ILS Position Statement: Seizure Disorders in Lifesaving and Lifeguarding

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  • 1. ILS Position Statement (Draft) SEIZURE and EPILEPSY: Risks for Bathing, Swimming, Lifesaving and Lifeguarding DR STEVE BEERMAN ILS Medical Committee Chair
  • 2. Learning Objectives
    • Participants will become aware of issues concerning Seizure Disorders and the unique nature of the condition in individuals
    • Participants will review the evidence and the evidenced based process for the seizure disorders and how this may or may not increase risks of drowning and water accidents.
    • Participants will review the principles and evidenced based recommendations for individuals with seizure disorders for swimming, lifesaving, lifeguarding.
  • 3. Seizures and Epilepsy Epilepsy is a Neurological Disorder both sexes all ages all countries definition: 2 or more unprovoked seizures -more than 24 hrs apart Epilepsy is multifactorial disorder 3 important influences - Threshold susceptibility - Epileptic focus - Precipitating condition
  • 4. Seizure Disorders
    • Developed Populations Developing Populations 0.5% prevalence 1-3% prevalence
    • 0.1% incidence 2-3% incidence
    • All nations/regions have adaptive and less adaptive = developing populations.
  • 5. Seizure Disorders
    • ILS Process of review
      • Form Key Questions
      • Literature Review
        • Determine Level of Evidence
        • Cross tabulated assessed studies
      • Background Statements
      • Key Assumptions
      • Recommendations
        • Determine Class of Recommendations
      • References
  • 6. Seizure Disorders – Key Questions
    • What is the existing evidence?
    • 1. Recreation, instruction and competition, on and in-water activity in shallow clear still water for persons with seizure disorders
    • 2. Open, deep water recreation, competition and lifeguard patrol duties for persons with seizure disorders
    • 3. Seizure free interval for safe, risk activities and vocations
  • 7. Seizure Disorder - Risk
    • The risk is sudden incapacitation
      • There is risk to the incapacitated
      • There is also risk to:
        • rescue victim
        • fellow lifeguards
        • program providers/employers/insurers
  • 8. WHO CREST Study
    • C ollaborative R esearch on E pilepsy S tigma P roject
      • Developing Global Approaches to Reducing Stigma of Epilepsy
    • • Epilepsy = world’s most common brain disorder, affecting 50 million people
    • - 4/5ths live in developing countries
    • • Stigma is a major contributor to the burden of epilepsy
    • • Reducing stigma = key to reducing impact & improving quality of life
  • 9. Seizure Disorders – Human Rights
    • Persons have a right to opportunity
    • Wide variations throughout the world
      • Statutory regulation in many countries
    • Discrimination must be avoided
  • 10. Seizure Disorders – Literature Review
    • Highlights
      • Normal intellect & neurological function, medically stable may have injury risks similar to “normal”.
      • Persons with seizure disorders, without control with co-morbidities have preventable submersion and drowning.
      • Seizure free interval is important.
      • No studies in lifesaving or lifeguarding
  • 11. Seizure Disorders – Relative Risk
    • Fatal Submersion Nonfatal Submersion
    • Total Seizure RR Total Seizure RR
    • 10 Studies
    • Retro 2195 130 11.9 761 39 10.2
    • Assume population risk 0.5%
    • (developed nations)
    • RR is 2195 X 0.005 = 10.97
    • expected drowning RR is 761 x 0.005 = 3.8
          • 130 / 10.97 = 11.85 39 / 3.8 = 10.2
  • 12. Demographics of the cohort
    • There is a very high risk subgroup
      • Persons with uncontrolled seizures
      • Persons with Co-morbidity
          • Physical Impairment
          • Mental Function Impairment
          • Judgment impairment
      • Very young
    • Lessons from the Retrospective Studies:
      • We can prevent drowning with focus on the high risk groups
  • 13. Relative Risk – Prospective Study
    • 792 UK persons with “epilepsy” followed for 14 yrs.
      • Standardized Mortality Ratio (SMR) of 1.8
        • highest in 48 hrs after diagnosis
        • higher in the first year after diagnosis
        • highest in individuals with convulsive seizures
      • - 5 epilepsy related deaths = non-significant
        • one drowning
          • Lhatoo S, Johnson A, Goodridge D et al
          • Annals of Neurology 2001:49:339-344
  • 14. Seizure Disorders
    • Key Assumptions:
    • 1. Lifeguard duties > risk of drowning and incapacitation than lifesaving training.
    • 2. Correlation of lifesaving training & lifeguard duties with driving a vehicle.
  • 15. What is the risk to an individual?
    • Depends on the population risks for drowning and epilepsy
      • - Driving death rate in Canada = 10.2/100,000
      • - Driving death rate in Vietnam = 12/100,000
      • - Epilepsy drowning death rate in Canada = 17/100,000
      • - Epilepsy drowning death rate in Vietnam = 176/100,000
  • 16. Seizure Disorders – Public Recommendations
      • - Individuals with unstable or potentially unstable epilepsy should avoid water activity until stability is re-established.
      • - Epilepsy submersion and drowning risk is greatest in an identified high risk group that includes:
        • those with frequent (more than one per year) seizures
        • those with unpredictable convulsive seizures and/or
        • those who have other disabilities.
      • Extra precautions are warranted. These individuals should avoid water activities or should participate in clear shallow still water, with a personal flotation device securely fastened and they should be within arm’s length of a capable support person.
      • (2 of 8 recommendations)
  • 17. Seizure Disorders- Lifesaving Recommendations
    • Lifesaving training should be available to individuals with epilepsy who have confident seizure control, treatment program compliance, knowledge of their risk and a seizure free period of at least 6 months.
    • This interval may be longer if the participant has high risk features. Proof of medical authorization, compliance and stability may be requested.
  • 18. Seizure Disorder – Lifesaving Recommendations
    • Individuals with controlled epilepsy and no unexplained or unpredictable seizure activity who wish to participate in Lifeguard patrol duty or in deep water recreation and competition activities, require a seizure free interval of more than one year prior to participation.
  • 19. Seizure Disorder – Lifesaving Recommendation
    • If an active patrol lifeguard and or deep open water recreation or competitive participant has seizure with clear medical cause, usual patrol and deep open water recreation or competition activities should be suspended. The criteria for resumption are medical authorization and 12 months of seizure free interval.
    • If lifesaving training program involves open deep water swimming, a safety craft should provide close supervision of the lifesaving learners to assist with any unusual incidents that might arise.
    • (4 of 6 recommendations)
  • 20. ILS Position Statement (Draft) SEIZURE and EPILEPSY: Risks for Bathing, Swimming, Lifesaving and Lifeguarding DR STEVE BEERMAN ILS Medical Committee Chair