1. Epilepsy Emergencies and How to Prevent Them
Marcelo Lancman, MD
Medical Director,
Northeast Regional Epilepsy Group

2. Epilepsy emergencies Breakthrough seizures Seizure clusters
Prolonged seizures (status epilepticus)
Sudden unexpected death in epilepsy (SUDEP)
Seizure-related injuries
Preparedness plans

3. Epilepsy emergencies Perspectives How to recognize them? What to do ?
Person with epilepsy (PWE)
Caregiver
Healthcare provider (nurse, MD)
How to recognize them?
What to do ?
How to prevent them?
How to prepare?

4. Breakthrough seizures
The severity and urgency depends on seizure type, seizure duration and external circumstances
Some seizures are more dangerous than others
Most seizures are self limited and there is no need for urgent intervention
Only a few need urgent care…and we need to be prepared for those

5. Breakthrough Partial Seizures
Simple partial (lower risk)
Sensory, motor, auditory, visual, psychic, autonomic
Complex partial (moderate risk)

6. Breakthrough Generalized Seizures
Absence (lower risk)
Atonic (higher risk)
Tonic (higher risk)
Clonic/myoclonic (moderate risk)
Tonic-clonic (higher risk)

7. Breakthrough seizures
Safety measures
When to worry?
When to call 911?
When to go to the hospital?
When to call your doctor?
When to use rescue medications?

8. Safety measures Clear the way: keep other people out of the way
Move objects that could injure PWE
Important to keep calm and track the time and characteristics of the seizure
Check if there is any information regarding seizure or epilepsy type on bracelet or necklace
Turn PWE on his/her side to keep airway clear
Cushion head
Loosen any tight neckwear
NOTES:
Tracking time is important because a seizure lasting longer than 5 minutes will require an emergency intervention.
Reassure other students and explain what is happening if necessary.
Turning the student to one side keeps the tongue from blocking the airway and allows saliva to drain from the mouth.
The palm of the hand or other soft object can be used to cushion the head.
Be sure that any object cushioning the head is not covering the mouth or nose and hampering breathing.
If necessary, remove eyeglasses and loosen tight neckwear.
To establish that student has regained full awareness of surroundings after the seizure, ask simple questions like, “What is your name?”
IMPORTANT! - If your school district has emergency seizure protocols, please explain them to the training participants now.

9. Safety measures
Do not try to stop movements related to the seizure or hold down PWE
Do not put anything in the PWE’s mouth during a seizure
After the seizure, remain with PWE until awareness of surroundings is fully regained
NOTES:
Tracking time is important because a seizure lasting longer than 5 minutes will require an emergency intervention.
Reassure other students and explain what is happening if necessary.
Turning the student to one side keeps the tongue from blocking the airway and allows saliva to drain from the mouth.
The palm of the hand or other soft object can be used to cushion the head.
Be sure that any object cushioning the head is not covering the mouth or nose and hampering breathing.
If necessary, remove eyeglasses and loosen tight neckwear.
To establish that student has regained full awareness of surroundings after the seizure, ask simple questions like, “What is your name?”
IMPORTANT! - If your school district has emergency seizure protocols, please explain them to the training participants now.

10. When to worry First time seizure (since you do not know this behavior)
Seizures lasting more than a few minutes (5?)
Repeated seizures without regaining consciousness
Increase in frequency of seizures
Different seizure types occur
PWE is injured, pregnant or with known associated medical condition
Seizure occurs in water
Difficulty breathing
NOTES:
If the student is not breathing after the seizure, begin rescue breathing until the ambulance arrives.

11. What to do When to call 911? (when you have any of the “worry” signs)
When to go to the hospital? (It is better to call 911 and have EMT trained personnel take care of the PWE)
When to call your doctor? (whenever you do not know what to do. However, if it an emergency call 911 first)

12. Breakthrough seizure-Rescue medications
What are rescue medications?
What are the side effects and possible complications?
Routes of administration:
Oral medications
Buccal
Sublingual
Rectal
Intranasal
Intramuscular
Intravenous

13. Breakthrough seizure-Rescue medications
What are rescue medications?
Medications that act very fast and can break seizures
They are usually not effective as routine antiepileptic treatment
It needs to be possible to administer them safely (oral, sublingual, rectal, nasal, intramuscular, intravenous)
They need to be available all the time to PWE and caregivers

