◦ They start and stop but occur one after another◦ The can last a very long time◦ They can lead to injuries and complications◦ They need to be treated aggressively
Seizure clusters
Types of medications◦ Oral◦ Buccal◦ Sublingual◦ Rectal◦ Intranasal◦ Intramuscular◦ Intravenous
Seizure clusters
What is status epilepticus? What to do? Why? What are the consequences if we do not act
in a timely manner?
Status epilepticus
Formal Definition: seizures that do not stop for 30 minutes. Or they happen on and off without regaining consciousness between seizures
Practical definition: 5 minutes
Status epilepticus
Types◦ Partial motor status epilepticus◦ Generalized convulsive status epilepticus◦ Non-convulsive status epilepticus◦ Myoclonic status epilepticus
Status epilepticus
This prolonged seizure involves just one part of the brain.
The person is awake and talking/interacting normally, but has persistent rhythmic jerking on one side of the body, say the hand, arm or face.
It requires emergency treatment, but is not usually as life-threatening as other forms.
Partial motor status epilepticus
This prolonged seizure involves the entire brain, and produces convulsive activity in all four extremities coupled with a lack of responsiveness.
This life-threatening condition requires urgent medical evaluation and treatment.
Generalized convulsive status epilepticus
This seizure, which could involve part of the brain or the entire organ, is far less dramatic than generalized convulsive status epilepticus, and produces subtle symptoms such as blinking, staring or confusion – or no obvious signs at all. It is less dangerous than the generalized convulsive type, but still requires prompt recognition and treatment.
A continuous EEG recording is the only way to diagnose non-convulsive status epilepticus.
Non-convulsive status epilepticus
Another seizure that involves the entire brain, this form produces prolonged jerking of all four extremities.
It is usually caused by a profound lack of oxygen to the brain due to heart dysfunction, but may also occur in those with myoclonic epilepsy.
Myoclonic status epilepticus
One of the most common life-threatening neurological disorders
Incidence: 50,000 to 200,000 cases annually in US.
Around 12% of patients with newly diagnosed epilepsy present with status epilepticus
Within 5 years of initial diagnosis of epilepsy, 20% of patients will have status epilepticus
Mortality rate: 3 to 53% (20%) 55,000 deaths in U.S. per year
Status epilepticus: Epidemiology
Cause: Unknown in 25 to 40% of cases
Age: elderly > pediatric > adult
What can cause it?
Most common causes:◦ Missing medications◦ Stroke◦ Alcohol withdrawal◦ Metabolic disorders◦ Hypoxia◦ Infections◦ Tumors◦ Trauma
What can cause it?
Effects on the body◦Hyper-sympathetic state (increased
HR, dysrhythmias, decreased cardiac output, increase in peripheral resistance, increase in BP followed by decreased BP)
◦Hyperpyrexia (increased body temperature) (central, infection or increase in muscle activity)- neuron damage
◦PH decreases ◦Hyperglycemia (increase in
catecholamines)
What are the consequences?
Effects on the brain
◦ Early stage: Increased oxygenation Increased blood flow (increased BP)
◦ Late stage: Decreased oxygenation Decreased blood flow High requirement of energy with low supply
brain injury Decreased glucose and increased lactate
What are the consequences?
Clinical assessment:
◦ Exam: trauma, infection◦ Drugs: ciprofloxacin, baclofen, flumazemil,
interferon, ifosfamide, theophyline, isoniazid, alcohol withdrawal, cocaine
◦ Infections: Mycoplasma pneumonia, cat-scratch encephalopathy, herpes simplex, AIDS
◦ Tumor (metastases), cortical dysplasia
How is status epilepticus approached?
Labs◦ Glucose level, electrolytes, CBC, toxic
screen, LFTs, AEDs levels, urine, ABG (hyponatremia, hypernatremia, hypercalcemia, hepatic encephalopathy)
◦ EKG◦ Others: mixedema, hyperparathyroidism◦ LP: if infection suspected
Neuroimaging◦ CT/MRI
How is status epilepticus approached?
EEG and VEEG
◦Rule out psychogenic seizures
◦Classify type of SE
How is status epilepticus approached?
