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Seizures and the EMS Response: “Treating the Cause” EMSWorld EXPO

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Seizures and the EMS Response: “Treating the Cause” EMSWorld EXPO November 13, 2014 – Nashville Aldith Steer, M.A., Program Manager, Epilepsy Foundation Gary McLean, RN, Paramedic – Sandy, OR Funded by CDC grant #1U58DP GENERAL INTRODUCTION: Three instructors representing the Epilepsy Foundation: Aldith Steer: Program Manager of Multicultural Affairs, Epilepsy Foundation, Landover, Maryland Tom McCarrier: Retired Police Officer and Retired Associate Dean of EMS and Fire Education Programs, Mid-State Technical College, Wisconsin Rapids, Wisconsin Gary McLean: RN, Paramedic – Sandy, Oregon 1

2 Videos, Photos and Drawings
Epilepsy Foundation Logo EMS World Expo ‘Print’ Presentation To reduce the size and for ease of printing and ing, many of the photos, video clips and logos used during the presentation have been removed from this print version. A URL address for each video clip (unedited) has been provided in exchange for the actual video. Many of the photos have also been removed and may be found online through various sources. Videos, Photos and Drawings All found online, not used for profit, and we thank the creators for their availability and use for this educational purposes. Information and references found online at numerous locations – 2

3 Informational Resources
Epilepsy Foundation Logo Informational Resources Epilepsy Foundation Epilepsy Therapy Project Robert Fisher, MD, PhD Epilepsy.Com EpilepsyProject.Com The American Epilepsy Society National Institutes of Health Information and references found online at numerous locations – 3

4 Why this topic? Definition of CONVULSION
A convulsion is what you actually see the person having. The shakes, the bizarre muscle movements and activity… It is a commonly used term, although incorrectly used, to also describe a seizure. -- often used in plural < a patient suffering from convulsions > 4

5 when transport necessary
EMS responders unsure regarding what they were seeing, how to treat, and when transport necessary Goal: 1. Current information 2. What you need to know 3. Positive outcome for the EMS crew, bystanders, family and most importantly, the individual needing EMS care. 4. Help decrease negative stigma of epilepsy and seizures through education 5

6 Topic Objectives - A&P Basics: What are you actually witnessing
- Treatment: When and How Transport: Is it always necessary? New approaches: Treatments you may see Quality of Life: The personal impact of Epilepsy Objectives: 1. A&P – Where the disorder located in the brain and what is it doing. Help explain what you are actually observing. 2. Treatments – What works where and why 3. Transport: Is ambulance transport always necessary 4. New medical treatments for seizure disorders 5. Psychosocial impact of having a seizure disorder 6. Cover some common questions asked about seizures by EMS providers. 6

7 What is going on inside the skull?
It involves the Cerebral Cortex, Neurons, Action Potentials and Neurotransmitters Add video, photo or drawing to help student cognitively understand above listed items. Remember basic brain anatomy? Lets talk about: The Cerebral Cortex: Neurons: Action Potentials: Neurotransmitters: 7

8 What is going on inside the skull?
Cerebral Cortex: Remember that large mass on the top of the brain? That’s called the cerebrum. It’s outer layer, the gray matter, is called the Cerebral Cortex. Within the cerebral Cortex are nerves called Neurons ... 8

9 What is going on inside the skull?
Neuron (Dendrites, Nucleus, Axon & Synaptic Terminals): Neurons are made up of a DENDRITE - where the signal is first received…. The signal goes to the CELL BODY and the NUCLEUS (aka SOMA) - the control center of the nerve…. The signal goes down the AXON to the SYNAPTIC TERMINALS…

10 What is going on inside the skull?
Neuron (Dendrites, Nucleus, Axon & Synaptic Terminals): Neurons are made up of a DENDRITE - where the signal is first received…. The signal goes to the CELL BODY and the NUCLEUS (aka SOMA) - the control center of the nerve…. The signal goes down the AXON to the SYNAPTIC TERMINALS…

11 What is going on inside the skull?
Action Potentials: Neurons send messages, called nerve impulses or action potentials, around the body, one neuron to another. Action Potentials: The signals that travel down the axon are called nerve impulses or action potentials, around the body, one neuron to another. The Action Potential is the ‘message’...

12 What is going on inside the skull?
Action Potentials: Sodium, Potassium and Calcium shifts Action Potentials: As the ACTION POTENTIAL travels down the axon, sodium (Na) and potassium (K) swap places inside and outside the nerve pathway, to creating an electrical current that continues to push the ACTION POTENTIAL traveling down the axon. Calcium also makes a shift in the pre-synaptic axon allowing further movement of the Action Potential

13 What is going on inside the skull?
Action Potentials: Sodium, Potassium and Calcium shifts Action Potentials: As the ACTION POTENTIAL travels down the axon, sodium (Na) and potassium (K) swap places inside and outside the nerve pathway, to creating an electrical current that continues to push the ACTION POTENTIAL traveling down the axon. Calcium also makes a shift in the pre-synaptic axon allowing further movement of the Action Potential

14 See the YouTube Video at:
What is going on inside the skull? Neurotransmitters: See the YouTube Video at: The Brain—Lesson 2—How Neurotransmission Works - - By: The Professor Ted https://www.youtube.com/watch?v=p5zFgT4aofA When an ACTION POTENTIAL gets to the SYNAPTIC TERMINALS at the end of the axon, it causes a release of chemicals called NEUROTRANSMITERS. There are many NEUROTRANSMITERS (over 50): Dopamine, Serotonin… NEUROTRANSMITERS help get the message across the SYNAPTIC GAP to the DENDRITE of the next NEURON. Here is a video that helps explain this in quick detail. Sound

15 What is going on inside the skull?
Neurotransmitters: Dopamine Adenosine Epinephrine Norepinephrine Oxytocin Histamine Serotonin Acetylcholine …… over 150 known When an ACTION POTENTIAL gets to the SYNAPTIC TERMINALS at the end of the axon, it causes a release of chemicals called NEUROTRANSMITERS. There are many NEUROTRANSMITERS (over 50): Dopamine, Serotonin… NEUROTRANSMITERS help get the message across the SYNAPTIC GAP to the DENDRITE of the next NEURON. Here is a video that helps explain this in quick detail.