14. Breakthrough seizure-Rescue medications
What are side effects
Sleepiness
May facilitate aspiration
Respiratory depression
May cause breathing problems

15. Oral rescue medications
Ativan, Valium, Klonopin
May be difficult to administer during a seizure
Very useful if there is an aura
Risk of injury by trying to put medication in mouth
Risk of aspiration
Never give liquids with medication during a seizure

16. Buccal rescue medications
Between gums and cheek
Problems: gagging, coughing and aspiration

17. Buccal route

18. Sublingual rescue medications
Klonopin wafers
Get absorbed faster than oral medications
May be difficult to administer during a seizure
Very useful if there is an aura
Risk of injury by trying to put medication in mouth
Risk of aspiration
Never give liquids with medication during a seizure

19. Sublingual route

20. Diazepam Rectal Gel
Used in acute or emergency situations to stop a seizure that will not stop on its own
Approved by FDA for use by parents and non-medical caregivers
State/school district regulations often govern use in schools
NOTES:
If your school district has specific protocols regarding the use of this medication, you (the presenter) should be prepared to explain them to the audience.
An additional training session may be necessary to provide specific instruction in the administration and use of this medication as per your state’s nurse practice act, school district regulations and school policy.

21. Emergency Treatment Rectal Diastat Clinically proven Hard to give
Adults don’t like it
Can’t self administer

22. Intranasal route Easy to administer
Increases production of nasal mucous and congestion

23. Intranasal Midazolam Easy to give Preferred route
Can be self- administered or given by caretaker
Under study
Efficacy and Side Effects unknown

24. Rescue medications-Intramuscular and Intravenous
Valium, Ativan, Midazolam (Versed)
Rapid effect
Needs caregiver to be trained
Only in rare occasions
Midazolam IM

25. How to prevent them The seizure threshold
What is the seizure threshold?
The amount of activity necessary to bring a seizure on.
We all have a seizure threshold
It is lower in PWE
What can change it?
The importance of knowing

26. How to prevent them Seizure triggers:
Missing medication doses (pill organizers, alarms)
Alcohol and drugs
Stress
Environmental temperature
Lights
Fever/illness

27. How to prevent them Seizure triggers: Hormonal changes
Hyperventilation
Sleep deprivation
Medications and supplements (very important to discuss with your doctor every time you take any new medication for any reason or any supplements—many can provoke seizures)
Travel across time zones

28. Seizure clusters What are seizure clusters
They start and stop but occur one after another
The can last a very long time
They can lead to injuries and complications
They need to be treated aggressively

29. Seizure clusters Types of medications Oral Buccal Sublingual Rectal
Intranasal
Intramuscular
Intravenous

30. Status epilepticus What is status epilepticus? What to do? Why?
What are the consequences if we do not act in a timely manner?

31. Status epilepticus
Formal Definition: seizures that do not stop for 30 minutes. Or they happen on and off without regaining consciousness between seizures
Practical definition: 5 minutes

32. Status epilepticus Types Partial motor status epilepticus
Generalized convulsive status epilepticus
Non-convulsive status epilepticus
Myoclonic status epilepticus

33. Partial motor status epilepticus
This prolonged seizure involves just one part of the brain.
The person is awake and talking/interacting normally, but has persistent rhythmic jerking on one side of the body, say the hand, arm or face.
It requires emergency treatment, but is not usually as life-threatening as other forms.

34. Generalized convulsive status epilepticus
This prolonged seizure involves the entire brain, and produces convulsive activity in all four extremities coupled with a lack of responsiveness.
This life-threatening condition requires urgent medical evaluation and treatment.

35. Non-convulsive status epilepticus
This seizure, which could involve part of the brain or the entire organ, is far less dramatic than generalized convulsive status epilepticus, and produces subtle symptoms such as blinking, staring or confusion – or no obvious signs at all. It is less dangerous than the generalized convulsive type, but still requires prompt recognition and treatment.
A continuous EEG recording is the only way to diagnose non-convulsive status epilepticus.

36. Myoclonic status epilepticus
Another seizure that involves the entire brain, this form produces prolonged jerking of all four extremities.
It is usually caused by a profound lack of oxygen to the brain due to heart dysfunction, but may also occur in those with myoclonic epilepsy.

