EMS Training. Epilepsy and Seizure Management TRAINER S GUIDE

EMS Training Epilepsy and Seizure Management TRAINER S GUIDE

The leads the fight to stop seizures, find a cure, and overcome the challenges created by epilepsy. The is the national voluntary agency solely dedicated to the welfare of nearly 3 million people with epilepsy in the U.S. and their families. The organization works to ensure that people with seizures are able to participate in all life experiences; to improve how people with epilepsy are perceived, accepted and valued in society; and to promote research for a cure. In addition to programs conducted at the national level, epilepsy clients throughout the United States are served by affiliates around the country. For more information visit the website or call. iv

Table of s Introduction. 1 Training Goals.. 1 About This Trainer s Guide 1 The Layout.. 2 Training-at-a-Glance... 3 Resources/Materials.. 3 Part 1: Training Opening & Overview.. 4 Opening/Introductions... 4 Highlights of the EMS Project. 4 Goals and Objectives 5 Part 2: Understanding Seizures... 7 General seizure statistics 7 Seizure description. 8 Seizure vs intoxication.. 8 Typical causes for seizures 9 Part 3: What is Epilepsy?. 11 Facts and myths about epilepsy. 11 Define epilepsy. 13 Epilepsy definition.. 13 Causes of epilepsy... 13 Possible triggers for epilepsy-related seizures.. 13 Two types of epilepsy-related seizures 14 Generalized seizures.. 15 Partial seizures.. 17 Part 4: Treating Seizures. 21 Treatment don ts. 21 Treatment do s 23 Postictal phase... 24 Situational treatments. 24 Treatment guidelines 25 ALS circumstances. 28 SAMPLE.. 29 Part 5: Wrap-Up 35 Medicines for Epilepsy Chart. 36 v

opyright Introduction The recognizes how important EMS response can be to the health and safety of people experiencing 7/2010 seizures. Proper training in responding to a seizure is particularly important considering the likelihood of EMS personnel encountering such a medical event there are nearly three million Americans subject to seizures caused by epilepsy and millions more who may experience one or more seizure episodes as a result of trauma or other acute or chronic illness. This training is designed to prepare EMS responders for these events and provide them with the information necessary to provide appropriate treatment. Training Goals This training is designed to: Strengthen EMS personnel knowledge about seizures. Enhance their ability to respond to those experiencing a seizure. Help EMS personnel make more informed decisions about additional care and hospital transport. About This Trainer s Guide The realizes that not all facilitators of this training will be EMS or other medical personnel. To accommodate this likelihood, this trainer s guide is designed to enable affiliate staff and/or trained volunteer facilitators to conduct the training as required. NOTE: Whenever possible, it is highly recommended that affiliate staff partner/co-facilitate with someone from the local EMS team or another medical expert to ensure that technical questions are addressed and local protocols honored. 1

opyright The Layout Each portion of this guide shows a time estimate at the top along with the section title. In some instances, the 7/2010 time estimate represents a range. This reflects the fact that there may be one or more optional activities that the trainer may choose depending on the amount of time available for the entire training. The left-hand column lists points of discussion for that segment of the training. Once you become fully familiar with the content and structure of this document, you will find that the left-hand column serves as an at-a-glance outline. The right-hand column contains the detailed content of the training, developed by a team of professionals. This area of the guide also serves as your sample script and occasionally includes shaded training tips and extra white space for handwritten notes. 5-10 minutes Activity Discuss general statistics Provide a high level description of a seizure PART 2: Understanding Seizures There are an estimated three million Americans of all ages who are subject to seizures caused by epilepsy. And there are perhaps millions more who may experience one or more seizure episodes as a result of trauma or some other acute or chronic illness. That translates into roughly 1 in 100 Americans A seizure is a sudden, brief disruption of the normal functioning of neurons in the brain. The disruption in the neurological environment causes some nerve cells to fire without stopping and spread to involve other nerve cells. When this happens TRAINING TIP: In this section, you may opt to ask a few participants to discuss 2