16 What is going on inside the skull?
GLUTAMATE and GABA (gamma-aminobutyric acid): the brain's major "workhorse" neurotransmitters that regulate action potential traffic. GABA = inhibitory = stops / slows action potentials. GLUTAMATE = excitatory = starts action potentials or keeps them going. Both work together to control many processes, including the brain's overall level of excitation. Two NEUROTRANSMITERS, one called GLUTAMATE and the other called Gamma-Aminobutyric Acid - aka GABA - speed and slow ACTION POTENTIALs. GLUTAMATE, an EXCITATORY NEURTRANSMITER, helps start or speed up ACTION POTENTIALS. GABA, called an INHIBITORY NEUROTRANSMITER, slows or stops the ACTION POTENTIAL from the next neuron. Both GABA and Glutamate work together to control or balance many processes, including the brain's overall level of excitation.

17 Maintaining a Balance Add video, photo or drawing showing how GABA and Glutamate are affected by caffeine, alcohol, PCP, etc. Many drugs of abuse affect either glutamate or GABA or both to exert tranquilizing or stimulating effects on the brain. GABA is capable of suppressing fear as well as many other emotional and motivational processes. Benzodiazepines (diazepam = VALIUM) couple with receptors along the FEAR circuit that "are closely coupled to GABA function in the brain.” In other words, benzodiazepines facilitate GABA activity and thereby reduce fear.

18 So then, what is a SEIZURE?
An unpredictable, uncontrolled, abnormal and excessive synchronization imbalance of the excitatory and inhibitory forces within the CNS network of cortical neurons in the cerebral cortex. Add video, photo or drawing showing how GABA and Glutamate are affected by caffeine, alcohol, PCP, etc. So what is a good definition for a seizure? Read definition…. When there is not enough GABA or too much glutamate, receiving neurons can be flooded with positively charged sodium particles (Na+) that tell the receiving neuron to rapidly pass on the message…. a person can have a seizure. Anyone can have a seizure ANYONE. It’s called your seizure threshold. 18

19 Imbalance Causes Fever: especially in infants or from heatstroke
Infection: Meningitis Drug ingestion/withdrawal: including alcohol and poisoning Acute neurological insult: stroke, trauma Brain tumor, degenerative diseases: Alzheimer's There are numerous things that can cause a seizure… Here’s a few. 19

20 Imbalance Causes Pregnancy: Complication
Metabolic disturbances: Hypoxia, Hypoglycemia, Hypocalcemia, Hyponatremia, Thyrotoxicosis Congenital conditions: Down syndrome; Angelman's syndrome; tuberous sclerosis and neurofibromatosis Unknown… Here’s a few more causes….. 20

21 Seizure Threshold: We all have one!
Add video, photo or drawing showing how certain substances can lower a person’s seizure threshold. Plus, drugs can cause a seizure by lowering your “seizure threshold”.

22 What’s the Common Denominator?
Increased permeability of neuronal cell membranes = increase in neuronal cell excitability. Neurons discharge action potentials irregularly without adequate suppression and attenuation of the abnormal activity...

23 What’s the Common Denominator?
… leading to a temporary change in the electrical functioning of the brain. 23

24 General Treatment Treat the Cause!
Hypoxia = Open airway, Ventilate, Oxygen Fever = Lower temperature, Treat the cause Metabolic = Fix it (Hypoglycemia = Glucose) Eclampsia = Magnesium, Give Birth Structural = Surgery, Decrease pressure Epilepsy = Several Ways General treatment approaches for most seizures > TREAT THE CAUSE! 24

25 If that’s a Seizure... …what is a Convulsion?
The visual - clinical manifestation of a seizure. It’s what you see the person doing. Our “Objective” (SOAP) If we now know what a seizure is and how to treat it, then what is a CONVULSION? Is there a difference? 25

26 General Treatment Treat the Cause... ...NOT the convulsions! Cause
Seizure Convulsion Do we treat convulsions? NO We treat the seizure…. 26

27 Epilepsy Foundation Logo
Title Slide 27

28 - Epilepsy - Chronic, recurrent seizures not otherwise provoked by an acute injury or health emergency. At least two unprovoked (or reflex) seizures occurring >24 h apart; (2) one unprovoked (or reflex) seizure and a probability of further seizures similar to the general recurrence risk (at least 60%) after two unprovoked seizures, occurring over the next 10 years; (3) diagnosis of an epilepsy syndrome. Definition of EPILEPSY... 28

29 - Epilepsy - Epilepsy is a disorder - - - - - - Seizures are symptoms
Epilepsy - aka ‘Seizure Disorder’ Further explanation of EPILEPSY...

30 Epidemiology of Epilepsy
Most common functional neurological disorder in the world An estimated 3 million in U.S. suffer from epilepsy-related seizures About 200,000 new cases occur each year 10% of population will experience a seizure 3% will develop epilepsy by 75 ~$17.6 billion in healthcare costs Per a 2012 World Health Organization report, “Epilepsy is the MOST COMMON, MOST SERIOUS, FUNCTIONAL brain disorder worldwide with no age, racial, social class, national nor geographic boundaries. 12% will have it. 40-5- million suffers worldwide 2 million new cases a year globally. 70-80% could lead normal lives if properly treated 30

31 What Causes Epilepsy? 30% - Most common causes are:
- Head trauma Infection of brain tissue Brain tumor and stroke Heredity - Prenatal disturbance of brain development 70% - Cause is not known (idiopathic) -Most people with epilepsy wonder what caused their disorder; yet in as many as 7 out of 10 people with epilepsy, no specific cause can be found. Head trauma can occur for a number of reasons, including automobile accidents, gunshot wounds, sports accidents, or falls or blows. The more severe the injury, the greater the risk of developing epilepsy. Lead and alcohol are examples of poisons that can damage the brain. In fact, each year more than 5,000 people have a seizure caused by alcoholism. A number of serious infections and causes of inflammation can lead to brain injury, including meningitis, viral encephalitis, and lupus erythematosus. The brain of a fetus may not develop properly during pregnancy, or a lack of oxygen during birth may damage delicate electrical systems within the brain. Finally, heredity plays a role. People may inherit varying degrees of susceptibility to seizures. This is assumed to be more likely when no other specific cause of seizures can be identified. In seniors, epilepsy may be due to stroke, Alzheimer’s disease, or other head trauma.

