seizure safety and risk - daniel friedman, md
DESCRIPTION
Seizure Safety and Seizure Risk: From First Aid to SUDEPTRANSCRIPT
DANIEL FRIEDMAN, MDASSISTANT PROFESSOR OF NEUROLOGY
NYU COMPREHENSIVE EPILEPSY CENTER
Seizure Safety and Seizure Risk: From First Aid to
SUDEP
Outline
Seizure First AidSeizure-related injuriesStrategies for preventionEpilepsy and drivingSeizure-related mortalitySudden 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 dangerSpeak in reassuring voiceStay with the person until they are fully
awareExplain 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 waterThe person is pregnant or diabeticThe seizure lasts > 5min or they
come one after anotherThe person does not wake up
appropriatelyThere is injury due to the seizureThere 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, burnsHowever, 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 epilepsyFalls may be due to
Seizure Post-ictal state Side-effects of medications
Most falls do not lead to significant injuryFractures can also occur from the seizure
itself Compression fractures, clavicular fractures, shoulder
fracturesConcusions 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 doctorDiscuss 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 aroundUse rear burners, insulated pot handles
(facing inward)MicrowavesCovered cups when drinking hot beveragesLimit use of glass containers, knives as much
as possibleUse 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 firstUse shower curtains or doors that swing outNon-skid padsDon’t bath alone (and don’t bath your child
alone)Keep the bathroom door unlockedHang doors to open outward
Home safety
Don’t climb ladders aloneDon’t light candles or fires while alonePower tools should have automatic shutoffUse rugs, especially on hard surfaces like tileLimit 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 alonePools are preferable to open water
Let the lifeguard know you have epilepsyWear helmets and protective equipment while
biking, skiingStay clear of ledgesWear life vests while boatingAvoid free weights, treadmills at the gymBefore 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
10
8
6
4
2
0SUD
EP ra
te (p
er 1
000
pers
on-y
ears
)
Children
Population-based Cohorts
Epilepsy
Patients
MR Patients
Refracto
ry Patients
Surgi
cal P
atients
(10)
(7)
(3)
(4)
(3)
(4)
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
Factors associated with increased SUDEP risk
Factors associated with decreased SUDEP risk
Frequent GTCs Seizure freedom
Subtherapeutic AED levels Sharing bedroom/monitoringAED PolytherapyEarly age of epilepsy onset/longer duration of epilepsyYoung ageMale sexMental retardation
Reviewed in Tomson et al Lancet Neurol 2008
Consistent Risk Factors
Increased GTCS frequencyPolytherapyIncreased duration of epilepsyEarly 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 oxygenationSeizures can reduce the drive to breath
(apnea)Some SUDEP may be failure to recover from
these breathing problemsSerotonin 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 heartsSome 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 SUDEPTarget 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 ~$800-1000Baby monitors are
affordable
Seizure Alarms – future horizons
Watch based devices?more reliableLinked to
phones/pagersPortableSmartphone
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?