Seizures in Seizures in AthletesAthletes

Kevin deWeber, MD, FAAFPKevin deWeber, MD, FAAFP

Director, Sports Medicine FellowshipDirector, Sports Medicine Fellowship

USUHSUSUHS

ObjectivesObjectives

• Refresh your knowledge of Refresh your knowledge of seizuresseizures• TypesTypes• EtiologyEtiology• Initial EvaluationInitial Evaluation• TreatmentsTreatments

• Discuss clearance considerations Discuss clearance considerations for athletes with epilepsyfor athletes with epilepsy

DefinitionDefinition

• SEIZURESEIZURE: an abnormal electrical : an abnormal electrical discharge of cortical neurons discharge of cortical neurons leading to sudden involuntary leading to sudden involuntary alteration in movement, perception alteration in movement, perception , or behavior., or behavior.

• EPILEPSYEPILEPSY: a disorder of recurrent : a disorder of recurrent seizuresseizures

Seizure classificationSeizure classification

• Partial seizuresPartial seizures• Localize in specific part Localize in specific part

of the brainof the brain• SIMPLE: no altered MSSIMPLE: no altered MS

• Limb twitchLimb twitch• Sensory disturbanceSensory disturbance• Psychic symptomsPsychic symptoms

• COMPLEX: involves COMPLEX: involves impaired consciousnessimpaired consciousness

• Can become Can become generalizedgeneralized

• Generalized seizuresGeneralized seizures• Bilateral cortical Bilateral cortical

dischargedischarge• COMPLEX in nature COMPLEX in nature

(impaired level of (impaired level of consciousness)consciousness)

• Tonic-clonicTonic-clonic• MyoclonicMyoclonic• AtonicAtonic• AbsenceAbsence

Seizure EtiologySeizure Etiology• Idiopathic (epilepsy)Idiopathic (epilepsy)• Trauma (concussion, hemorrhage)Trauma (concussion, hemorrhage)• Heat illnessHeat illness• Electrolyte abnormalities (Na)Electrolyte abnormalities (Na)• Toxins (Etoh, drugs, meds)Toxins (Etoh, drugs, meds)• Mass lesionsMass lesions• Metabolic disordersMetabolic disorders• Cerebral ischemia (gas embolism, stroke)Cerebral ischemia (gas embolism, stroke)• InfectionInfection

Seizure first aidSeizure first aid

• Monitor ABC’sMonitor ABC’s• Remove from any dangerous settingsRemove from any dangerous settings• Clear objects away to prevent injuryClear objects away to prevent injury• Monitor seizure closelyMonitor seizure closely

• Onset time, initial manifestation/aura, Onset time, initial manifestation/aura, altered LOC, cyanosis, automatic activities, altered LOC, cyanosis, automatic activities, tongue biting, incontinence, durationtongue biting, incontinence, duration

• If longer than 10 minutes If longer than 10 minutes STATUS STATUS EPILECTICUSEPILECTICUS

Additional pre-hospital Additional pre-hospital evaleval

• Check blood glucoseCheck blood glucose• Check core tempCheck core temp• Monitor Pox, VSMonitor Pox, VS• Review medical hx for possible Review medical hx for possible

cluesclues• Start IV if status epilepticusStart IV if status epilepticus

Status EpilepticusStatus Epilepticus

• Seizure > 10 min, or recurrent seizures Seizure > 10 min, or recurrent seizures >30 min w/o full recovery>30 min w/o full recovery

• Immediate treatment is needed to Immediate treatment is needed to prevent serious sequelaeprevent serious sequelae• Anoxic brain injuryAnoxic brain injury• IC hemorrhageIC hemorrhage• Cardiopulmonary arrestCardiopulmonary arrest• Renal failureRenal failure• HyperthermiaHyperthermia• Aspiration pneumoniaAspiration pneumonia• DeathDeath

Status EpilepticusStatus Epilepticus

• IF no IV access:IF no IV access:• Rectal diazepam in Rectal diazepam in

childrenchildren• Sublingual Sublingual

lorzezpamlorzezpam• IM midazolamIM midazolam• IM fosphenytoinIM fosphenytoin

• IV access ready:IV access ready:• IV lorazepam bolusIV lorazepam bolus• If persists >5min: IV If persists >5min: IV

fosphenytoin AND fosphenytoin AND phenytoinphenytoin

• If persists: ICU If persists: ICU admin, induce coma, admin, induce coma, add IV short-acting add IV short-acting drug (midazolam, drug (midazolam, thiopental, propofol)thiopental, propofol)

Case study: Case study: 16 yo softball player is at 16 yo softball player is at

tournament all day, very hot out, got tournament all day, very hot out, got home at 2200 hrs, has seizure, home at 2200 hrs, has seizure,

rushed to ED.rushed to ED.