32 Epidemiology of Epilepsy
Breakdown by Age: Children: birth traumas, infections, such as meningitis, congenital abnormalities or high fevers Middle years: infections, alcohol, stimulant drugs or medication side effects, Traumatic Brain Injury (Veterans) Breakdown by age... Elderly: brain tumors and strokes cause a higher proportion of seizures

33 Epilepsy may also occur with:
Cerebral palsy Cognitive impairments ADD/ADHD Developmental disabilities Autism Traumatic Brain Injury You can also have EPILEPSY while at the same time also having another neuro disorder. 33

34 Epileptics may also have seizures triggered by:
Failure to take medication correctly Brand to generic switching Sleep deprivation/fatigue Stress/ illness Hypoglycemia/dehydration Items that might trigger a seizure for those with EPILEPSY. 34

35 ? General Treatment Treat the Cause! Slow the Action Potential!
What if there is no cause or acute insult? ? So, what is the general treatment for EPILEPTIC seizures? Slow the action potentials! And, as you have already seen, how do we do that? Slow the Action Potential! 35

36 General Treatment Sodium Channel Blockers 36
We have at least six different pharmaceutical approaches to try and several other more invasive we will discuss later. Regarding a drug approach, we can Increase GABA, decrease Glutamte, decrease the Sodium (Na) and Calcium (Ca) channels activity, or try drugs that work for reasons we have no clue…. =========================================================== Newer AED (ie. Lamictal, keppra, topamax) - Decrease the excitation of neurons by blocking Na+ channels Carbonic anhydrase inhibitors are a class of pharmaceuticals that suppress the activity of carbonic anhydrase. Carbonic anhydrases (or carbonate dehydratases) form a family of enzymes that catalyze the rapid interconversion of carbon dioxide and water to bicarbonate and protons (or vice versa), a reversible reaction that occurs rather slowly in the absence of a catalyst. Inhibiting the carbonic anhydrase enzyme reduces abnormal electrical activity in brain cells. 36

37 General Treatment Sodium Channel Blockers Calcium Current Inhibitors
We have at least six different pharmaceutical approaches to try and several other more invasive we will discuss later. Regarding a drug approach, we can Increase GABA, decrease Glutamte, decrease the Sodium (Na) and Calcium (Ca) channels activity, or try drugs that work for reasons we have no clue…. =========================================================== Newer AED (ie. Lamictal, keppra, topamax) - Decrease the excitation of neurons by blocking Na+ channels Carbonic anhydrase inhibitors are a class of pharmaceuticals that suppress the activity of carbonic anhydrase. Carbonic anhydrases (or carbonate dehydratases) form a family of enzymes that catalyze the rapid interconversion of carbon dioxide and water to bicarbonate and protons (or vice versa), a reversible reaction that occurs rather slowly in the absence of a catalyst. Inhibiting the carbonic anhydrase enzyme reduces abnormal electrical activity in brain cells. 37

38 General Treatment Sodium Channel Blockers Calcium Current Inhibitors
GABA Enhancers and/or Glutamate Blockers We have at least six different pharmaceutical approaches to try and several other more invasive we will discuss later. Regarding a drug approach, we can Increase GABA, decrease Glutamte, decrease the Sodium (Na) and Calcium (Ca) channels activity, or try drugs that work for reasons we have no clue…. =========================================================== Newer AED (ie. Lamictal, keppra, topamax) - Decrease the excitation of neurons by blocking Na+ channels Carbonic anhydrase inhibitors are a class of pharmaceuticals that suppress the activity of carbonic anhydrase. Carbonic anhydrases (or carbonate dehydratases) form a family of enzymes that catalyze the rapid interconversion of carbon dioxide and water to bicarbonate and protons (or vice versa), a reversible reaction that occurs rather slowly in the absence of a catalyst. Inhibiting the carbonic anhydrase enzyme reduces abnormal electrical activity in brain cells. 38

39 General Treatment Sodium Channel Blockers Calcium Current Inhibitors
GABA Enhancers and/or Glutamate Blockers Other drugs with unknown mechanisms of action We have at least six different pharmaceutical approaches to try and several other more invasive we will discuss later. Regarding a drug approach, we can Increase GABA, decrease Glutamte, decrease the Sodium (Na) and Calcium (Ca) channels activity, or try drugs that work for reasons we have no clue…. =========================================================== Newer AED (ie. Lamictal, keppra, topamax) - Decrease the excitation of neurons by blocking Na+ channels Carbonic anhydrase inhibitors are a class of pharmaceuticals that suppress the activity of carbonic anhydrase. Carbonic anhydrases (or carbonate dehydratases) form a family of enzymes that catalyze the rapid interconversion of carbon dioxide and water to bicarbonate and protons (or vice versa), a reversible reaction that occurs rather slowly in the absence of a catalyst. Inhibiting the carbonic anhydrase enzyme reduces abnormal electrical activity in brain cells. 39

40 Anti-Epileptic Drugs (AEDs)
Phenobarbitol Dilantin (phenytoin) Depakote (Valproic acid) Gabatril (tiagabine) Keppra (levetiracetam) Lamictal (lamotrigine) Topamax (topiramate) Neurontin (gabapentin) Tegretol (carbamezepine) Trileptal (oxcarbazepine) Felbatol (felbamate) Zonegran (zonisamide) Lyrica (pregabalin) Here is a partial list - some you may have seen - for the treatment of seizures. Phenobarbital increases the activity of GABA and decreases the activity of glutamate in the brain. Dilantin works by affecting sodium channels in the brain. It does not prevent abnormal brain activity from starting; instead, it prevents the abnormal activity from spreading to other parts of the brain. They all work differently, some on only certain types of seizures and/or at certain locations in the brain. Due to the many various causes, it can be a “crap shoot” to find the correct medication. As such, it can take months to find the correct medication and dose for that particular patient. Some of these medications are also used for other medical treatments, such as ‘Neurotin’ for shingles and Lyrica for fibromyalgia. New meds are coming out every year. 40

41 Anti-Epileptic Drugs (AEDs)
Phenobarbitol Increases GABA, Decreases Glutamate Dilantin (phenytoin) Depakote (Valproic acid) Gabatril (tiagabine) Keppra (levetiracetam) Lamictal (lamotrigine) Topamax (topiramate) Neurontin (gabapentin) Tegretol (carbamezepine) Trileptal (oxcarbazepine) Felbatol (felbamate) Zonegran (zonisamide) Lyrica (pregabalin) Phenobarbital increases the activity of GABA and decreases the activity of glutamate in the brain. 41