This is an emergency where time is of the essence
Steps:◦ Control of airway and ventilation◦ Arterial blood gas monitoring◦ EKG and BP monitoring◦ IV: glucose and Thiamine◦ Blood work: CBC, CPM, electrolytes and AED levels
How is status epilepticus treated?
Pharmacological treatment◦ Benzodiazepines loading
Lorazepam Diazepam
◦ Phenytoin or Fosphenytoin loading◦ If no response:
Phobarbital, Depakon, Keppra, Vimpat◦ Refractory:
ICU: midazolam, propofol and pentobarbital
Treatment
EMERGENCY SITUATION
TIME IS OF THE ESSENCE
DELAY IN TREATMENT COULD RESULT IN BRAIN DAMAGE OR DEATH
Status epilepticus-Conclusion
What is SUDEP?◦ SUDEP stands for Sudden Unexpected Death in
Epilepsy. ◦ SUDEP could be the possible cause of death when
there is no evidence of trauma or drowning and there is no other clear cause of death (Heart attack, etc.)
◦ SUDEP is believed to be the cause of approximately 10% of seizure related deaths.
SUPED
◦ Unfortunately, due to the unpredictable nature of SUDEP it remains an understudied phenomena.
◦ Our understanding of this process is very limited and much remains to be investigated about these occurrences and what causes them.
◦ Thankfully, SUDEP is relatively rare, occurring in about 1 out of 1000 patients with epilepsy per year, but its consequences can be catastrophic
SUPED
All patients with Epilepsy are at some risk
Higher risk:◦ Long history of poorly controlled seizures (risk of 1 in
150) ◦ Patients with generalized tonic-clonic seizures ‘Grand
Mal’◦ SUDEP also appears to typically affect younger adults
with epilepsy. (Approximately 75% of all SUDEP deaths occur in individuals between 20 to 50 years of age)
Children, have a relatively lower risk of SUDEP.
Who is at risk?
Patients with varying degrees of cognitive or neurological impairment.
Poor compliance with medications Use of alcohol or illicit drugs Nocturnal seizures
Who is at risk
Not completely understood, but there are several theories:
◦ There is interruption of cardiac (cardiac arrest, arrhythmias) or respiratory function
◦ The brain is highly interconnected with the heart and respiratory functions
◦ Seizures could disrupt that connections
What causes it?
Patients and families must work together with their doctors to obtain optimal seizure control.
Taking anti-seizure medication consistently and regular follow ups with the patient’s health care provider are key.
Autopsies show that many of those who die from SUDEP have low levels of antiepileptic medications in their system.
SUDEP-What can you do
Maintain a regular sleep schedule (including when traveling across time zones)
Avoid alcohol and illicit drugs There is a growing number of safety devices
that have appeared on the market (none are FDA approved however)
SUDEP-what can you do?
Devices to monitor seizures to alert caregivers when a seizure is happening
They achieve this by recognizing rhythmic movements or detecting changes in heart rate which can occur during a seizure
Low tech options include baby monitors to other more sophisticated devices
Seizure service dogs
Anything else to prevent it?
Failure to detect all seizures False alarms:
◦ occur when the bed exit alarm function is in use and the patient gets out of bed to go to the bathroom.
◦ Other false alarms can occur if an individual is particularly restless at night
Limitations of these devices
There is no device proven to prevent SUDEP
Some devices are marketed but have not been studied
Some devices are currently under study
Speak to your MD before purchasing
Safety Devices to Prevent SUDEP
Sleep Safe PillowAir passes through contoured
surface and body of the pillow
Pulse OxymeterNon-invasive medical devices that attach
to a fingertip or a toe to measure heart rate and blood oxygenation percentage
SmartWatch by SmartMonitor
Emfit Movement Monitor (outside US and Canada: Emfit Tonic-Clonic Seizure Monitor
Aremco
Neurovista
High Tech?
Knowledge of SUDEP and the factors that are thought to increase the chances of being affected by it are crucial to its prevention.
It is important to develop a management plan for the seizure events, and family and friends should learn basic life support skills.
SUDEP
Increased incidence of head and soft tissue injuries
Tongue and mouth lacerations Submersion (10 fold) Fractures (2 fold) Burns (3% of burn units admissions) Car accidents Sport related injuries
Seizure-related injuries
Confusion: may walk into a dangerous area Aspiration pneumonia
Post seizure-related injuries
In Case of Seizure: Please keep calm and stay with me until the seizure ends.
