1. Seizures in Athletes Kevin deWeber, MD, FAAFP Director, Sports Medicine Fellowship USUHS

2. Objectives Refresh your knowledge of seizuresRefresh your knowledge of seizures TypesTypes EtiologyEtiology Initial EvaluationInitial Evaluation TreatmentsTreatments Discuss clearance considerations for athletes with epilepsyDiscuss clearance considerations for athletes with epilepsy

3. Definition SEIZURE: an abnormal electrical discharge of cortical neurons leading to sudden involuntary alteration in movement, perception, or behavior.SEIZURE: an abnormal electrical discharge of cortical neurons leading to sudden involuntary alteration in movement, perception, or behavior. EPILEPSY: a disorder of recurrent seizuresEPILEPSY: a disorder of recurrent seizures

5. Seizure classification Partial seizuresPartial seizures Localize in specific part of the brainLocalize in specific part of the brain SIMPLE: no altered MSSIMPLE: no altered MS Limb twitchLimb twitch Sensory disturbanceSensory disturbance Psychic symptomsPsychic symptoms COMPLEX: involves impaired consciousnessCOMPLEX: involves impaired consciousness Can become generalizedCan become generalized Generalized seizuresGeneralized seizures Bilateral cortical discharge COMPLEX in nature (impaired level of consciousness) Tonic-clonic Myoclonic Atonic Absence

7. Seizure 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

9. Seizure first aid Monitor ABCsMonitor ABCs 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, altered LOC, cyanosis, automatic activities, tongue biting, incontinence, durationOnset time, initial manifestation/aura, altered LOC, cyanosis, automatic activities, tongue biting, incontinence, duration If longer than 10 minutes STATUS EPILECTICUSIf longer than 10 minutes STATUS EPILECTICUS

10. Additional pre-hospital eval Check blood glucoseCheck blood glucose Check core tempCheck core temp Monitor Pox, VSMonitor Pox, VS Review medical hx for possible cluesReview medical hx for possible clues Start IV if status epilepticusStart IV if status epilepticus

11. Status Epilepticus Seizure > 10 min, or recurrent seizures >30 min w/o full recoverySeizure > 10 min, or recurrent seizures >30 min w/o full recovery Immediate treatment is needed to prevent serious sequelaeImmediate treatment is needed to prevent serious sequelae Anoxic brain injuryAnoxic brain injury IC hemorrhageIC hemorrhage Cardiopulmonary arrestCardiopulmonary arrest Renal failureRenal failure HyperthermiaHyperthermia Aspiration pneumoniaAspiration pneumonia DeathDeath

12. Status Epilepticus IF no IV access:IF no IV access: Rectal diazepam in childrenRectal diazepam in children Sublingual lorzezpamSublingual lorzezpam IM midazolamIM midazolam IM fosphenytoinIM fosphenytoin IV access ready:IV access ready: IV lorazepam bolus If persists >5min: IV fosphenytoin AND phenytoin If persists: ICU admin, induce coma, add IV short-acting drug (midazolam, thiopental, propofol)

13. Case study: 16 yo softball player is at tournament all day, very hot out, got home at 2200 hrs, has seizure, rushed to ED.

14. Evaluation after first seizure 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% epilepsyRecurrent rate about 20% epilepsy

15. Athletes 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

16. Clearance Concepts Sad fact: only 5% of epileptics participate in regular physical activitySad fact: only 5% of epileptics participate in regular physical activity Happy factsHappy facts Exercise improves seizure controlExercise improves seizure control Exercise improves psych well-being, socializationExercise improves psych well-being, socialization Encourage participation in epileptics!Encourage participation in epileptics!

17. Clearance Concepts Well-controlled seizures: very few contra-indicated sportsWell-controlled seizures: very few contra-indicated sports Benefits outweigh small riskBenefits outweigh small risk Poorly-controlled seizures: be cautiousPoorly-controlled seizures: be cautious Individualize decisionsIndividualize decisions

18. Individualizing Clearance for 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 athlete if a seizure occurs?What risk will this sport pose to the athlete if a seizure occurs? What risk will this sport pose to OTHERS if a seizure occurs?What risk will this sport pose to OTHERS if a seizure occurs? What can be done to prevent seizure occurrence?What can be done to prevent seizure occurrence?

19. Clearance Decisions Aerobic sports: OKAerobic sports: OK Consider headgear for skiing and skatingConsider headgear for skiing and skating Contact sportsContact sports Controlled: OKControlled: OK Poorly controlled: individualize decisionPoorly controlled: individualize decision Epilepsy and athletics. Clin Sports Med 2003;22(3)

20. Clearance Decisions Water sports--OK with caveats:Water sports--OK with caveats: Provide visual supervisionProvide visual supervision No open-water swimmingNo open-water swimming Boating with floatation deviceBoating with floatation device SCUBA diving: prohibited if activeSCUBA diving: prohibited if active X

21. Clearance 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: OK if controlledOK if controlled Discourage parallel bars & acrobatics if poorly controlledDiscourage parallel bars & acrobatics if poorly controlled Diving: prohibitedDiving: prohibited Equestrian:Equestrian: OK if controlledOK if controlled Discouraged if poorly controlledDiscouraged if poorly controlled Epilepsy and athletics. Clin Sports Med 2003;22(3)

22. Clearance Decisions Motor sports: Prohibited, unless no szrs >2yrs and eligible for drivers licenseMotor sports: Prohibited, unless no szrs >2yrs and eligible for drivers license Wheeled sports (e.g. wheelchair)Wheeled sports (e.g. wheelchair) OK if ControlledOK if Controlled Prohibited if poorly controlledProhibited if poorly controlled Shooting sportsShooting sports Individualize based on szr type & frequency, and type of weapon usedIndividualize based on szr type & frequency, and type of weapon used Epilepsy and athletics. Clin Sports Med 2003;22(3)

23. Clearance Decisions Sports involving repetitive blows to the headSports involving repetitive blows to the head Boxing, martial artsBoxing, martial arts No evidence of further seizure riskNo evidence of further seizure risk IndividualizeIndividualize

24. Preventing Seizures Avoid precipitantsAvoid precipitants DehydrationDehydration Extremes of heat/coldExtremes of heat/cold Fatigue & sleep deprivationFatigue & sleep deprivation HyperventilationHyperventilation HypoxiaHypoxia HypoglycemiaHypoglycemia

25. Anti-epileptic medications Many are sedatingMany are sedating Caution in risky sportsCaution in risky sports May decrease coordinationMay decrease coordination Follow levels if appropriateFollow levels if appropriate

26. Summary of key points Exercise improves seizure control and should be encouragedExercise improves seizure control and should be encouraged Well-controlled epileptics have very few contra-indicated sportsWell-controlled epileptics have very few contra-indicated sports SCUBA, divingSCUBA, diving Poorly-controlled (>1 szr/yr): fall, shooting & collision sports discouragedPoorly-controlled (>1 szr/yr): fall, shooting & collision sports discouraged