42 Anti-Epileptic Drugs (AEDs)
Phenobarbitol Dilantin (phenytoin) Sodium Channels Depakote (Valproic acid) Gabatril (tiagabine) Keppra (levetiracetam) Lamictal (lamotrigine) Topamax (topiramate) Neurontin (gabapentin) Tegretol (carbamezepine) Trileptal (oxcarbazepine) Felbatol (felbamate) Zonegran (zonisamide) Lyrica (pregabalin) Dilantin works by affecting sodium channels in the brain. It does not prevent abnormal brain activity from starting; instead, it prevents the abnormal activity from spreading to other parts of the brain. Used in the book/movie: “One Flew Over the Cuckoo’s Nest” to control seizures, anxiety and as a mood stabilizer. 42

43 Anti-Epileptic Drugs (AEDs)
Phenobarbitol Dilantin (phenytoin) Depakote (Valproic acid) - Gabatril (tiagabine) Keppra (levetiracetam) Lamictal (lamotrigine) Topamax (topiramate) calcium current inhibitor Tegretol (carbamezepine) Trileptal (oxcarbazepine) Felbatol (felbamate) Zonegran (zonisamide) Lyrica (pregabalin) Here is a partial list - some you may have seen - for the treatment of seizures. Phenobarbital increases the activity of GABA and decreases the activity of glutamate in the brain. Dilantin works by affecting sodium channels in the brain. It does not prevent abnormal brain activity from starting; instead, it prevents the abnormal activity from spreading to other parts of the brain. They all work differently, some on only certain types of seizures and/or at certain locations in the brain. Due to the many various causes, it can be a “crap shoot” to find the correct medication. As such, it can take months to find the correct medication and dose for that particular patient. Some of these medications are also used for other medical treatments, such as ‘Neurotin’ for shingles and Lyrica for fibromyalgia. New meds are coming out every year. 43

44 Anti-Epileptic Drugs (AEDs)
Phenobarbitol Dilantin (phenytoin) Depakote (Valproic acid) Gabatril (tiagabine) Keppra (levetiracetam) Lamictal (lamotrigine) Topamax (topiramate) Neurontin (gabapentin) Tegretol (carbamezepine) Trileptal (oxcarbazepine) Felbatol (felbamate) Zonegran (zonisamide) Lyrica (pregabalin) Here is a partial list - some you may have seen - for the treatment of seizures. Phenobarbital increases the activity of GABA and decreases the activity of glutamate in the brain. Dilantin works by affecting sodium channels in the brain. It does not prevent abnormal brain activity from starting; instead, it prevents the abnormal activity from spreading to other parts of the brain. They all work differently, some on only certain types of seizures and/or at certain locations in the brain. Due to the many various causes, it can be a “crap shoot” to find the correct medication. As such, it can take months to find the correct medication and dose for that particular patient. Some of these medications are also used for other medical treatments, such as ‘Neurotin’ for shingles and Lyrica for fibromyalgia. New meds are coming out every year. 44

45 Anti-Epileptic Drugs (AEDs)
Other Uses Phenobarbitol Dilantin (phenytoin) Depakote (Valproic acid) Gabatril (tiagabine) Keppra (levetiracetam) Lamictal (lamotrigine) Topamax (topiramate) migraine headaches, diabetic neuropathy, and bipolar disorders. Neurontin (gabapentin) pain following "shingles" (postherpetic neuralgia) and restless leg syndrome. Trileptal (oxcarbazepine) Felbatol (felbamate) Zonegran (zonisamide) Lyrica (pregabalin) Here is a partial list - some you may have seen - for the treatment of seizures. Phenobarbital increases the activity of GABA and decreases the activity of glutamate in the brain. Dilantin works by affecting sodium channels in the brain. It does not prevent abnormal brain activity from starting; instead, it prevents the abnormal activity from spreading to other parts of the brain. They all work differently, some on only certain types of seizures and/or at certain locations in the brain. Due to the many various causes, it can be a “crap shoot” to find the correct medication. As such, it can take months to find the correct medication and dose for that particular patient. Some of these medications are also used for other medical treatments, such as ‘Neurotin’ for shingles and Lyrica for fibromyalgia. New meds are coming out every year. 45

46 What’s in a name? Convulsion or Seizure Ictus, event,
spell, attack, and fit are all used to refer to? Convulsion or Seizure Before we proceed further, we need to discuss several new terms you will hear…. First off, all these words can be used to describe a seizure...

47 What’s in a name? Ictus: A sudden attack, blow, stroke, or seizure.
Ictal: Of or relating to a seizure or convulsion Ictus: A sudden attack, blow, stroke, or seizure. Ictal: Of or relating to a seizure or convulsion Ictus: A sudden attack, blow, stroke, or seizure. Ictal: Of or relating to a seizure or convulsion Definition of ICTUS and ICTAL: 47

48 What’s in a name? Pre-ictal Ictus Post-ictal
Ictus: A sudden attack, blow, stroke, or seizure. Ictal: Of or relating to a seizure or convulsion Pre-ictal Ictus Post-ictal EEG strip showing where Pre-, Post- and Ictal take place. Add video, photo or drawing to help student cognitively understand above listed words. 48

49 Seizure Classification
Generalized Partial Partial - FOCAL - only a certain part of the brain. Full Brain Half Brain 49

50 Seizure Classification
Generalized Seizure (consciousness is lost) Partial Seizure (consciousness is not lost) Add video, photo or drawing showing half brain. Generalized = Full Brain = Consciousness is lost 50

51 Seizure Classification
Partial Seizure (consciousness is not lost) Simple Partial - Awareness is not altered Complex Partial - Awareness is altered Half Brain = Consciousness NOT lost Two sub-sets: Awareness is NOT impaired Awareness IS impaired. 51

52 Partial Seizures: Simple and Complex (No Loss of Consciousness)
Also called ‘Focal Seizuers” Add video, photo or drawing showing half brain. 52

53 (Awareness NOT impaired)
Simple Partial (Awareness NOT impaired) Self-explanatory Reminder that in a Simple Partial Consciousness is NOT lost, nor is AWARENESS IMPARED 53