These symptoms/behaviors will tell you that I’m having a seizure: (list specific characteristics of your seizures, for example, falling, jerking limbs, etc.) _________________________________________________________________
The things you should do to ensure my safety are: (for example,
gently move me away from danger, if possible; loosen any restrictive clothing, etc.) ___________
_________________________________________________________________ Please do not put anything in my mouth during the seizure!
THE SEIZURE PREPAREDNESS PLAN
Please observe me carefully so you can describe everything you saw during the seizure. I’ll report what you’ve said to my doctor and it may help with my treatment.
Please call 911 if the seizure is prolonged (lasts longer
than two to three minutes), is associated with breathing difficulties, causes injury, or becomes a series of seizures. Brief seizures that end spontaneously without injury do not require a 911 call, but may require a call to my doctor. My doctor’s phone number is: _________________________________________________________________
THE SEIZURE PREPAREDNESS PLAN
If several seizures occur in a row, please give me my rescue seizure
medication as follows: (list instructions obtained from your doctor. If you wear a VNS, include instructions to swipe it once over the implant.) _________________________________________________________________
__________________________________________________________________ After the seizure, please help me find a place to rest. It is also
important that I get regular meals and take my seizure medications on schedule.
If you have a school-age child with epilepsy, the Seizure Preparedness Plan should be given to the school nurse or other appropriate school official, as well as the teachers, coaches, camp director, camp counselor, babysitters and anyone else who may be caring for the child.
THE SEIZURE PREPAREDNESS PLAN
Make your home as safe as possible by doing the following: Make sure that your floors are carpeted and any sharp corners (e.g.,
table corners) are padded to reduce the risk of injury due to a fall. Don’t smoke. Don’t light a fire or a candle when you are home alone. Make sure the drains in your bathtub and shower are working
properly to prevent drowning should you lose consciousness while showering.
Set your water temperature to a moderate level to avoid being scalded if you lose consciousness while running the hot water.
Safety at Home
Don’t take a bath in deep water, to prevent drowning. Don’t lock the bathroom door, use an “occupied” sign on the doorknob instead.
Install a bathroom door that opens outward for easier access, in case you have a seizure and fall against the door.
Use plastic glasses and dinnerware instead of glass and china to keep from cutting yourself if you lose consciousness while holding them.
Some people also use medical alert systems that notify emergency personnel that they’ve fallen and need assistance. Baby monitors can be helpful to parents of babies or young children who have epileptic seizures during sleep, as they can pick up unusual sounds.
I’m often asked about epilepsy detectors, which are devices that monitor breathing, and/or detect urine or vomit in the bed and send warning signals if something is amiss. While it’s an intriguing idea, none of them are FDA-approved for home use.
Safety at Home
Safety at home
Always tell your family and/or friends where you are going and when you expect to return.
Wear a Medic-Alert bracelet and/or jewelry printed with your medical
information. Put your emergency contact numbers on speed-dial on your cell phone.
Don’t drive without medical permission.
Keep a supply of rescue medication on hand. Stay away from the tracks at train and subway stations. If you fall frequently during seizures, consider taking an elevator instead
of the stairs or an escalator.
Safety Away From Home
Safety away from home
Give your friends and family a copy of your travel itinerary, with phone numbers and addresses where you can be reached.
Become familiar with the hospitals in the areas you are visiting, in case of emergency.
Bring an adequate supply of seizure medication with you. Carry on the plane with you. Do not put in luggage.
If the trip is a long one, consider finding a medical provider in the area to provide refills. However, be aware that not all countries have access to every seizure medication prescribed in the United States. Find out in advance which ones are available, and talk to your doctor about other medicines that are acceptable.
Longer flights and jet lag can cause disrupted sleep, which can trigger a seizure. Talk to your doctor about getting a prescription sleep aid for the trip.
General Travel Guidelines
Avoid excessive alcohol.
Eat regular meals. Don’t forget to consider time zone changes when taking your
medications. Take the medication as close as possible to the time you would be taking it at home.
If you travelling to a foreign country, consider learning basic
phrases to request medical assistance such as “I need help” and “Where is the hospital?” Even better, travel with someone who knows the native language.
