Epilepsy and Epilepsy and Seizure Seizure

ManagementManagementFor EMS Personnel

This product was developed with support from the Centers for Disease Control and Prevention under cooperative agreement number 5U58DP000606-05. Its contents are

solely the responsibility of the authors and do not necessarily represent the official views of the CDC.

This training is designed to:This training is designed to:

Prepare EMS responders to Prepare EMS responders to recognize and respond recognize and respond

appropriately to seizures caused appropriately to seizures caused by epilepsy or as a result by epilepsy or as a result of trauma or other acute or chronic of trauma or other acute or chronic

illness.illness.

A seizure is:A seizure is:

A sudden, brief disruption of the normal A sudden, brief disruption of the normal functioning of neurons in the brainfunctioning of neurons in the brain

A seizure may appear as:A seizure may appear as:

A sudden cry and fall, followed byA sudden cry and fall, followed by Convulsive movements of all limbsConvulsive movements of all limbs Shallow/interrupted breathing - Shallow/interrupted breathing -

cyanosiscyanosis Loss of bowel/bladder controlLoss of bowel/bladder control Slow return to consciousness, post-Slow return to consciousness, post-

seizure confusion and/or fatigueseizure confusion and/or fatigue

This is a generalized tonic-clonic or “grand mal” seizure.

or a seizure may be…or a seizure may be…

Blank staring, chewing, other repetitive Blank staring, chewing, other repetitive purposeless movementspurposeless movements

Wandering, confusion, incoherent speechWandering, confusion, incoherent speech Crying, screaming, running, flailingCrying, screaming, running, flailing A sudden loss of muscle tone and fallA sudden loss of muscle tone and fall Picking at clothes, disrobingPicking at clothes, disrobing

This is one type of partial seizure known as a complex partial seizure.

Seizure CausesSeizure Causes

High fever, especially in infantsHigh fever, especially in infants Drug use, alcohol withdrawalDrug use, alcohol withdrawal Near-drowning or lack of oxygen Near-drowning or lack of oxygen

from another cause from another cause Metabolic disturbancesMetabolic disturbances Head traumaHead trauma Brain tumor, infection, strokeBrain tumor, infection, stroke Complication of diabetes or pregnancyComplication of diabetes or pregnancy

A common cause of A common cause of seizures is seizures is epilepsyepilepsy – –

Epilepsy (also known as a ‘seizure disorder’) is a chronic neurological disorder characterized by recurring

seizures that are not otherwise provoked by an acute injury or health

emergency.

Epilepsy is Epilepsy is not contagiousnot contagious, , it is it is not a mental illnessnot a mental illness or a cognitive or a cognitive

disabilitydisability. The . The neurological dysfunction seen in neurological dysfunction seen in

epilepsy can begin at birth, epilepsy can begin at birth, childhood, adolescence, or even childhood, adolescence, or even

in adulthood.in adulthood.

StrokeStroke Brain tumorBrain tumor Brain infectionBrain infection Past head injuryPast head injury Metabolic problemsMetabolic problems

Causes of epilepsy include:Causes of epilepsy include:

Over 3 million Americans of all ages have epilepsy. Other neurological conditionsOther neurological conditions

Genetic factorsGenetic factors

Epilepsy may occur with:Epilepsy may occur with:

Cerebral palsyCerebral palsy Cognitive Cognitive

impairmentsimpairments ADD/ADHDADD/ADHD

Developmental Developmental disabilitiesdisabilities

AutismAutism

… … but the majority of people who have epilepsy do not have other impairments and live very normal lives.

In a In a generalized generalized seizure seizure

the the electrical electrical disruption disruption

involves the involves the entire brain.entire brain.

Loss of consciousness, fall and Loss of consciousness, fall and stiffening of limbs, followed by stiffening of limbs, followed by rhythmic shaking.rhythmic shaking.

Breathing may stop temporarily - Breathing may stop temporarily - skin, nails, lips may turn blue skin, nails, lips may turn blue

Loss of bladder/bowel control may occurLoss of bladder/bowel control may occur Generally lasts 1 to 3 minutesGenerally lasts 1 to 3 minutes Followed by confusion, sleepinessFollowed by confusion, sleepiness

Tonic-Clonic SeizureTonic-Clonic Seizure -“grand mal”

In a partial seizure In a partial seizure

the electrical the electrical disruption disruption

involves a limited involves a limited area of the brain.area of the brain.