37. Status epilepticus: Epidemiology
One of the most common life-threatening neurological disorders
Incidence: 50,000 to 200,000 cases annually in US.
Around 12% of patients with newly diagnosed epilepsy present with status epilepticus
Within 5 years of initial diagnosis of epilepsy, 20% of patients will have status epilepticus
Mortality rate: 3 to 53% (20%)
55,000 deaths in U.S. per year

38. What can cause it? Cause: Unknown in 25 to 40% of cases
Age: elderly > pediatric > adult

39. What can cause it? Most common causes: Missing medications Stroke
Alcohol withdrawal
Metabolic disorders
Hypoxia
Infections
Tumors
Trauma

40. What are the consequences?
Effects on the body
Hyper-sympathetic state (increased HR, dysrhythmias, decreased cardiac output, increase in peripheral resistance, increase in BP followed by decreased BP)
Hyperpyrexia (increased body temperature) (central, infection or increase in muscle activity)- neuron damage
PH decreases
Hyperglycemia (increase in catecholamines)

41. What are the consequences?
Effects on the brain
Early stage:
Increased oxygenation
Increased blood flow (increased BP)
Late stage:
Decreased oxygenation
Decreased blood flow
High requirement of energy with low supply  brain injury
Decreased glucose and increased lactate

42. How is status epilepticus approached?
Clinical assessment:
Exam: trauma, infection
Drugs: ciprofloxacin, baclofen, flumazemil, interferon, ifosfamide, theophyline, isoniazid, alcohol withdrawal, cocaine
Infections: Mycoplasma pneumonia, cat- scratch encephalopathy, herpes simplex, AIDS
Tumor (metastases), cortical dysplasia

43. How is status epilepticus approached?
Labs
Glucose level, electrolytes, CBC, toxic screen, LFTs, AEDs levels, urine, ABG (hyponatremia, hypernatremia, hypercalcemia, hepatic encephalopathy)
EKG
Others: mixedema, hyperparathyroidism
LP: if infection suspected
Neuroimaging
CT/MRI

44. How is status epilepticus approached?
EEG and VEEG
Rule out psychogenic seizures
Classify type of SE

45. How is status epilepticus treated?
This is an emergency where time is of the essence
Steps:
Control of airway and ventilation
Arterial blood gas monitoring
EKG and BP monitoring
IV: glucose and Thiamine
Blood work: CBC, CPM, electrolytes and AED levels

46. Treatment Pharmacological treatment Benzodiazepines loading
Lorazepam
Diazepam
Phenytoin or Fosphenytoin loading
If no response:
Phobarbital, Depakon, Keppra, Vimpat
Refractory:
ICU: midazolam, propofol and pentobarbital

47. Status epilepticus-Conclusion
EMERGENCY SITUATION
TIME IS OF THE ESSENCE
DELAY IN TREATMENT COULD RESULT IN BRAIN DAMAGE OR DEATH

48. SUPED
What is SUDEP?
SUDEP stands for Sudden Unexpected Death in Epilepsy.
SUDEP could be the possible cause of death when there is no evidence of trauma or drowning and there is no other clear cause of death (Heart attack, etc.)
SUDEP is believed to be the cause of approximately 10% of seizure related deaths.

49. SUPED
Unfortunately, due to the unpredictable nature of SUDEP it remains an understudied phenomena.
Our understanding of this process is very limited and much remains to be investigated about these occurrences and what causes them.
Thankfully, SUDEP is relatively rare, occurring in about 1 out of 1000 patients with epilepsy per year, but its consequences can be catastrophic

50. Who is at risk? All patients with Epilepsy are at some risk
Higher risk:
Long history of poorly controlled seizures (risk of 1 in 150)
Patients with generalized tonic-clonic seizures ‘Grand Mal’
SUDEP also appears to typically affect younger adults with epilepsy. (Approximately 75% of all SUDEP deaths occur in individuals between 20 to 50 years of age)
Children, have a relatively lower risk of SUDEP.

51. Who is at risk
Patients with varying degrees of cognitive or neurological impairment.
Poor compliance with medications
Use of alcohol or illicit drugs
Nocturnal seizures

52. What causes it?
Not completely understood, but there are several theories:
There is interruption of cardiac (cardiac arrest, arrhythmias) or respiratory function
The brain is highly interconnected with the heart and respiratory functions
Seizures could disrupt that connections

53. SUDEP-What can you do
Patients and families must work together with their doctors to obtain optimal seizure control.
Taking anti-seizure medication consistently and regular follow ups with the patient’s health care provider are key.
Autopsies show that many of those who die from SUDEP have low levels of antiepileptic medications in their system.