opyright Training-at-a-Glance This trainer s guide is divided into five 7/2010parts: TOPICS ACTIVITIES TIME 1. Training Opening & Overview goals and objectives Highlight the role of EMS Set the tone of the training 3-5 2. Understanding Seizures Define seizures Describe types of seizures List typical causes 3. What is Epilepsy? Describe epilepsy Dispel myths about epilepsy List causes and triggers Discuss generalized and partial seizures 4. Treatment Options Review general treatment do s and don ts Review treatment guidelines for various scenarios 5-10 15-20 20-30 5. Wrap-Up Resources/Materials Review the Participant s Guide Pose final questions Bring session to a close 5-10 The entire package consists of: Trainer s Guide Participant s Guide Instructional DVD A Guide to Seizure Management for Emergency Responders 3

opyright 3-5 minutes Introduce yourself (and co-facilitator as appropriate) PART 1: 7/2010 TRAINING OPENING & OVERVIEW I d like to officially welcome you to the start of the Epilepsy and Seizure Management training specially designed for EMS personnel by the Epilepsy Foundation. My name is and I m. Describe their important role in treating seizures As EMS personnel, you are often the first responders when someone is experiencing a seizure. The Epilepsy Foundation recognizes how important that EMS response can be to the health and safety of an estimated three million Americans subject to seizures caused by epilepsy; and to the millions more who may experience one or more seizure episodes as a result of trauma or other acute or chronic illness. Given the prevalence and critical nature of these events, the Foundation has prepared this manual to provide information and training crucial to an effective EMS response to seizures. Review the overall goals of the training Share the goals and learning objectives roadmap for the training This training is designed to educate EMS personnel about epilepsy and responding to persons experiencing seizures. In general, the goals are to : Strengthen your knowledge about seizures Enhance your ability to respond to those experiencing a seizure Help you make more informed decisions about additional care and hospital transport 4

opyright 3-5 minutes PART 1: TRAINING OPENING & OVERVIEW 7/2010 Specifically, our objectives are to: Optional prepared chart Mention the role of local protocols Mention Parking Lot Define what a seizure is and list various causes. Explore the basics of epilepsy. Differentiate between the types of epileptic seizures. and discuss appropriate treatment options for seizures. Review considerations for determining whether further medical care and/or transport to the hospital is warranted. The recommendations from the Foundation made in this training program are built on solid experience. However, they should be regarded as guidelines. EMS responders should follow local regulations, practices and/or medical controls. As we explore dealing with seizures together, where differences arise between these recommendations and your local protocols, you are encouraged to raise the issues with your leadership to see if modifications in local practice would enhance patient care and outcomes. 5

opyright 3-5 minutes 3-5 minutes PART 1: TRAINING OPENING PART 1: & OVERVIEW TRAINING 7/2010 OPENING OVERVIEW Likewise, there may be questions and issues that come Likewise, up during there this session may be that questions may need and to issues be answered that come up offline. during I/we this have session created that a may Parking need to Lot be where answered they may offline. be noted I/we have for later created resolution. a Parking Lot where they may be noted for later resolution. TRAINING TIP: If you do not have access to chart paper, TRAINING request that TIP: participants If you do not note have their access question to chart for paper, request themselves. that Briefly participants review note them their at the question end of for the training themselves. resolve Briefly those review that them can at be the answered end of the on the training spot and suggest resolve that those the that participants can be answered seek answers on the to spot the rest and from suggest their that supervisors. the participants seek answers to the rest from their supervisors. Other questions may be addressed in FAQs at back of Other your participant s questions may guide. be addressed Be sure to in check FAQs there at back for of additional your participant s resources! guide. Be sure to check there for additional resources! If there are no questions at this point, let s get into the If body there of are this no training. questions at this point, let s get into the body of this training. TRAINER S NOTES: TRAINER S NOTES: 6 6

opyright 5-10 minutes Establish the importance of this training and topic PART 2: 7/2010 UNDERSTANDING SEIZURES By a show of hands, how many of you here have ever responded to a seizure call? What do you remember about that experience? TRAINING TIP: This question is designed to establish an idea of the experience level in the room and to engage the participants. Unless the group is small, taking comments from only a few participants will suffice to help you manage the limited time. Discuss general statistics It was mentioned earlier what is the estimate for the number of people in the US who are subject to seizures caused by epilepsy? There are an estimated three million Americans of all ages who are subject to seizures caused by epilepsy. And there are perhaps millions more who may experience one or more seizure episodes as a result of trauma or some other acute or chronic illness. That translates into roughly 1 in 100 Americans experiencing a seizure at some point in their lives. In fact, by age 80, nearly 10% of us will have experienced at least one seizure. At some point in time, you will encounter a seizure as an EMS responder. Before we talk about protocols and treatment options, we need to first understand what a seizure is and some of the causes. This may be new information for some of us here and serve as a review for others. 7

