Seizure Safety and Risk - Daniel Friedman, MD


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Seizure Safety and Seizure Risk: From First Aid to SUDEP

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Seizure Safety and Risk - Daniel Friedman, MD

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