54. SUDEP-what can you do?
Maintain a regular sleep schedule (including when traveling across time zones)
Avoid alcohol and illicit drugs
There is a growing number of safety devices that have appeared on the market (none are FDA approved however)

55. Anything else to prevent it?
Devices to monitor seizures to alert caregivers when a seizure is happening
They achieve this by recognizing rhythmic movements or detecting changes in heart rate which can occur during a seizure
Low tech options include baby monitors to other more sophisticated devices
Seizure service dogs

56. Limitations of these devices
Failure to detect all seizures
False alarms:
occur when the bed exit alarm function is in use and the patient gets out of bed to go to the bathroom.
Other false alarms can occur if an individual is particularly restless at night

57. Safety Devices to Prevent SUDEP
There is no device proven to prevent SUDEP
Some devices are marketed but have not been studied
Some devices are currently under study
Speak to your MD before purchasing

58. Sleep Safe Pillow
Air passes through contoured surface and body of the pillow

59. Pulse Oxymeter
Non-invasive medical devices that attach to a fingertip or a toe to measure heart rate and blood oxygenation percentage

60. SmartWatch by SmartMonitor
for those with the condition, their families and caretakers. Smart Monitor knows that the freedom of folks with epilepsy is curtailed by trepidation caused by the unpredictability of seizures, so it's created the SmartWatch. The device is a wristwatch, roughly the size of a WIMM One, that has a GPS module and a proprietary accelerometer/gyroscopic sensor inside to detect the excessive and repeated motions that occur during grand mal seizures. It then records the time, duration and location of the occurrences and sends that information via Bluetooth to the accompanying app on your Android smartphone (an iOS version is in the works). The app tracks and stores the info and automatically calls your designated caretakers to alert them of the seizure, thusly ensuring the safety of the watch wearer. The watch also has physical buttons on the side that allow users to cancel a false alert or manually send one out with a single press. Smart Monitor SmartWatch hands-on
Aside from the real-time safety net that comes with wearing the watch, it also provides valuable information to neurologists over the long term. When and where seizures take place is data that those who study and treat epilepsy find useful, and it can be quite difficult for folks to recall such info after a seizure. SmartWatch can give doctors an accurate long term look at a patient's episodic history that they wouldn't be able to obtain otherwise. Because it's a motion detection unit, the device is only for those who suffer from tonic clonic, or grand mal seizures, so it's not a universal seizure detector. However, the company's clinical trials with the device are ongoing, and Smart Monitor will submit it for FDA approval as a tonic clonic seizure sensor later this year.
From Company
SmartWatch is a patent protected, intelligent wristwatch that continuously monitors movements and alerts upon the onset of excessive or repetitive shaking motion. Automatic text message and phone call alerts are sent to designated family members and caregivers. Users can also summon help with a simple push of a “Help” button. The ability to track and record motion is an additional benefit of the SmartWatch. It records the time, duration and location of any unusual occurrences.  Users can securely access their archived information for later review.
The SmartWatch is currently available in two versions:
-          SmartWatch Premium
-          SmartWatch Standard
Click Here to Compare Features
The newly introduced SmartWatch Premium has all the safety and convenience features of the SmartWatch Standard, with even more attributes to bring peace-of-mind to the users and their family. In addition to continuous monitoring and the customizable sensitivity and duration levels, the SmartWatch Premium has the following capabilities:
Snooze: The user can temporarily “pause” the watch if they know they are going to be participating in activities that may trigger an alert inadvertently
GPS location: Physical location information of the SmartWatch user is included with alerts.
Multiple Contacts: Text message and phone call alerts can now be sent to multiple recipients
Often called the “peace-of-mind device”, SmartWatch is an easy-to-use, non-invasive, portable movement monitor. SmartWatch can be worn continuously – in and out of bed, indoors or outdoors, as people go about their day-to-day activities.
SmartWatch can alleviate fears that something could happen without being able to notify or get help in a timely fashion. SmartWatch offers autonomy and privacy for users and peace-of-mind for their families.
How SmartWatch Works SmartWatch works in conjunction with an Android smart phone:  We recommend the Nexus S 4G, Samsung Galaxy Nexus or Galaxy S II Skyrocket. The SmartWatch user needs to carry one of these phones with them or have it within a 10 foot range. When the SmartWatch detects movement outside a normal spectrum it wirelessly signals the smart phone which then automatically sends out text messages and phone calls to designated family members.