54 Different parts have different functions, and different seizures!
As the various areas of the brain have different functions, abnormalities in the firing of neurons from any area to another will present differently… Example: Motor area - may cause muscle movement or jerks. Visual area - may cause visualization disturbances. All of the brain at once

55 Simple Partial Seizure:
Seizure activity in the brain causing: Rhythmic movements isolated twitching of arms, face, legs Sensory symptoms – tingling, weakness, sounds, smells, tastes, feeling of upset stomach, visual distortions Psychic symptoms déjà vu, hallucinations, feelings of fear or anxiety Usually last less than one minute May precede a generalized seizure Some of the symptoms a person might report or signs you may observe with a person experiencing a SPS. 55

56 See the YouTube video at:
Simple Partial See the YouTube video at: https://www.youtube.com/watch?v=rtjPs_B99Bo&list=PLA14AEA342DA6F8C4 Child is still conscious - Awareness is NOT impaired. 56

57 Simple Partial AKA Focal Motor Seizure 57

58 Pre-hospital Treatment - Simple Partial Seizure (SPS)
Usually no medical treatment necessary If confused, assess per altered mental status protocols. Consult OLMC, activate ALS and/or rapidly transport to receiving facility if confusion or loss of consciousness occurs. Usually no PHC - EMS treatment needed.- Can always check a CBG: 58

59 (Awareness IS impaired)
Complex Partial (Awareness IS impaired) Altered awareness, Blank staring Confusion, inability to respond Emotional outbursts Title page 59

60 Complex Partial Seizure (CPS) -
Altered awareness, Blank staring Confusion, inability to respond Emotional outbursts Automatisms: purposeless behaviors such as picking at clothes, disrobing, chewing or mumbling Some of the symptoms a person might report or signs you may observe with a person experiencing a CPS. AUTOMATISMS - Not usually seen in those intoxicated or on drugs. May be confused with drunkenness or drug use, willful belligerence, non-responsive 60

61 See the YouTube Video at:
Complex Partial See the YouTube Video at: https://www.youtube.com/watch?v=E0o1ktu-9C4 Adult: Conscious? Yes Impaired? Yes Automatisms? Yes 61

62 See the YouTube video at:
Complex Partial See the YouTube video at: https://www.youtube.com/watch?v=wvG5wY0LgJg Adult: Conscious? Yes Impaired? Yes Automatisms? Yes Sound 62

63 Pre-hospital Treatment - Complex Partial Seizure (CPS)
(Clues to help differentiate between CPS and other causes) Look for sudden loss of awareness, mumbling, automatisms and/or wandering. Look for medical or identifying information. Sudden loss of awareness = CPS Slow loss of awareness = Alcohol, drugs, something else. Usually no automatisms with alcohol/drugs. 63

64 Pre-hospital Treatment - Complex Partial Seizure (CPS)
Usually no medical treatment required. Approach cautiously, speak calmly Contain – don’t restrain Avoid triggering violent behavior by minimizing physical contact. Usually no EMS-PHC needed. WARNING: MINIMIZE PHYSICAL CONTACT! May cause violent , non-directed, response. Contain - DO NOT RESTRAIN 64

65 Question witnesses: After a first-time seizure,
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 Stand back and observe. Keep person safe. Block doors. Direct towards safe area. 65

66 Post-CPS phase: Monitor recovery, check blood glucose Re-orient to surroundings Evaluate for injury More in-depth history as appropriate If confusion persists or loss of consciousness occurs and lasts more than 5 minutes, consult OLMC, activate ALS and/or rapidly transport to ED. What EMS-PHC needs to do... 66

67 Add video, photo or drawing showing full brain.
Generalized Seizures Add video, photo or drawing showing full brain. Tittle page 67

68 Add video, photo or drawing showing how full brain.
Generalized Seizures In a generalized seizure the electrical disruption involves the entire brain Consciousness is always lost! Add video, photo or drawing showing how full brain.

69 Generalized Seizure Types
Absence (“Petit mal”, non-convulsive transient) (Mal = illness; disease) Atonic (without muscle tone, aka “Drop” seizure) Myoclonic (Muscle + Rapid contraction) Tonic (Prolonged muscle tone, contraction) Tonic - Clonic (“Grand mal” – Contraction + Relaxation) Fire (5) primary sub-sets of generalized seizures. Some generalized seizures can be caused or triggered by partial seizures that spread to the full brain. 69

70 See the YouTube Video at:
Absence Seizure See the YouTube Video at: https://www.youtube.com/watch?v=UACyepoANVA *** SOUND NEEDED *** ABSENCE = You are absent for just a few seconds…. But then right back again. Schoolteachers usually pick this up. Sound 70

71 See the YouTube Video at:
Atonic Seizure See the YouTube Video at: https://www.youtube.com/watch?v=9obFVWW47NE A = Without Tonic = Muscle Tone 71

72 See the YouTube Video at:
Myoclonic Seizure See the YouTube Video at: https://www.youtube.com/watch?v=VC6HJPZr1VU Myo = Muscle Colonic = (Greek = ‘turmoil’) - Rapid contraction / relaxation of muscles... ================================================== Myoclonic Starts Sleep Start Sleep Myclonus Hiccups Other types 72

73 See the YouTube Video at:
Tonic Seizure See the YouTube Video at: https://www.youtube.com/watch?v=2m0qkKSpq9k TONIC = Increased Muscle Tone - ‘Continuous Tension’ 73

74 Tonic-Clonic Seizure (GTC)
Generalized Tonic-Clonic Seizure (GTC) TONIC: “continuous muscle tension” CLONIC: from Greek klonos = turmoil Clonus  (noun) - a type of convulsion characterized by rapid contraction and relaxation of a muscle The old term was ‘Grand mal’ - No longer used. 74

75 A GTC seizure may appear as:
A sudden “cry,” and fall, followed by: Loss of consciousness, fall and stiffening of limbs, followed by rhythmic shaking and convulsive movements of all limbs. Shallow/interrupted breathing or breathing may stop temporarily - skin, nails, lips may turn cyanotic. An eTCO2 monitor may show: The ‘CRY’ is caused when air is forced out of the lungs against tight chest wall and neck muscles. Loss of consciousness --> Gravity takes over. Tonic - Clonic activity: Not breathing or short shallow breaths --> Exhalation through clenched teeth cause a frothing around the mouth. eTCO2 should read ZERO during seizure activity No way to fake this. 75