Prepare a plan for an emergency trip back home. Discuss this plan with someone you trust before you go.
General Travel Guidelines
Wear a Medic-Alert bracelet/necklace that includes a description of your seizure(s).
Carry a list on your person of all of your current medications (plus enough
medicine to last you from start to end of your trip).
Carry emergency contact information on your person, either on an index card or numbers programmed into your cell phone and listed under contacts as ICE (In Case of Emergency).
Disclose your seizure history to transportation personnel and provide them with a letter from your doctor.
Let the flight attendants, conductor or driver know that you have epilepsy.
If you have a VNS device implanted, carry a VNS registration card so that people will know that you cannot get an MRI, should not have deep heat treatment and so on.
Traveling Alone
ACTIVITY PRECAUTIONS
Baseball
● Wear protective clothing: elbow or knee pads helmet protective eyeglasses or goggles
Basketball
● Wear protective clothing: elbow or knee pads consider a helmet protective eyeglasses or goggles
Bike Riding
● Avoid busy streets● Ride on bike paths ● Ride on side streets ● Wear a helmet
SAFETY PRECAUTIONS WHEN ENGAGING IN SPORTS
Boxing
● High risk activity - should be avoided by all
Bungee Jumping
● High risk activity - should be avoided by all
Canoeing/ Kayaking
● Never canoe/kayak alone; take a “buddy” who knows seizure first aid.● Always wear a high quality, well-fitting life vest when near the water to prevent drowning.
Football
● Wear protective clothing: elbow or knee pads helmet protective eyeglasses or goggles
Gymnastics
● Have a “buddy” when using equipment like balance beams, parallel bars or when vaulting● Consider a helmet when using a balance beam or parallel bars or when vaulting● Consider a shock-absorbing mat● Take frequent breaks● Keep hydrated
*Hang Gliding
● High risk activity - should be avoided by individuals with uncontrolled seizures
Horseback Riding
● Wear protective clothing: elbow or knee pads helmet protective eyeglasses or goggles
Ice Hockey
● Wear protective clothing: elbow or knee pads helmet protective eyeglasses or goggles
Jet Skiing
● High risk activity - should be avoided by individuals with uncontrolled seizures
Martial Arts:Karate, Tai
Kwando, Judo
● High risk activity - should be avoided by individuals with uncontrolled seizures
*Mountain Climbing
● High risk activity - should be avoided by individuals with uncontrolled seizures
Pilates
● Consider a shock-absorbing mat● Have a ‘buddy” when using equipment ● Take frequent breaks● Keep hydrated
*Rappelling
● High risk activity - should be avoided by individuals with uncontrolled seizures
*Rock
Climbing
● High risk activity - should be avoided by individuals with uncontrolled seizures
Rollerblading
● Wear protective clothing: elbow or knee pads helmet protective eyeglasses or goggles
Rugby
● Wear protective clothing: elbow or knee pads helmet protective eyeglasses or goggles
*Scuba Diving
● High risk activity - should be avoided by individual with uncontrolled seizures
Skateboarding
● Wear protective clothing: elbow or knee pads helmet protective eyeglasses or goggles
Skiing
● Dress for warmth● Wear protective gear● Consider a safety strap when riding the t-bar● Have a “buddy”● Don’t go off open trails
Snorkeling
● High risk activity - should be avoided by individuals with uncontrolled seizures
*Skydiving
● High risk activity - should be avoided by individuals with uncontrolled seizures
Soccer
● Wear protective clothing: elbow or knee pads helmet protective eyeglasses or goggles
Surfing/Wind
Surfing
● High risk activity - should be avoided by individuals with uncontrolled seizures
Swimming
● Never swim alone. Have a “buddy” who knows seizure first aid● Always wear a high-quality, well-fitting life vest when near the water to help prevent drowning. ● Inform the lifeguard about your condition if swimming in a pool
Tai chi
● Consider a shock-absorbing mat● Take frequent breaks● Keep hydrated
Yoga
● Consider a shock-absorbing mat
Follow state laws
If you have regained your driving privileges, be safe and avoid driving if you are tired or have any known risks for seizures
Don’t hide seizures from your doctor to avoid losing your driver’s license
Driving
Complications and emergencies are rare
But, always be prepared!
Final words