Seizure-Related Emergencies

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 doesnt 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 199940120-2
7
Not all Status Epilepticus is Created Equal
8
Why is Status Epilepticus Dangerous?
9
Treatment of Status Epilepticus
10
Questions, questions, questions

• Why did Edward go into Status Epilepticus?
• How could it have been prevented?

11
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

12
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

13
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

14
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

15
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

16
Seizure Control
17
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

18
Why wasnt I told about SUDEP?

• Some doctors dont 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 everyones risk of SUDEP is the same

19
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

20
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

21
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

22
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

23
Seizure Safety
24
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 persons head (but
  NOT a pillow!)
• Stay calm and stay with the person
• Time the length of the seizure
• Never place anything in the persons mouth!
• Do not try to restrain the person during a seizure

25
When should I call 911?

• If this is the persons 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

26
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).

27
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

28
SmartWatch by SmartMonitor
29
Emfit Movement Monitor (outside US and Canada
Emfit Tonic-Clonic Seizure Monitor
30
Aremco
31
Neurovista
32
NeuroPace
33
High Tech?
34
Where can I learn more about SUDEP?

• Here are a list of websites with more information
  on SUDEP
• Epilepsy Foundation www.epilepsyfoundation.org/a
  bout/SUDEP/faqs.cfm
• Epilepsy. com
• www.epilepsy.com/EPILEPSY/sudep_epilepsy
• SUDEP Aware
• www.sudepaware.com
• Epilepsy Bereaved
• www.sudep.org

35
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

36
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

37
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