Evaluation after first Evaluation after first seizureseizure

• Chem 20, CBC, ammoniaChem 20, CBC, ammonia• Drug screen, Etoh levelDrug screen, Etoh level• CT in ER, if negative f/u with MRICT in ER, if negative f/u with MRI• Refer for EEGRefer for EEG• If w/u negative for underlying cause:If w/u negative for underlying cause:

• No treatment neededNo treatment needed• Observation indicatedObservation indicated• Recurrent rate about 20% Recurrent rate about 20% epilepsy epilepsy

Athletes with EpilepsyAthletes with Epilepsy

• Become familiar with the seizuresBecome familiar with the seizures• TypeType• FrequencyFrequency• Known precipitantsKnown precipitants• Medications and complianceMedications and compliance• Adequacy of controlAdequacy of control

Clearance ConceptsClearance Concepts

• Sad fact: only 5% of epileptics Sad fact: only 5% of epileptics participate in regular physical activityparticipate in regular physical activity

• Happy factsHappy facts• Exercise improves seizure controlExercise improves seizure control• Exercise improves psych well-being, Exercise improves psych well-being,

socializationsocialization

• Encourage participation in epileptics!Encourage participation in epileptics!

Clearance ConceptsClearance Concepts

• Well-controlled seizures: very few Well-controlled seizures: very few contra-indicated sportscontra-indicated sports• Benefits outweigh small riskBenefits outweigh small risk

• Poorly-controlled seizures: be Poorly-controlled seizures: be cautiouscautious• Individualize decisionsIndividualize decisions

Individualizing Clearance Individualizing Clearance for Athletes with Epilepsyfor Athletes with Epilepsy

• How good is seizure control?How good is seizure control?• Poorly controlled: >1/yearPoorly controlled: >1/year• Controlled but actively treatedControlled but actively treated• Resolved; no treatmentResolved; no treatment

• What risk will this sport pose to the What risk will this sport pose to the athleteathlete if a seizure occurs? if a seizure occurs?

• What risk will this sport pose to What risk will this sport pose to OTHERSOTHERS if a seizure occurs?if a seizure occurs?

• What can be done to prevent seizure What can be done to prevent seizure occurrence?occurrence?

Clearance DecisionsClearance Decisions

• Aerobic sports: Aerobic sports: OKOK• Consider headgear for skiing Consider headgear for skiing

and skatingand skating

• Contact sportsContact sports• Controlled: Controlled: OKOK• Poorly controlled: Poorly controlled:

individualize decisionindividualize decision

Epilepsy and athletics. Clin Sports Med 2003;22(3)

Clearance DecisionsClearance Decisions

• Water sports--Water sports--OK with caveatsOK with caveats::• Provide visual supervisionProvide visual supervision• No open-water swimmingNo open-water swimming• Boating Boating withwith floatation device floatation device

• SCUBA diving: SCUBA diving: prohibited if activeprohibited if active

X

Clearance DecisionsClearance Decisions

• Sports at heightsSports at heights• Sky diving, hang gliding, rock climbing:Sky diving, hang gliding, rock climbing:

• Discouraged if controlledDiscouraged if controlled• Prohibited if poorly controlledProhibited if poorly controlled

• Gymnastics: Gymnastics: • OKOK if controlled if controlled• DiscourageDiscourage parallel bars & acrobatics if poorly parallel bars & acrobatics if poorly

controlledcontrolled

• Diving: Diving: prohibitedprohibited• Equestrian: Equestrian:

• OKOK if controlled if controlled• Discouraged if poorly controlledDiscouraged if poorly controlled

Epilepsy and athletics. Clin Sports Med 2003;22(3)

Clearance DecisionsClearance Decisions

• Motor sports: Motor sports: Prohibited, unlessProhibited, unless no no szrs >2yrs and eligible for drivers szrs >2yrs and eligible for drivers licenselicense

• Wheeled sports (e.g. wheelchair)Wheeled sports (e.g. wheelchair)• OKOK if Controlled if Controlled• ProhibitedProhibited if poorly controlled if poorly controlled

• Shooting sportsShooting sports• Individualize based on szr type & Individualize based on szr type &

frequency, and type of weapon usedfrequency, and type of weapon used

Epilepsy and athletics. Clin Sports Med 2003;22(3)

Clearance DecisionsClearance Decisions

• Sports involving repetitive blows to Sports involving repetitive blows to the headthe head• Boxing, martial artsBoxing, martial arts• No evidence of further seizure riskNo evidence of further seizure risk• IndividualizeIndividualize

Preventing SeizuresPreventing Seizures

• Avoid precipitantsAvoid precipitants• DehydrationDehydration• Extremes of heat/coldExtremes of heat/cold• Fatigue & sleep deprivationFatigue & sleep deprivation• HyperventilationHyperventilation• HypoxiaHypoxia• HypoglycemiaHypoglycemia

Anti-epileptic Anti-epileptic medicationsmedications

• Many are sedatingMany are sedating• Caution in risky sportsCaution in risky sports

• May decrease coordinationMay decrease coordination• Follow levels if appropriateFollow levels if appropriate

Summary of key pointsSummary of key points

• Exercise improves seizure control Exercise improves seizure control and should be encouragedand should be encouraged

• Well-controlled epileptics have Well-controlled epileptics have very few contra-indicated sportsvery few contra-indicated sports• SCUBA, divingSCUBA, diving

• Poorly-controlled (>1 szr/yr): fall, Poorly-controlled (>1 szr/yr): fall, shooting & collision sports shooting & collision sports discourageddiscouraged