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Seizure-Related Emergencies

Seizure-Related Emergencies. Status Epilepticus and SUDEP. Evan Fertig MD, Northeast Regional Epilepsy Group. I think I will call myself “BRAIN”. Outline. Status Epilepticus SUDEP Causes Prevention Devices Seizure Safety. Case 1.

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Seizure-Related Emergencies

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  1. Seizure-Related Emergencies Status Epilepticus and SUDEP Evan Fertig MD, Northeast Regional Epilepsy Group

  2. I think I will call myself “BRAIN”

  3. Outline • Status Epilepticus • SUDEP • Causes • Prevention • Devices • Seizure Safety

  4. Case 1 • Edward is a 12 year old child with absence seizures (staring and blinking episodes) and grand mal (GTC) seizures who takes Depakote • His friend texts him and ask him to stay over • Mom picks him up Sunday PM and he doesn’t seem “right”. He responds intermittently and is blinking frequently. His uncle says that he has been like this “since lunch” like he is in a “stupor”. • EEG in ER reveals he is in “absence” status epilepticus

  5. Status Epilepticus “TIME IS BRAIN” • A medical and neurologic emergency • 55,000 deaths in U.S. per year • Early recognition and treatment are essential

  6. Why is Status Different than Usual Seizures? Lowenstein: Epilepsia 1999;40:120-2

  7. Seizure Types Generalized Focal Focus

  8. Classification of Seizures Partial - Onset • Simple partial • Complex partial • Secondarily generalized Generalized - Onset • Absence • Myoclonic • Generalized tonic-clonic • Tonic • Clonic • Atonic

  9. Not all Status Epilepticus is Created Equal

  10. Why is Status Epilepticus Dangerous?

  11. Treatment of Status Epilepticus

  12. Questions, questions, questions • Why did Edward go into Status Epilepticus? • How could it have been prevented?

  13. Causes of Status Epilepticus • Medication Non-adherence with Known Epilepsy • Can occur even with good medical adherence! • No Epilepsy • Alcohol Withdrawal • Meningitis (Brain Infection) • Stroke • Head trauma • Lack of Oxygen after Cardiac Event

  14. Case Continued • The neurologist on call gives Edward ativan and he immediately recovers • Bloodwork: Low depakote level • Seizure Action Plan/Diastat prescribed • Neurologist and Mom talk and the conversation comes around to “worst case scenarios”

  15. What is SUDEP? • SUDEP stands for Sudden Unexpected Death in Epilepsy • May be the cause of death when: • A healthy person with epilepsy dies suddenly without drowning or trauma • The person may or may not have had a seizure before death • No other reason for death is found upon exam after death • Person was not using illegal drugs (example: cocaine) • Person did not have a heart attack

  16. What causes SUDEP? • The exact cause is not yet known • Some common theories causing SUDEP include: • Heart arrhythmias (abnormal heart rhythms) • Breathing trouble • Lack of protective brain chemicals • A combination of causes

  17. Who is at risk for SUDEP? • 1 out of 1,000 patients with epilepsy die unexpectedly each year • In those with uncontrolled epilepsy, risk increases to 1 out of every 150 people • Risk of SUDEP increases when: • Seizures are not well controlled (treatment resistant epilepsy) • Treatment resistant epilepsy = failure of 2 medication trials • A patient suffers from generalized tonic-clonic (“grand mal”) seizures, esp at night when the person is sleeping

  18. Seizure Control

  19. Risks in Perspective • Overall risk of SUDEP in patients with epilepsy: 1 in 1,000 (0.10%) per year • Risk of SUDEP in patients without seizure control: 1 in 150 (0.66%) per year • Lifetime probability of dying in car accident: 1 in 83 (1.2%) [1 in 6500 chance each year]

  20. Why wasn’t I told about SUDEP? • Some doctors don’t know about SUDEP • Doctors that do know about SUDEP may not discuss it because: • Not much is known about the cause or prevention of SUDEP • No proof that one can prevent it except to control seizures as much as possible • Some doctors feel that talking about SUDEP would be unnecessarily frightening to some patients • Time in the office visit is short – this time is better spent making sure seizures are under control • Not everyone’s risk of SUDEP is the same