Seizure activity in the brain causing:Seizure activity in the brain causing: Rhythmic movements - Rhythmic movements -

isolated twitching of arms, face, isolated twitching of arms, face, legslegs

Sensory symptoms - Sensory symptoms - tingling, weakness, sounds, smells, tingling, weakness, sounds, smells, tastes, tastes, feeling of upset stomach, feeling of upset stomach, visual distortionsvisual distortions

Psychic symptoms - Psychic symptoms - déjà vu, hallucinations, déjà vu, hallucinations, feelings of fear or anxietyfeelings of fear or anxiety

Usually last less than one minuteUsually last less than one minute May precede a generalized seizureMay precede a generalized seizure

Simple Partial SeizureSimple Partial Seizure

Characterized by altered awarenessCharacterized by altered awareness Confusion, inability to respondConfusion, inability to respond Automatic, purposeless behaviors such Automatic, purposeless behaviors such

as picking at clothes, chewing or as picking at clothes, chewing or mumbling.mumbling.

Emotional outburstsEmotional outbursts May be confused with:May be confused with:

Drunkenness or drug useDrunkenness or drug use Willful belligerence, aggressivenessWillful belligerence, aggressiveness

Complex Partial SeizureComplex Partial Seizure

Anti-epileptic MedicationsAnti-epileptic Medications

• Depakote (Valproic Depakote (Valproic acid)acid)

• Felbatol (felbamate)Felbatol (felbamate)• Gabatril (tiagabine)Gabatril (tiagabine)• Keppra Keppra

(levetiracetam)(levetiracetam)• Lamictal (lamotrigine)Lamictal (lamotrigine)• Dilantin (phenytoin)Dilantin (phenytoin)• phenobarbitolphenobarbitol

•Neurontin (gabapentin)

•Tegretol

(carbamezepine)

•Trileptal (oxcarbazepine)

•Topamax (topiramate)

•Zonegran (zonisamide)

•Lyrica (pregabalin)

Medications ChartMedications Chart

Medications Chart (cont.)Medications Chart (cont.)[This chart also found on pages 30 and 36 of the final Participant’s and Trainer’s Guides, [This chart also found on pages 30 and 36 of the final Participant’s and Trainer’s Guides,

respectively].respectively].

Surgical treatmentSurgical treatment

Factors influencing decision:Factors influencing decision: Ability to identify focus of seizuresAbility to identify focus of seizures Area of brain involved can Area of brain involved can

be safely removed – without be safely removed – without resulting in a significant deficitresulting in a significant deficit

Other treatments have been Other treatments have been unsuccessfulunsuccessful

Vagus Nerve StimulatorVagus Nerve Stimulator

An implanted device that An implanted device that sends regular, mild sends regular, mild electrical pulses to the electrical pulses to the brain via the vagus nerve brain via the vagus nerve

May also be activated May also be activated by an external magnetby an external magnet Functioning of the VNS may be Functioning of the VNS may be affected by the use of a taser device.affected by the use of a taser device.

More information about the VNS can be found at: www.cyberonics.org

Patients with epilepsy may Patients with epilepsy may still have seizures due to: still have seizures due to:

Failure to take medication Failure to take medication correctlycorrectly Variation in medication Variation in medication effectivenesseffectiveness Sleep deprivationSleep deprivation Stress/Stress/ IllnessIllness Hypoglycemia/dehydrationHypoglycemia/dehydration Alcohol/drug use or withdrawalAlcohol/drug use or withdrawal Hormonal fluctuationsHormonal fluctuations Flashing lights or other triggersFlashing lights or other triggers

Some epilepsy patients never achieve Some epilepsy patients never achieve effective seizure control and may effective seizure control and may

experience varying degrees of experience varying degrees of financial, social and legal problems.financial, social and legal problems.

