Seizure Safety and Risk - Daniel Friedman, MD
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Seizure Safety and Seizure Risk: From First Aid to SUDEP

Seizure Safety and Seizure Risk: From First Aid to SUDEP

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Seizure Safety and Risk - Daniel Friedman, MD Seizure Safety and Risk - Daniel Friedman, MD Presentation Transcript

  • Daniel Friedman, MD
    Assistant Professor of Neurology
    NYU Comprehensive Epilepsy Center
    Seizure Safety and Seizure Risk: From First Aid to SUDEP
  • Outline
    Seizure First Aid
    Seizure-related injuries
    Strategies for prevention
    Epilepsy and driving
    Seizure-related mortality
    Sudden unexpected death in epilepsy (SUDEP)
  • Seizure First Aid
    What should I do if my family member has a seizure?
    What should I tell my family to do if I have a seizure?
  • Complex partial and absence seizures
    Observe the person and gently move the person away from danger (e.g. hot stove, stairs, road)
    Careful to avoid restraining people during seizures unless there’s immediate danger
    Speak in reassuring voice
    Stay with the person until they are fully aware
    Explain to others what is happening
    From www.epilpesyfoundation.org
  • Generalized tonic-clonic seizures
    Stay calm and reassure bystanders
    Don’t restrain the person
    Keep track of time (90% of seizures stop after 2 min)
    Clear the area of potential hazards and loosen collar or tie
    Turn the person on their side to help clear secretions
    Do not force as shoulder dislocation can occur
    If necessary, wait until the seizure is over
    DON’T PUT ANYTHING IN THE MOUTH
    Stay with the person until the seizure ends and consciousness is back to normal
    Speak calmly to the person and let them know what happened
    From www.epilpesyfoundation.org
  • When to call 911
    Most seizures stop on their own and there are few lasting effects; EMS is usually not needed unless:
    There is no known history of epilepsy
    The seizure occurred in the water
    The person is pregnant or diabetic
    The seizure lasts > 5min or they come one after another
    The person does not wake up appropriately
    There is injury due to the seizure
    There is difficulty breathing
  • Emergency Plans
    Discuss with your doctor what to do if you have a seizures
    Some patients with a tendency to have prolonged seizures or repetitive seizure may benefit from a rescue medication
    Benzodiazepines
    Rectal Valium (Diastat™)
    Intranasal Midazolam (Versed™)
    Lorazepam tablets (Ativan™)
    Clonazepam tablets or wafers (Klonopin™)
    When to call 911, when to call the office
  • Seizures and Injuries
    ~15-20% of patients will have at least one seizure related injury
    Most common are:
    Bruises, lacerations/abrasions, fractures, concussions, sprains, burns
    However, rates of injuries are only ~5% higher in people with epilepsy compared to general population
    Kwan et al. Epilepsia 2010
  • Falls & Fractures
    Most common cause of injury in epilepsy
    Falls may be due to
    Seizure
    Post-ictal state
    Side-effects of medications
    Most falls do not lead to significant injury
    Fractures can also occur from the seizure itself
    Compression fractures, clavicular fractures, shoulder fractures
    Concusions can occur in ~10% of seizure-related falls
  • Burns
    About 5% of patients with epilepsy will get burns requiring medical attention
    Burns are more common in patients with epilepsy
    Often related to falls or loss of awareness :
    Kitchen while cooking
    In the bathroom with hot water running
    Radiators
    Smoking
    Ironing
    Drinking hot beverages
  • Drowning
    People with epilepsy are 15 x more likely to drown than the general population
    Swimming and bathing
    Risk is even higher inc children, mostly in bathtubs
  • Prevention strategies
    General Strategies:
    Strive for optimal seizure control
    Discuss drug side effects with doctor
    Discuss your risks of osteoporosis with your doctor
    Weight bearing exercise
    Calcium and vitamin D
    Screening tests when indicated
    Appraise your situation: What would happen if you were to have seizure?
  • Kitchen & Bathroom safety
    If possible, cook with someone else around
    Use rear burners, insulated pot handles (facing inward)
    Microwaves
    Covered cups when drinking hot beverages
    Limit use of glass containers, knives as much as possible
    Use rubber gloves when washing dishes or cutting
  • Kitchen and bathroom safety, cont.
    Set boiler thermostat to <110 deg (saves money, too)
    Use single handle shower fixtures with scald guards or thermal regulator valves
    Always turn cold water on first
    Use shower curtains or doors that swing out
    Non-skid pads
    Don’t bath alone (and don’t bath your child alone)
    Keep the bathroom door unlocked
    Hang doors to open outward
  • Home safety
    Don’t climb ladders alone
    Don’t light candles or fires while alone
    Power tools should have automatic shutoff
    Use rugs, especially on hard surfaces like tile
    Limit clutter, sharp corners