76 A GTC seizure may appear as:
Convulsive movements generally last 1 to 3 minutes, followed by confusion, sleepiness Slow return to consciousness, post-ictal confusion and/or fatigue Loss of bladder/bowel control may occur. May bite their tongue. Items for PHC-EMS crews to consider. 76

77 See the YouTube Video at:
GTC Seizure See the YouTube Video at: https://www.youtube.com/watch?v=0VEdCXZ10Ms Video Sound 77

78 Generalized Seizure Treatments
DO NOT... DO NOT - Restrain person DO NOT - Put anything in the person’s mouth DO NOT - Try to hold down or restrain the person DO NOT - Give oral anti-seizure medication There are several common responses to a generalized tonic-clonic seizure that may be extremely harmful to the person experiencing a seizure. Do not put anything in the person’s mouth. Do not attempt to give the person antiseizure medication by mouth, and do not give food or drink until the person is fully aware. Finally, do not hold down or restrain movement. During a seizure the brain is sending instructions to various parts of the body. Even if that part of the body is restrained, for instance an arm or leg, it will still follow the instruction(s) received from the brain. Outside restraint could thus lead to sprained or torn muscles or even a broken bone. Finally, do not keep the person on his back, facing up throughout the convulsion. This may increase the risk that the person will inhale (aspirate) gastric fluids and suffocate.

79 Generalized Seizure Treatments
DO... Assure scene safety - Protect head and limbs from injury Add photo of Recovery Position If trauma is not suspected, place patient in recovery position - Maintain Airway PHC-EMS treatment Medical treatment usually NOT required Follow the C-A-B protocol: Monitor cardio-respiratory status Maintain airway – suction PRN Administer O2 79

80 Generalized Seizure Treatments
First time GTC seizure 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 PHC-EMS Treatments when present activate ALS and/or rapidly transport to receiving facility 80

81 Question witnesses: Description of seizure event
Identifying information for patient, emergency contacts Prior history of seizures or other medical problems Talk to bystanders, witnesses, family members… First time seizure needed to go to ED by ambulance. 81

82 After the seizure stops: The Post-ictal Phase
See the YouTube video at: https://www.youtube.com/watch?v=Uyx65dqm33M When the GTC seizure stops --> the post-ictal phase begins. The brain resets ... The body rests... 82

83 After the seizure stops:
Continue to monitor cardio-respiratory status Evaluate for injury Assess for return of consciousness/re-orient Obtain pertinent medical history and emergency contact information if possible If consciousness does not return, or confusion persists more than 5 minutes post-seizure, activate ALS and/or rapidly transport to receiving facility Remember to check for a pulse Check eTCO2 for reading and normal wave patterns Check CBG is not already done so. 83

84 After the seizure stops:
Understand the embarrassment that many individuals feel after a seizure. Confused, partial loss of memory Incontinent Very tired Painful, bitten tongue Musculoskeletal pains Remember to check for a pulse Check eTCO2 for reading and normal wave patterns Check CBG is not already done so. 84

85 ALS response to a seizure lasting longer than 5 minutes:
Status Epilepticus! It MUST be STOPPED! This is the situation where EMS crews can make a big difference... 85

86 Status Epilepticus (SE)
1) Continuous seizure lasting 30 minutes, or 2) Two or more discrete seizures between which the patient does not recover consciousness. Sustained by excess excitation and reduced inhibition. Too much Glutamate or too little GABA! Estimated to have ,000 case of SE in US annually. Males and females equally. Most common cause with known epileptics is a change in medications. However, HIV infection and use of illicit drugs were reported with increasing frequency. Children (70%) younger than 16 years, most common cause were of febrile and/or infection. In adults (highest incidence in population greater than 60 years), the most common cause as cerebrovascular disease (25%). SE may be used to describe a continuing seizure of any type. 86

87 Status Epilepticus Why stop it?
The sooner you stop SE, the easier it is to stop it. After 30 minutes: pathologic changes seen. After 60 minutes: neurons start to die. Tachycardia, cardiac arrhythmias, hyperglycemia: Thought to result from the catecholamine surge that accompanies the seizures. Body temperature increases: correlated with poor neurologic outcomes. Significant physiologic changes accompany generalized convulsive SE. Many of these systemic responses (eg, tachycardia, cardiac arrhythmias, hyperglycemia) are thought to result from the catecholamine surge that accompanies the seizures. Prolonged seizure activity results in pathologic changes after 30 minutes. After 60 minutes, neurons start to die. The hippocampus (involved in memory forming, organizing, and storing) is especially vulnerable. Neuronal death is thought to occur from the inability to handle large increases in intracellular calcium brought on by prolonged exposure to excitatory neurotransmitters. Body temperature may increase and has been correlated with poor neurologic outcomes and treated aggressively.

88 Status Epilepticus Why stop it?
Marked acidosis: Both respiratory and metabolic, resolves with termination of the seizure. Not normally treated. Pulmonary edema: Fluid accumulation in the lungs from an increase in pulmonary capillary hydrostatic pressure can cause a neurogenic pulmonary edema.. Increased cerebral metabolic demand: Cerebral blood flow and oxygenation are thought to be preserved or even elevated in the course. Marked acidosis, with both a respiratory and a metabolic component, usually occurs. Should not normally be treated. Acidosis is known to have an anticonvulsant effect. Acidosis resolves with termination of the seizure. Convulsive SE affects not only the mechanical aspects of breathing but also can cause neurogenic pulmonary edema (NPE). The pathophysiology of NPE is poorly understood. It is believed to be a neurohumeral response after seizure or brain injury with release of α-adrenergic agonists and an increase in pulmonary capillary hydrostatic pressure. Increased pulmonary capillary permeability also is thought to be a component of this process. These 2 mechanisms result in acute pulmonary edema. Many of the meds we use to stop seizures (benzos) inhibit respiratory drive both individually and synergistically when given in combination. Cerebral metabolic demand increases greatly with convulsive SE. However, cerebral blood flow and oxygenation are thought to be preserved or even elevated in the course.