DVD: DVD: A Guide toA Guide to

Seizure Management for Seizure Management for Emergency Medical Emergency Medical

RespondersResponders

Pre-hospital Treatment – Pre-hospital Treatment – Generalized tonic-clonic Generalized tonic-clonic

seizureseizure Assure scene safety If trauma is not suspected,

place patient in recovery position Protect head/limbs from injury Follow A B C protocol:

Maintain airway – suction PRN

Administer O2

Monitor cardio-respiratory status

Traumatic injury Possible aspiration (seizure in water) Elderly, pregnant or diabetic patient

Check blood glucose

Seizure lasting longer than 5 minutes, or occurring in a series

During GTC seizure, assess During GTC seizure, assess for:for:

When present, activate When present, activate ALS and/or rapidly transport to ALS and/or rapidly transport to

receiving facility receiving facility

After the seizure stops:After the seizure stops: Continue to monitor cardiorespiratory status Evaluate for injury Assess for return of consciousness/re-orient Obtain pertinent medical history and

emergency contact information if possible

Activate ALS and/or rapidly Activate ALS and/or rapidly transport to receiving facility if transport to receiving facility if

consciousness does not return, or consciousness does not return, or confusion persists more than 20 confusion persists more than 20

minutes post-seizureminutes post-seizure

Question witnesses:Question witnesses:

Description of seizure event Identifying information for patient,

emergency contacts Prior history of seizures or other

medical problems

After a first-time GTC seizure, or if After a first-time GTC seizure, or if there is another medical condition, there is another medical condition,

medical evaluation is necessary medical evaluation is necessary to identify and treat the cause.to identify and treat the cause.

ALS response to a GTC seizure ALS response to a GTC seizure that has lasted longer than 5 that has lasted longer than 5

minutes:minutes:Per local protocols, administer

meds to stop seizure activity: Diazepam (Valium) – IV or Diastat rectal gel form * Midazolam (Versed) – IV, IM,

buccal or intranasal

Lorazepam (Ativan) – IV or IM

Support ventilation PRN

*For more information about Diastat see: www.diastatacudial.org

Options for Treating Options for Treating Repetitive SeizuresRepetitive Seizures

The only FDA-approved treatment for acute repetitive seizures is rectal Diastat, but nasal or buccal midazolam have been shown to be equally effective. Some services make arrangements to use alternate forms.*

* These alternate methods are currently in a Phase 1 FDA clinical trial. (www.clinical trials.gov) with an estimated completion date of April 2012.

After stabilizing the patient, transport to receiving facility. Monitor vital signs.

Report to ED the type and dose of seizure rescue medication that was administered.

Pre-hospital Treatment – Pre-hospital Treatment – Complex Partial Seizure (CPS)Complex Partial Seizure (CPS)

May be reported as drunkenness/illegal drug use medical conditions such as a

stroke or diabetic reaction “person acting strangely”

Look for sudden loss of awareness Look for sudden loss of awareness and automatic, purposeless and automatic, purposeless

behaviors such as behaviors such as picking at clothes, chewing, picking at clothes, chewing,

mumbling or wandering.mumbling or wandering.

Response to suspected Response to suspected complex partial seizure:complex partial seizure:

Approach cautiously, speak calmly Contain – don’t restrain Prevent from injuring self Look for medical ID, identifying

information

Avoid triggering violent behavior Avoid triggering violent behavior by minimizing physical contact.by minimizing physical contact.

Post-ictal phase (post-Post-ictal phase (post-seizure):seizure): Monitor recovery, check blood glucose Re-orient to surroundings Evaluate for injury More in-depth history as appropriate

Activate ALS and/or rapidly Activate ALS and/or rapidly transport to receiving facility if transport to receiving facility if injury is present or if confusion injury is present or if confusion

persists over 20 minutes persists over 20 minutes after seizure ends.after seizure ends.

Question Question witnesses:witnesses: Description of seizure event Any known history of seizures? If possible, obtain medical history, ID

and emergency contact information

After a first-time seizure, After a first-time seizure, medical evaluation is medical evaluation is necessary to identify necessary to identify

and treat the cause.and treat the cause.

Contact the Epilepsy Foundation for more Contact the Epilepsy Foundation for more information:information:

1-800-332-1000 1-800-332-1000 www.epilepsyfoundation.org

Or Click Here to Contact your Local Epilepsy Foundation Affiliate