  • What if you live alone?
    Have routine check ins with friends, family or neighbors
    Consider giving multiple reliable people keys to your home
    Consider medical alert device/service (e.g. Philips Lifeline™)
  • Sports and Recreation
    Never swim, ski, hike alone
    Pools are preferable to open water
    Let the lifeguard know you have epilepsy
    Wear helmets and protective equipment while biking, skiing
    Stay clear of ledges
    Wear life vests while boating
    Avoid free weights, treadmills at the gym
    Before engaging in an activity, ask: what would happen if I had a seizure?
  • Driving & other transportation
    Having even a brief seizure with altered awareness while driving can be deadly though seizure related car accidents are rare
    Laws in NY, NJ mandate 1 year of seizure freedom prior to driving; 3-6 mo in CT
    Period can be shortened if seizure is deemed unlikely to occur
    Determined by Neurological Disorders Committee in NJ
    Determined by MD in NY
  • Prevention
    Honor and obey your states restrictions regarding driving and seizures
    Avoid driving when reducing or making medication changes – discuss with your MD
    If you have an aura, pull over as safely and quickly as possible
    Avoid missing medications or other provocative factors
  • Epilepsy Mortality
    Epilepsy mortality is ~2.3 x higher than the general population
    Common causes of death in epilepsy included:
    Progression of underlying condition
    Status epilepticus
    Drowning
    Suicide
    Pneumonia
    Sudden death
  • Sudden unexpected death in epilepsy
    Definite: The sudden, unexpected, witnessed or unwitnessed, non-traumatic, and non-drowning death in patients with epilepsy with or without evidence for a seizure in which postmortem examination does not reveal a structural or toxicological cause for death
    Excluding status epilepticus
    Probable: sudden deaths occurring in benign circumstances with no known competing cause for death but without autopsy
    Possible: limited information regarding death circumstances or there is a plausible competing explanation for death
    Nashef, 1997; Annegers, 1997
  • Incidence of SUDEP
    Sudden death is ~24x more common in people with epilepsy compared with the general population
    Most common condition-related cause of death in chronic epilepsy
    100-fold range in SUDEP incidence within the epilepsy population
    0.09/1000 in prospective community-based studies of newly diagnosed patients
    9/1000 in epilepsy surgery candidates
  • SUDEP Rates
  • In comparison
    Risk of death from epilepsy surgery is ~1/1500
    Refractory epilepsy patients have the same risk of death in about 1 month
  • Risk Factors
    • Case-control studies have identified several factor associated with SUDEP risk
    Reviewed in Tomson et al Lancet Neurol 2008
  • Consistent Risk Factors
    Increased GTCS frequency
    Polytherapy
    Increased duration of epilepsy
    Early age of onset
    Hesdorffer et al. 2011
  • When does SUDEP occur?
    Sillipana & Shinnar 2010
  • Mechanisms of SUDEP
    Witnessed, EMU-recorded, and post-mortem studies all support a seizure, typically GTC, as the terminal event
    Three main mechanism emerge from EMU observed cases:
    Primary respiratory causes: central or obstructive apnea
    Cerebral shutdown: diffuse post-ictal suppression of EEG preceding EKG or respiratory changes
    Cardiac arrythmias
  • Resipiratory
    Seizures can caused decreased oxygenation
    Seizures can reduce the drive to breath (apnea)
    Some SUDEP may be failure to recover from these breathing problems
    Serotonin may play an important role
  • Brain Shutdown
    After a seizure, shutdown in brain function can:
    Reduce drive to breath
    Limit protective reflexes
    E.g. turning over when face is in pillow
  • Cardiac Arrhythmias
    Seizures may lead to heart arrythmias in some
    Some people may already have underlying heart disease
    Seizure is the ultimate stress test
    Most people have normal hearts
    Some people may carry genes that predispose them to arrythmias
    Some gene defects can predispose individuals to BOTH epilepsy and heart arrythmias
  • Preventing SUDEP
    No intervention is proven to prevent SUDEP
    Target modifiable risk factors:
    Optimize seizure control, especially GTCS
    Medications, surgery, devices if appropriate
    Compliance
    Lifestyle factors: good sleep, avoid excess alcohol
    Limiting # of total drugs?
    Supervision?
    Bed alarms
    Baby monitors
    Room sharing
  • Seizure alarms
    No evidence that they prevent SUDEP
    Not FDA approved for that purpose
    Frequent false alarms with current models may limit use
    Costly ~$800-1000
    Baby monitors are affordable
  • Seizure Alarms – future horizons
    Watch based devices
    ?more reliable
    Linked to phones/pagers
    Portable
    Smartphone applications
  • Anti-suffocation pillows
    Special pillows to prevent complete occlusion of the face when the person is face down
    Not proven to prevent SUDEP
  • For more information
     www.sudep.org  www.epilepsy.com www.sudepaware.org
    www.epilepsyfoundation.org
  • Questions?