Seizure Safety and Risk - Daniel Friedman, MD

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

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Seizure Safety and Risk - Daniel Friedman, MD

by NYU FACES on Jun 06, 2011

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Seizure Safety and Risk - Daniel Friedman, MD Presentation Transcript