61. Emfit Movement Monitor (outside US and Canada: Emfit Tonic-Clonic Seizure Monitor
Emfit Tonic-Clonic Seizure Monitor NO CLINICAL STUDIES
Emfit’s tonic-clonic seizure monitor’s use is for detecting and notifying a caregiver if the person with epilepsy experiences a tonic-clonic seizure that causes faster, continued body movements while in bed. Additionally, it can also monitor an individual’s presence in bed and will give notification if the monitored person leaves the bed or does not return to the bed within a preset amount of time.  This feature can be disabled via a DIP switch located inside the control unit.  Available outside the USA/Canada only.  If you reside in the USA or Canada please see Movement Monitor
Overview
Testimonials
FAQ
Product overview
The Emfit tonic-clonic seizure monitor consists of two main components; a flexible and durable bed sensor (L-4060SL) placed under the mattress and a bed-side monitor (D G) with sophisticated embedded software. Together they detect the micro-movements of a person lying on the bed - even the heart beat and breathing, and the faster movements such as muscle spasms when person has a tonic-clonic seizure. There are no particular weight limits; sensitivity can be adjusted for child 2-12 years, adolescent 12-21 years, or adult.
The monitor can be placed next to the bed or on the wall using the included fastening bracket. It is operated with 2 pcs AA size 1,5 V batteries. An optional, medical grade AC adapter is also available.

