Epilepsy and Seizure Management For EMS Personnel This product was developed with support from the Centers for Disease Control and Prevention under cooperative agreement number 5U58DP 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: Prepare EMS responders to recognize and respond appropriately to seizures caused by epilepsy or as a result of trauma or other acute or chronic illness. Prepare EMS responders to recognize and respond appropriately to seizures caused by epilepsy or as a result of trauma or other acute or chronic illness.

A seizure is: A sudden, brief disruption of the normal functioning of neurons in the brain

A seizure may appear as: A sudden cry and fall, followed by  Convulsive movements of all limbs  Shallow/interrupted breathing - cyanosis  Loss of bowel/bladder control  Slow return to consciousness, post- seizure confusion and/or fatigue This is a generalized tonic-clonic or “grand mal” seizure.

or a seizure may be…  Blank staring, chewing, other repetitive purposeless movements  Wandering, confusion, incoherent speech  Crying, screaming, running, flailing  A sudden loss of muscle tone and fall  Picking at clothes, disrobing This is one type of partial seizure known as a complex partial seizure.

Seizure Causes  High fever, especially in infants  Drug use, alcohol withdrawal  Near-drowning or lack of oxygen from another cause  Metabolic disturbances  Head trauma  Brain tumor, infection, stroke  Complication of diabetes or pregnancy

A common cause of seizures is epilepsy – A common cause of seizures is epilepsy – 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 not contagious, it is not a mental illness or a cognitive disability. The neurological dysfunction seen in epilepsy can begin at birth, childhood, adolescence, or even in adulthood.

 Stroke  Brain tumor  Brain infection  Past head injury  Metabolic problems Causes of epilepsy include: Over 3 million Americans of all ages have epilepsy.  Other neurological conditions  Genetic factors

Epilepsy may occur with:  Cerebral palsy  Cognitive impairments  ADD/ADHD  Developmental disabilities  Autism

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

In a generalized seizure the electrical disruption involves the entire brain.

 Loss of consciousness, fall and stiffening of limbs, followed by rhythmic shaking.  Breathing may stop temporarily - skin, nails, lips may turn blue  Loss of bladder/bowel control may occur  Generally lasts 1 to 3 minutes  Followed by confusion, sleepiness Tonic-Clonic Seizure Tonic-Clonic Seizure -“ grand mal”

In a partial seizure the electrical disruption involves a limited area of the brain.

Seizure activity in the brain causing: Rhythmic movements - isolated twitching of arms, face, legs Rhythmic movements - isolated twitching of arms, face, legs Sensory symptoms - tingling, weakness, sounds, smells, tastes, feeling of upset stomach, visual distortions Sensory symptoms - tingling, weakness, sounds, smells, tastes, feeling of upset stomach, visual distortions Psychic symptoms - déjà vu, hallucinations, feelings of fear or anxiety Psychic symptoms - déjà vu, hallucinations, feelings of fear or anxiety  Usually last less than one minute  May precede a generalized seizure Simple Partial Seizure

 Characterized by altered awareness  Confusion, inability to respond  Automatic, purposeless behaviors such as picking at clothes, chewing or mumbling.  Emotional outbursts  May be confused with: Drunkenness or drug use Drunkenness or drug use Willful belligerence, aggressiveness Willful belligerence, aggressiveness Complex Partial Seizure

Anti-epileptic Medications Depakote (Valproic acid) Depakote (Valproic acid) Felbatol (felbamate) Felbatol (felbamate) Gabatril (tiagabine) Gabatril (tiagabine) Keppra (levetiracetam) Keppra (levetiracetam) Lamictal (lamotrigine) Lamictal (lamotrigine) Dilantin (phenytoin) Dilantin (phenytoin) phenobarbitol phenobarbitol Neurontin (gabapentin) Tegretol (carbamezepine) Trileptal (oxcarbazepine) Topamax (topiramate) Zonegran (zonisamide) Lyrica (pregabalin)

Medications Chart

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

Surgical treatment Factors influencing decision:  Ability to identify focus of seizures  Area of brain involved can be safely removed – without resulting in a significant deficit  Other treatments have been unsuccessful

Vagus Nerve Stimulator  An implanted device that sends regular, mild electrical pulses to the brain via the vagus nerve  May also be activated by an external magnet  Functioning of the VNS may be affected by the use of a taser device. More information about the VNS can be found at:

Patients with epilepsy may still have seizures due to:  Failure to take medication correctly  Variation in medication effectiveness  Sleep deprivation  Stress/Illness  Stress/ Illness  Hypoglycemia/dehydration  Alcohol/drug use or withdrawal  Hormonal fluctuations  Flashing lights or other triggers

Some epilepsy patients never achieve effective seizure control and may experience varying degrees of financial, social and legal problems.

DVD: DVD: A Guide to Seizure Management for Emergency Medical Responders

Pre-hospital Treatment – Generalized tonic-clonic seizure   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 O 2 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 for: When present, activate ALS and/or rapidly transport to receiving facility

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 transport to receiving facility if consciousness does not return, or confusion persists more than 20 minutes post-seizure

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 there is another medical condition, medical evaluation is necessary to identify and treat the cause.

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

Options for Treating Repetitive 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. ( 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 – 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 and automatic, purposeless behaviors such as picking at clothes, chewing, mumbling or wandering.

Response to suspected 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 by minimizing physical contact.

Post-ictal phase (post-seizure):   Monitor recovery, check blood glucose   Re-orient to surroundings   Evaluate for injury   More in-depth history as appropriate Activate ALS and/or rapidly transport to receiving facility if injury is present or if confusion persists over 20 minutes after seizure ends.

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

Contact the Epilepsy Foundation for more information: Or Click Here to Contact your Local Epilepsy Foundation Affiliate Or Click Here to Contact your Local Epilepsy Foundation Affiliate