  21. How can I reduce the risk of SUDEP? • Reduce number of seizures • Medication control • Avoid triggers: alcohol, sleep deprivation, missed medications • Consider having an evaluation at an Epilepsy Center if you have persistent seizures despite treatment or cannot tolerate your medication • Practice good seizure safety when seizures do happen • “TRUST” • Seizure safety tips • When to call 911

  22. Medication Control • Take your medicine as instructed by your doctor • Use pill box, alarms, reminders, etc • Have a method to determine whether or not you already took your dose (e.g., weekly pill box) • Do not change or stop medications without talking to your doctor first • Call for refills long before you run out of medicine • Each time you get your meds: • Make sure the med name, instructions, and dose are the same • Make sure they are from the same manufacturer • If your medicine label is different when you pick up your meds, ask the pharmacist or call your doctor

  23. Avoid Seizure Triggers • Take your medicine. Low drug levels number 1 cause • Get enough sleep • Avoid alcohol in excess • Avoid specific seizure triggers if you have any

  24. Where Can I Find Specialist Care? • Poor seizure control? Too many side effects? Consider seeing a specialist at a comprehensive epilepsy center • www.efnj.com/content/info/epilepsy_centers.htm • Epilepsyfoundation.org • Find closest local affiliate • National Association of Epilepsy Centers • www.naecepilepsy.org/find.htm

  25. Seizure Safety

  26. Seizure Safety • What should I do if someone is having a seizure? • “ TRUST ” • Turn person on his or her side (especially head at end of seizure) • Remove all objects around person (glasses, sharp objects, etc.) • Use something soft under the person’s head (but NOT a pillow!) • Stay calm and stay with the person • Time the length of the seizure • Never place anything in the person’s mouth! • Do not try to restrain the person during a seizure

  27. When should I call 911? • If this is the person’s first seizure • The person is pregnant or diabetic • If the person was injured during the seizure or does not wake up properly • If the person is having trouble breathing • If the seizure lasts more than 5 minutes

  28. Seizure Safety Tips • Never swim or bathe alone if you have uncontrolled seizures (if you have a child, do not bathe the child alone either) • Keep shower drains unclogged • Do not lock bathroom door • If possible, cook with someone else around • Use rear burners • Limit clutter and sharp objects in your home • If you live alone, have routine check ins with family or neighbors • Stop all dangerous activities if you have an aura (stop driving if your doctor has allowed you to drive, turn off power tools you are using, etc).

  29. Safety Devices to Prevent SUDEP • There is no device proven to prevent SUDEP • Several devices are marketed but have not been studied • Some devices are currently under study • Speak to your MD before purchase

  30. SmartWatch by SmartMonitor

  31. Emfit Movement Monitor (outside US and Canada: Emfit Tonic-Clonic Seizure Monitor

  32. Aremco

  33. Neurovista

  34. High Tech?

  35. Where can I learn more about SUDEP? • Here are a list of websites with more information on SUDEP • Epilepsy Foundation: www.epilepsyfoundation.org/about/SUDEP/faqs.cfm • Epilepsy. com • www.epilepsy.com/EPILEPSY/sudep_epilepsy • SUDEP Aware: • www.sudepaware.com • Epilepsy Bereaved: • www.sudep.org

  36. Where can I get support? • Contact your local Epilepsy Foundation for support groups • For NJ residents: www.efnj.com • For other states, find your local Epilepsy Foundation using: www.epilepsyfoundation.org • Contact your local hospital for bereavement groups • If you need to speak with a healthcare professional in private, call your physician

  37. What is being done to help prevent SUDEP or determine its cause? • More than ever before • Many international meetings • Combined Epilepsy Foundation and American Epilepsy Society Task Force (done) • National Institutes of Health multidisciplinary 2.5 day workshop (done) • Creation of the SUDEP Coalition • EFA, AES, CURE, SUDEP Aware, Epilepsy Therapy Project • 3 day joint meeting for scientists and consumers being planned • June 21-24, 2012 (location to be announced) • NIH SUDEP “Center Without Walls” grant • Center for Disease Control: registry? • Areas of active research • Animal models, devices, seizure monitoring equipment, etc

  38. A Special Thanks • A special thank you for the research and development of the content of this presentation and the coordination of this project done in conjunction with EFNJ: • Amy Schmelzer, MS, MPH, CTTS • Contributors to this presentation Lawrence Hirsch, MD Evan Fertig, MD Eric Geller, MD Madeline Fields, MD

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