62. Aremco DETECTION FUNCTIONS AVAILABLE
Depending on the sensor systems selected, any combination of the following detection functions can be included.
BODY BREATHING MOVEMENTS (ASSOCIATED WITH RES PIRATION) When the Monitor has detected a pattern of breathing movements via the sensor plate, this is indicated on the display. The monitor can be pre-set to detect cessation of breathing for periods of as short as 10 seconds or to as long as 60 seconds. The detection of respiration has an adjustable sensitivity threshold to compensate for variations in thickness, structure and composition of the mattress and the depth and degree of the user's breathing movements. This detection circuit will provide an automatic bed leaving alarm when the bed is vacated. If this feature is not required and the user cannot switch the alarm circuit off and on again, a bed occupancy detection sensor and relay circuit can be provided to cause a temporary disablement of the breathing alarm circuit while the bed is unoccupied.
Using the movement sensor plate, a seizure alarm can be set to activate whenever spasms have an energy which is greater than a pre-set detection level and faster than a pre-set rate, as well as lasting for at least a pre-set alarm time delay period.
BED TIME BODY SPASMS
The monitor keeps track of the respiration rate and the display is updated every 10 seconds. Fast or Slow breathing rate alarms can be set to operate if the breathing rate detected falls outside pre-set limits.
RESPIRATION RATE
A microphone is located in the top of the monitor enclosure. The monitor is designed to react only to transient or noncontinuous sounds, in order to eliminate the effect of background noises such as ventilation systems. The alarm is activated when a set number of transient sounds above a pre-set sound level occur within a pre-set time period. For example, it can be set to respond to a baby crying or personal vocalisations or to calls for help.
TRANSIENT SOUNDS
Excessive perspiration or bed wetting with urine can be a consequence of an epileptic seizure. A moisture detection sensor positioned under the bed sheet can activate an alarm if dampened with a fluid of sufficient electrical conductivity. The sensitivity to the conductivity of the fluid required to trigger the alarm can be adjusted in 5 steps between perspiration, which is least conductive, and urine, which is most conductive.
BODY FLUIDS (Perspiration and urination)
A moisture detection sensor positioned under the pillow cover can activate an alarm if it becomes dampened by a fluid of sufficient electrical conductivity. The sensitivity to the conductivity of the fluid required to trigger the alarm can be adjusted in 5 steps between saliva, which is least conductive, and vomit, which is most conductive.
PILLOW MOISTURE (Saliva or vomit)
It is often necessary to know whether a person in care has vacated the bed. The use of a bed occupancy sensor connected to the monitor provides a bed leaving alarm function. It can also be used to prevent the respiration monitor from activating an alarm when a bed is vacated. The sensor can be either the Bedwatch device for location under a bed leg or a pressure sensitive mat for use in the bed underneath the user.
BED OCCUPANCY
A call button switch can be plugged into the monitor which, when pressed manually by the user, will create an alarm condition.
DISTRESS CALL
MULTIFUNCTION ALARM OUTPUT
This function enables a switch signal from an external device to be routed through the monitor and its alarm circuits.
AUXILIARY ALARM
The monitor is fitted with a back-up battery to supply power in the event of power failure via the AC Adaptor. The battery charge condition and performance is continually checked and battery charging occurs automatically with an indication when the battery is no longer serviceable. A battery level indicator shows the percentage of charge remaining in the battery.
BATTERY BACKUP
The monitor has a multi-purpose alarm output socket which can be used with a variety of wired connections to alternative alarm circuits e.g. nurse call systems, remote alarms, telephone autodiallers etc.
A highly visible red light on the monitor is always activated by the various alarm situations. In multiple use situations in a hospital ward it allows rapid identification of which user requires attention. The exact reason for the alarm is always displayed on the illuminated display screen. The monitor also has an in-built audible alarm that can be disabled to remain silent if not required.
INTEGRAL VISIBLE AND AUDIBLE ALARM
RADIO TRANSMITTER (OPTIONAL)
The monitor can be supplied with an integral radio transmitter, if required. Alarm data can then be transmitted to a remote portable radio text pager or a computer monitoring station. The transmitted information includes the status of all the alarm conditions, the breathing rate and the monitor identification number. Each transmission is secured with an error checking code to protect the integrity of the data. Signals are sent every few seconds at randomised intervals to maximise the probability of receiving the information. The receiving device is able to give a warning in the event of a radio-link failure.
(Sensing and detection components have no contact with the user and are provided seperately) Dimensions & Weight152 (W) x 70 (H) x 135mm (D), 700g Battery backup duration 5 days (Typically)Inputs
SPECIFICATIONS
Motion detection (Black phono socket)Pillow Moisture (Blue phono socket)Body Moisture (Blue phono socket)Distress Call (Red phono socket), normally open<Auxiliary Input (Yellow phono socket), normally open or closedBed Leaving (3.5mm stereo socket), normally open and/or closedPower Supply(2.1mm DC socket) 12 volts DCOutputs
Relay output can be used to give normally open or normally closed contact output, or a voltage output to drive an external alarm.Cessation of breathing alarm
Breathing rate limit adjustable from 30 to 60 breaths per minute in 5 bpm stepsSeizure alarm
Breathing rate limit adjustable from 5 to 20 breaths per minute in 5 bpm stepsFast breathing rate alarm
Response time adjustable from 10 to 60 seconds in 5 second stepsSlow breathing rate alarm
Adjustable for 1 to 20 transient sounds, within an adjustable time period from 5It is not intended for this equipment to be used in diagnosis of medical conditions or for the measurement of any physiological processes. If the user is considered to be at risk it should not be used without medical advice and support.
Response time adjustable from 5 to 60 seconds in 5 second stepsSpasm rate setting 12 to 120 movements per minute.Transient sound alarm
When set up and used properly and in accordance with the instructions, the equipment can be used to provide warnings of detection of symptoms which may be related to particular conditions. The equipment, for a number of reasons, cannot always detect the symptoms being monitored and is not a substitute for direct supervision.

63. Neurovista
Seattle-based NeuroVista was founded in 2002 by Dr. Daniel DiLorenzo to develop an implantable device for the early detection of epileptic seizures.
The NeuroVista seizure advisory system is based on an implantable device that senses EEG irregularities that precede a seizure. Early warning allows patients to take medicine and find a safe place to lie down. Although some epilepsy sufferers can feel seizures coming, many cannot.
In NeuroVista’s Seizure Advisory System (SAS), intracranial EEG signals are recorded through electrodes implanted between the skull and the brain surface. Data storage and signal telemetry takes place within the pectorally-implanted can that transmits signals wirelessly to an external handheld device that processes the data and transmits visual and audible signals to the patient. The external pager-like receiver displays a blue light when there is a low likelihood of seizures, white indicates medium susceptibility, and red alerts to a high likelihood of impending seizure.

64. High Tech?

65. SUDEP
Knowledge of SUDEP and the factors that are thought to increase the chances of being affected by it are crucial to its prevention.
It is important to develop a management plan for the seizure events, and family and friends should learn basic life support skills.