opyright 5-10 minutes Provide a high level description of a seizure Introduce the idea of a generalized seizure Introduce the idea of a partial seizure PART 2: UNDERSTANDING SEIZURES 7/2010 Normal nerve cells, or neurons, in the brain fire billions of electrical signals to each other by means of tiny bursts of energy. They start and then stop, over and over again. Think of these bursts as flashes of energy. A seizure is a sudden, brief disruption of the normal functioning of neurons in the brain. The disruption in the neurological environment causes some nerve cells to fire without stopping and spread to involve other nerve cells. When this happens, a kind of electrical pulse sweeps through the brain and typically causes the affected person to stare, to fall, and to experience the massive muscular contractions generally known as convulsions. A seizure that involves the entire brain is called a generalized seizure. But not all seizures are dramatic. More limited disruptions of brain function produce less dramatic changes in movement or behavior, depending on what part, or how much of the brain is affected. These episodes are all called seizures better known as partial seizures because only part of the brain is affected. We ll talk more about these two types of seizures shortly. A seizure usually lasts a few seconds to a few minutes, and return to full awareness may be rapid or slow. Describe seizures vs. intoxication It may sometimes be tricky to differentiate between someone who is experiencing a seizure from someone who is intoxicated or reacting to legal or illegal substances. 8

opyright 5-10 minutes PART 2: UNDERSTANDING SEIZURES 7/2010 A seizure begins suddenly, whereas intoxication is a slowly building process. Information from bystanders/friends about the way the episode began will help identify which condition is present. During a seizure, the muscles of the body alternately contract and relax while the patient is unconscious. This massive relaxation of muscles may include those involved with bladder and bowel control. After a seizure, recovery may occur over a matter of minutes to an hour. An intoxicated person takes considerably longer to become alert, oriented and regain clear speech than someone suffering from a seizure. However, do not rely on the smell of alcohol as a telltale sign that it is intoxication rather than a seizure. The person may have simply had a glass of wine prior to the seizure episode. List typical causes of seizures A seizure may be idiopathic - that is, it is of unknown cause. Or a seizure may be secondary to an injury, infection or other disorder affecting the brain. Typical causes (of the disruption in the neurological environment making way for a seizure) include: Optional chart Head trauma Poisoning Chemical imbalances Certain drugs Severe infections of the brain High fever Flashing lights 9

opyright 5-10 minutes Establish epilepsy as a common cause of seizures PART 2: UNDERSTANDING SEIZURES 7/2010 One of the most common causes of seizures is epilepsy. It is a neurological disorder that has recurring seizures as its primary symptom. TRAINER S NOTES: 10