89 Status Epilepticus TREATMENT: HOW DO WE STOP IT?
1. Need chemical that slows the Action Potential: Either increase GABA or decrease GLUTAMATE 2. Chemical must rapidly cross the Blood-Brain Barrier 3. Side-effects must be manageable So, how do we stop SE?? 89

90 Status Epilepticus Benzodiazepines! TREATMENT:
Enhance the action of GABA! Results in anticonvulsant, sedative, anti-anxiety, muscle relaxant and amnesic action. Suppress the action potential by: Giving a benzo to enhance GABA - BENZOs work fast. 90

91 General Treatment of SE
For seizures lasting longer than 5 minutes, administer: Diastat (Diazepam) Rectal Gel ($300/10mg tube!) Diazepam (Valium) – IV Lorazepam (Ativan) – IV, IM Midazolam (Versed) – IV, IM, IN, Buccal Support ventilation PRN Oxygen per nasal cannula Follow local protocol - Family members - school teachers - etc, might have or have given DIASTAT gel prior to your arrival.. Diastat is expensive! Midazolam can be given IV, IM, IN or Buccal (dripped inside cheek). ALL benzos can cause respiratory depression. Transport for further evaluation/treatment 91

92 Pre-hospital Double-blind Randomized Clinical Trial of the Efficacy of
IM versus IV? “RAMPART STUDY” (Feb. 16, The New England Journal of Medicine) Pre-hospital Double-blind Randomized Clinical Trial of the Efficacy of IM Midazolam vs. IV Lorazepam 73% of IM group seizure-free upon hospital arrival. 63% of IV group seizure-free upon hospital arrival. Patients received IM 3.6 minutes faster than IV Both groups had similarly low rates of recurrent seizures. Feb. 16, 2012 issue of The New England Journal of Medicine. Rapid Anticonvulsant Medication Prior to Arrival Trial IM patients less likely to require hospitalization than those receiving IV group. Both groups had similarly low rates of recurrent seizures. 92

93 YES! NOT Can your patient be in Status Epilepticus and
exhibit convulsive activity? YES! Clinical Seizure: Convulsions observed Subclinical (Electrographic) Seizure: No convulsions observed. Only EEG changes 93

94 Non-convulsive Status Epilepticus
(NCSE) A mental status change from base line of at least 30 to 60 minutes duration associated with continuous or near continuous ictal discharges on EEG. May present as absence, complex partial, or electrographic SE. NCSE is not rare, but it is clearly undiagnosed.” A diagnosis is difficult to establish. Observation is important! Is your patient improving? 94

95 Non-convulsive Status Epilepticus
(NCSE) If no improvement in LOC and awareness after 5 minutes of being post-ictal, consult with OLMC for possible administration of a benzodiazapine and/or transport to ED. Contact OLMC if you think NCSE is a possibility due to your observations. 95

96 Psychogenic Non-Epileptic -----------------------
Seizures (PNES) AKA Non-Epileptic Attack Disorder (NEAD) AKA Pseudoseizures Looks like an seizure, but not caused by abnormal electrical discharges. Stress-related or “emotional.” Most common condition misdiagnosed as epilepsy. A question that always pops up Can you ‘fake a seizure?’ 96

97 Psychogenic Non-Epileptic See the YouTube Video at:
Seizures (PNES) See the YouTube Video at: https://www.youtube.com/watch?v=6f69Zz19Mg8 Video of a PNES Watch the muscles and kicking - Monitor their eTCO2 if capable - Always check CBG - - Remember, most seizures stop after a few minutes, so no reason to treat or give a BENZO if they stop. 97

98 Additional TREATMENT Options
Title Slide

99 Ketogenic Diet High fat Diet: low carbohydrate and protein intake
Starvation - burning fat has antiepileptic effect. Each meal has about four times as much fat as protein or carbohydrate. Each meal must be customized for each person. The ketogenic diet is not a drug; however, it helps the body to make substances that have an antiepileptic effect. The diet is based on the observation that starvation, which burns fat for energy and produces ketones, has an antiepileptic effect. The goal of the diet is to make the body get its energy from fat and become ketotic. The diet is used primarily to treat severe childhood epilepsy. Used primarily to treat severe childhood epilepsy, effective in some adults and adolescents Requires strong family commitment The amounts of food and liquid at each meal have to be carefully worked out and weighed for each person. Persons who follow the diet are instructed to eat foods high in fat and low in carbohydrate and protein. Usually, the diet is started in the hospital so that physicians may monitor the progress. The exact reasons why the diet works remain unclear. Medical studies suggest that about one-third of patients are substantially helped, another third have some reduction in seizure, and one third have no change. People with epilepsy should not fast in the hope that it will help their seizure; in fact, fasting may trigger seizures. The keto diet is serious medicine, with its own set of side effects, and should never be tried without medical advice.

100 Vagus Nerve Stimulator (VNS)
Implanted device, sends regular, mild electrical pulses to the brain via the vagus nerve May be activated by an external magnet NEW APPROACHES: Pass around example? The vagal nerve stimulator is thought to exert its effect via subcortical pathways that presumably synapse in the thalamus. Functioning may be affected by the use of a Taser type device. 100

101 Surgical treatment/Ablation (Surgical, Laser and ‘Gamma Knife’)
Factors influencing decision: Ability to identify focus of the seizures Area of brain involved can be safely removed – without resulting in a significant deficit Other treatments unsuccessful Treatment Options: Surgery When antiepileptic drugs fail to control or substantially reduce seizures, surgery on the brain may be considered. Although some of the techniques are recent, surgical removal of seizure-producing areas of the brain has been an accepted form of treatment for more than 50 years. Brain surgery can be a successful way of treating epilepsy. "We found that when the entire lesions could be targeted, radiosurgery did more than reduce the seizures," says lead author Pascale Bourgeois. "There also were encouraging effects on cognition and quality of life. While the procedure is ineffective for large lesions, gamma knife surgery should be a first line surgical therapy for small hamartomas." NOTE – CBS VIDEO LINK TO INTERNET ATTACHED…CLICK AT BOTTOM OF PAGE ON ICON (will launch in separate internet window if internet is available in conference room) 101

102 Experimental Treatment – Deep Brain Stimulator (DBS) Responsive Neurostimulator (RNS)
NEW APPROACHES: Deep Brain Stimulation Similar to focal application of an anticonvulsant drug, it may be possible to stop or suppress seizures by focal electrical stimulation within the epileptic focus itself or within a modulating pathway.