66. Seizure-related injuries
Increased incidence of head and soft tissue injuries
Tongue and mouth lacerations
Submersion (10 fold)
Fractures (2 fold)
Burns (3% of burn units admissions)
Car accidents
Sport related injuries

67. Post seizure-related injuries
Confusion: may walk into a dangerous area
Aspiration pneumonia

68. THE SEIZURE PREPAREDNESS PLAN
In Case of Seizure:
Please keep calm and stay with me until the seizure ends.
These symptoms/behaviors will tell you that I’m having a seizure: (list specific characteristics of your seizures, for example, falling, jerking limbs, etc.) _______________________________________________________________ __
The things you should do to ensure my safety are: (for example, gently move me away from danger, if possible; loosen any restrictive clothing, etc.) ___________
_________________________________________________________________
Please do not put anything in my mouth during the seizure!

69. THE SEIZURE PREPAREDNESS PLAN
Please observe me carefully so you can describe everything you saw during the seizure. I’ll report what you’ve said to my doctor and it may help with my treatment.
Please call 911 if the seizure is prolonged (lasts longer than two to three minutes), is associated with breathing difficulties, causes injury, or becomes a series of seizures. Brief seizures that end spontaneously without injury do not require a 911 call, but may require a call to my doctor. My doctor’s phone number is: ____________________________________________________ _____________

70. THE SEIZURE PREPAREDNESS PLAN
If several seizures occur in a row, please give me my rescue seizure medication as follows: (list instructions obtained from your doctor. If you wear a VNS, include instructions to swipe it once over the implant.) _________________________________________________________________
__________________________________________________________________
After the seizure, please help me find a place to rest. It is also important that I get regular meals and take my seizure medications on schedule.
If you have a school-age child with epilepsy, the Seizure Preparedness Plan should be given to the school nurse or other appropriate school official, as well as the teachers, coaches, camp director, camp counselor, babysitters and anyone else who may be caring for the child.

71. Safety at Home
Make your home as safe as possible by doing the following:
Make sure that your floors are carpeted and any sharp corners (e.g., table corners) are padded to reduce the risk of injury due to a fall.
Don’t smoke.
Don’t light a fire or a candle when you are home alone.
Make sure the drains in your bathtub and shower are working properly to prevent drowning should you lose consciousness while showering.
Set your water temperature to a moderate level to avoid being scalded if you lose consciousness while running the hot water.

72. Safety at Home Don’t take a bath in deep water, to prevent drowning.
Don’t lock the bathroom door, use an “occupied” sign on the doorknob instead.
Install a bathroom door that opens outward for easier access, in case you have a seizure and fall against the door.
Use plastic glasses and dinnerware instead of glass and china to keep from cutting yourself if you lose consciousness while holding them.
Some people also use medical alert systems that notify emergency personnel that they’ve fallen and need assistance. Baby monitors can be helpful to parents of babies or young children who have epileptic seizures during sleep, as they can pick up unusual sounds.
I’m often asked about epilepsy detectors, which are devices that monitor breathing, and/or detect urine or vomit in the bed and send warning signals if something is amiss. While it’s an intriguing idea, none of them are FDA-approved for home use.

73. Safety at home

74. Safety Away From Home
Always tell your family and/or friends where you are going and when you expect to return.
Wear a Medic-Alert bracelet and/or jewelry printed with your medical information.
Put your emergency contact numbers on speed-dial on your cell phone.
Don’t drive without medical permission.
Keep a supply of rescue medication on hand.
Stay away from the tracks at train and subway stations.
If you fall frequently during seizures, consider taking an elevator instead of the stairs or an escalator.

75. Safety away from home

76. General Travel Guidelines
Give your friends and family a copy of your travel itinerary, with phone numbers and addresses where you can be reached.
Become familiar with the hospitals in the areas you are visiting, in case of emergency.
Bring an adequate supply of seizure medication with you. Carry on the plane with you. Do not put in luggage.
If the trip is a long one, consider finding a medical provider in the area to provide refills. However, be aware that not all countries have access to every seizure medication prescribed in the United States. Find out in advance which ones are available, and talk to your doctor about other medicines that are acceptable.
Longer flights and jet lag can cause disrupted sleep, which can trigger a seizure. Talk to your doctor about getting a prescription sleep aid for the trip.

77. General Travel Guidelines
Avoid excessive alcohol.
Eat regular meals.
Don’t forget to consider time zone changes when taking your medications. Take the medication as close as possible to the time you would be taking it at home.
If you travelling to a foreign country, consider learning basic phrases to request medical assistance such as “I need help” and “Where is the hospital?” Even better, travel with someone who knows the native language.
Prepare a plan for an emergency trip back home. Discuss this plan with someone you trust before you go.

78. Traveling Alone
Wear a Medic-Alert bracelet/necklace that includes a description of your seizure(s).
Carry a list on your person of all of your current medications (plus enough medicine to last you from start to end of your trip).
Carry emergency contact information on your person, either on an index card or numbers programmed into your cell phone and listed under contacts as ICE (In Case of Emergency).
Disclose your seizure history to transportation personnel and provide them with a letter from your doctor.
Let the flight attendants, conductor or driver know that you have epilepsy.
If you have a VNS device implanted, carry a VNS registration card so that people will know that you cannot get an MRI, should not have deep heat treatment and so on.

79. SAFETY PRECAUTIONS WHEN ENGAGING IN SPORTS
ACTIVITY
PRECAUTIONS
Baseball
● Wear protective clothing:
elbow or knee pads
helmet
protective eyeglasses or goggles
Basketball
consider a helmet
Bike Riding
● Avoid busy streets
● Ride on bike paths
● Ride on side streets
● Wear a helmet

80. Boxing Bungee Jumping Canoeing/ Kayaking Football Gymnastics
Boxing
● High risk activity - should be avoided by all
Bungee Jumping
Canoeing/ Kayaking
● Never canoe/kayak alone; take a “buddy” who knows seizure first aid.
● Always wear a high quality, well-fitting life vest when near the water to prevent drowning.
Football
● Wear protective clothing:
elbow or knee pads
helmet
protective eyeglasses or goggles
Gymnastics
● Have a “buddy” when using equipment like balance beams, parallel bars or when vaulting
● Consider a helmet when using a balance beam or parallel bars or when vaulting
● Consider a shock-absorbing mat
● Take frequent breaks
● Keep hydrated

81. *Hang Gliding
● High risk activity - should be avoided by individuals with uncontrolled seizures
Horseback Riding
● Wear protective clothing:
elbow or knee pads
helmet
 protective eyeglasses or goggles
Ice Hockey
Jet Skiing

82. ● Consider a shock-absorbing mat ● Take frequent breaks
Martial Arts:
Karate, Tai Kwando, Judo
● High risk activity - should be avoided by individuals with uncontrolled seizures
*Mountain Climbing
Pilates
● Consider a shock-absorbing mat
● Have a ‘buddy” when using equipment
● Take frequent breaks
● Keep hydrated
*Rappelling
*Rock Climbing
Rollerblading
● Wear protective clothing:
elbow or knee pads
helmet
 protective eyeglasses or goggles

83. ● Wear protective clothing: elbow or knee pads helmet
Rugby
● Wear protective clothing:
elbow or knee pads
helmet
protective eyeglasses or goggles
*Scuba Diving
● High risk activity - should be avoided by individual with uncontrolled seizures
Skateboarding
 protective eyeglasses or goggles
Skiing
● Dress for warmth
● Wear protective gear
● Consider a safety strap when riding the t-bar
● Have a “buddy”
● Don’t go off open trails

84. Snorkeling *Skydiving
Snorkeling
● High risk activity - should be avoided by individuals with uncontrolled seizures
*Skydiving
Soccer
● Wear protective clothing:
elbow or knee pads
helmet
protective eyeglasses or goggles

85. ● Never swim alone. Have a “buddy” who knows seizure first aid
Surfing/Wind Surfing
● High risk activity - should be avoided by individuals with uncontrolled seizures
Swimming
● Never swim alone. Have a “buddy” who knows seizure first aid
● Always wear a high-quality, well-fitting life vest when near the water to help prevent drowning.
● Inform the lifeguard about your condition if swimming in a pool
Tai chi
● Consider a shock-absorbing mat
● Take frequent breaks
● Keep hydrated
Yoga

86. Driving Follow state laws
If you have regained your driving privileges, be safe and avoid driving if you are tired or have any known risks for seizures
Don’t hide seizures from your doctor to avoid losing your driver’s license

87. Final words Complications and emergencies are rare
But, always be prepared!