103 IS TRANSPORT ALWAYS NECESSARY?
The American with Disabilities Act (AMA) helps protect those with numerous medical disorders... 103

104 Always necessary if: First time seizure 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 Always transport via an ambulance (ALS if possible) if these items are noted. when present activate ALS and/or rapidly transport to receiving facility

105 Might be unnecessary if:
Legal age Alert and oriented (Person, Place, Time, Event, Understands risks of refusing transport) History of seizures Under a physician’s care Currently taking anti-seizure medications as prescribed, Usual frequency of seizure activity. Do they have a plan? (If not transported, document per agency standards.) Not everyone needs ambulance transport or an ED evaluation. Contact OLMC if questionable . Follow local protocols and procedures. Always do what you believe is best for the patient...

106 Patient’s Legal Rights
Always consider a ‘seizure’ as a possible cause of altered mental status. Don’t provoke the patient Don’t restrain the patient Don’t be in a hurry to transport due to ‘system’ issues. Contact OLMC if there is a question. Always err on the side of caution The American with Disabilities Act (AMA) helps protect those with numerous medical disorders... 106

107 Common Q&A Title Slide

108 Can brushing your teeth, reading,
looking at a dress with a plaid pattern, sunshine shimmering off water or flickering through trees trigger a seizure? Yes. It’s called “Reflex Seizure” PHOTOSENSITIVE EPILEPSY is the most common type of Reflex Seizures. May be triggered by exposure to: Television screens: flicker or rolling images, Computer monitors, Video games or TV broadcasts. Rapid flashes or alternating patterns of different colors, Intense strobe lights like visual fire alarms. 108

109 YES Catamenial Epilepsy Can menses influence seizure activity?
Frequency and severity exacerbated by menstrual hormonal changes. Can seizures be influenced by variations in sex hormone secretion during menses? YES - Called Catamenial Epilepsy Estrogen has proconvulsant effects. - Progesterone has anticonvulsant properties.

110 SUDEP Can people die from epilepsy? Sudden, unexpected, non-traumatic,
non-drowning death in an individual with epilepsy, witnessed or unwitnessed, in which postmortem examination does not reveal an anatomic or toxicologic cause for the death. People do die from EPILEPSY. It happens… We just don’t know why.

111 Program Manager, Multicultural Affairs
Clarifying the Misperceptions, Misunderstandings and Misinterpretations around epilepsy Increasing Knowledge and Understanding - Reducing Stigma - Aldith Steer, MA Program Manager, Multicultural Affairs Epilepsy Foundation, Landover, MD (301) Thank you for attending. We hope that this was helpful to you all. Please contact your local Epilepsy Foundation affiliate for further information or on-site educational opportunities. EF also has online CME available for EMS responders. 111

112 More common than you think…
1 in 26 people in the United States will develop epilepsy at some point in their lifetime. For about 60% of people with epilepsy, the cause is unknown. Approximately one third of people with epilepsy live with uncontrollable seizures because no available treatment works for them. More than 2.1 million adolescents nationwide are impacted by major depressive episodes.

113 Misperceptions, Misunderstandings & Misinterpretations
Epilepsy is not a true medical illness like heart disease and diabetes. Epilepsy is a product of witchcraft. Epilepsy is contagious. People with epilepsy are usually dangerous and violent. Epilepsy results from a personality weakness or character flaw.

114 Misperceptions, Misunderstandings & Misinterpretations
People could just snap out of it if they tried hard enough. People with epilepsy shouldn't be in jobs of responsibility and stress. Epilepsy is rare and there aren't many people who have it. People with epilepsy are physically limited in what they can do. With today's medication, epilepsy is largely a solved problem.

115 STIGMA… … a “collection of negative attitudes, beliefs, thoughts, and behaviors that influence the individual, or the general public, to fear, reject, avoid and discriminate against others. ” Stigma manifests in and through social interactions with others. Attitudes, beliefs and stigma about epilepsy develop during childhood and adolescence.

116 Impact on the Quality of Life for people living with epilepsy
Self, children, adolescents, women, elderly, family members Education, employment, social relationships, sexual relationships 116

117 Effective Stigma Reduction
STARTS EARLY! The youth and young adult years are an opportune time to encourage positive attitudes, reduce stigma and reduce the burden of illness across the life span. Reducing stigma among all youth and young adults reforms the culture, within social networks, that embraces discussion about epilepsy, and is inclusive of young people living with epilepsy. This reform of the peer culture may ultimately increase mental health and epilepsy treatment seeking behaviors. Interventions should be accessible, acceptable, and tailored to young people, situated in the community for rapid dissemination and the broadest impact. 117

118 live, learn, work, play, thrive and
Effective Stigma Reduction STARTS EARLY! 1. Emphasize being a “real” person comes first – epilepsy and/or a mental health need second. 2. Use personal stories to broaden others’ ideas about people with epilepsy and/or mental health needs. 3. Emphasize the link between treatment and positive outcomes. Promote inclusion so people with epilepsy can live, learn, work, play, thrive and participate fully. When raising awareness about epilepsy and improving mental health literacy reduce stigma by: Introduce people who are in sustained recovery/ whose seizures are under control, indistinguishable from individuals without psychiatric or epilepsy diagnosis. Encourage audience members to broaden their ideas about people with mental disorders. This subdues blame and demonstrates that individuals do not have a mental health need and/or epilepsy by choice. Link treatment regimens with recovery and/or control. Promote inclusion so that people with epilepsy/mental health needs can live, learn, work, play, thrive and participate fully. 118

119 How Can EMS Personnel Help?
Be an informed and empathic listener Encourage compliance Provide information to individual, family members and community… and to your co-workers!

120 EMS Responder Resources:
1. Link with your local affiliate! 2. - Free (CECBEMS approved) online EMS education - Training programs for EMS - Training programs for law enforcement 120

121 ----------------------------
Seizures and the EMS Response: “Treating the Cause” EMSWorld EXPO November 13, 2014 – Nashville Aldith Steer, M.A., Program Manager, Epilepsy Foundation Gary McLean, RN, Paramedic – Sandy, OR Funded by CDC grant #1U58DP GENERAL INTRODUCTION: Three instructors representing the Epilepsy Foundation: Aldith Steer: Program Manager of Multicultural Affairs, Epilepsy Foundation, Landover, Maryland Tom McCarrier: Retired Police Officer and Retired Associate Dean of EMS and Fire Education Programs, Mid-State Technical College, Wisconsin Rapids, Wisconsin Gary McLean: RN, Paramedic – Sandy, Oregon 121


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