opyright 15-20 minutes 15-20 minutes Facts and myths Facts about and epilepsy? myths about epilepsy? (Optional Q&A activity) (Optional Q&A activity) Optional - capture responses Optional - capture on chart paper responses on chart paper Address typical questions Address typical and myths questions about and myths epilepsy about epilepsy PART 3: 7/2010 WHAT PART IS EPILEPSY? 3: WHAT IS EPILEPSY? Before we define epilepsy, let s talk for a few moments Before about some we define of the epilepsy, myths surrounding let s talk for it. a When few moments the average about some person of the hears myths the surrounding word epilepsy, it. what When do the you average think comes person to mind hears for the them? word What epilepsy, are some what do of you the think myths? comes to mind for them? What are some of the myths? TRAINING TIP: Encourage them to call out answers. You TRAINING may get TIP: responses Encourage about them persons to call swallowing out answers. their tongues, You may get it s something responses about that only persons old people swallowing suffer their from, tongues, it s contagious, it s something you need that to hold only them old people still, etc. suffer There from, is it s no contagious, need to address you need whether to hold or them not their still, answers etc. There are true is no or need false. to address Simply encourage whether or them not their to surface answers what are they true or believe false. are Simply myths encourage about epilepsy them to surface set the what foundation they believe for are sharing myths the about facts. epilepsy to set the foundation for sharing the facts. This 3-5 minute activity below is optional, depending This upon 3-5 how minute much activity time is below available. is optional, You may depending opt to use it if upon your how session much is time scheduled is available. for 75-90 You minutes. may opt to use it if Otherwise, your session skip is the scheduled Q&A and for pick 75-90 up with minutes. Define Otherwise, Epilepsy on skip page the 13 Q&A of this and guide. pick up These with questions Define are Epilepsy captured on in page the back 13 of this the participant s guide. These guide questions and can are be captured referenced in the there back after of the the participant s training. guide and can be referenced there after the training. While we won t be able to deal with all of the myths and questions While we won t about be epilepsy able to today, deal with let s all cover of the a few myths that and often questions come about up. epilepsy today, let s cover a few that often come up. Q: Is it true that flashing lights can trigger a seizure? Q: Is it true that flashing lights can trigger a seizure? Yes. Some people with epilepsy are Yes. photosensitive. Some people This with means epilepsy that are they may have a seizure photosensitive. if exposed This to means intense, that strobe-type they may light have or a seizure a group if of exposed lights flashing to intense, synchronously. strobe-type light or a group of lights flashing synchronously. 11 11

opyright EMS EMS Trainer s Trainer s Guide Guide 15-20 minutes Q: Is epilepsy contagious? PART 3: WHAT IS EPILEPSY? 7/2010 No, epilepsy is not contagious in any way. People used to be afraid that contact with the saliva that may collect around the mouth when someone has a seizure could pass the condition on. However, we know now that this is totally untrue. You cannot catch epilepsy or seizure disorders. Q: Then is epilepsy considered a disease? Not in the sense that it can be caught from or passed on to another person. It is better described as a disorder or health condition. Q: Do people with epilepsy have a mental illness? Epilepsy is not considered to be a mental illness, although a seizure may briefly affect mental functioning. However, like any other person, people who have epilepsy may also have mental health problems including depression and anxiety. Q: Is epilepsy the same as a seizure disorder? Yes. Epilepsy may be referred to as a seizure disorder or vice versa. Because of the lingering stigma associated with the condition, some people may strongly deny that they have epilepsy. But they may acknowledge having a seizure disorder instead. EMS responders should use both terms epilepsy and seizure disorder when taking a patient history. What is epilepsy? It is one of the most common causes Epilepsy Epilepsy Foundation Foundation 12 12

opyright 15-20 minutes Define epilepsy PART 3: WHAT IS EPILEPSY? 7/2010 of seizures, and is also called a seizure disorder. Specifically, epilepsy is a neurological disorder characterized by recurring seizures not otherwise provoked by acute injury or other health emergency. It is one of the potential causes that should always be considered by EMS personnel when called to respond to a seizure event or a person displaying signs of altered mental functioning (mentation). Share causes of epilepsy In 70% of cases, no cause can be found and it s estimated that genetic factors play a role. Known causes include head injuries, stroke, brain tumors, poisoning, problems in brain development before birth, or serious infections such as encephalitis or meningitis. List possible triggers for epilepsy-related seizures Among elderly people, epilepsy is most often caused by stroke, cardiovascular disease, brain tumors or Alzheimer s disease. Epilepsy is also more prevalent in children with mental retardation, Down syndrome, autism, cerebral palsy, and other developmental disorders. Many returning veterans with head injuries develop epilepsy. Except for stroke, epilepsy is the most common neurological disorder in the United States, affecting some three million Americans of all ages, or at least one in every 100 people. In many cases, there is no obvious trigger for a seizure in someone who has been diagnosed with epilepsy. In addition, the possibility of seizures exists despite use of seizure-preventing medication. Nevertheless, there are some key triggers that may produce seizures in people with epilepsy. They include: 13

opyright 15-20 minutes PART 3: WHAT IS EPILEPSY? 7/2010 Failure to take medication or running out of medication Effects of a planned change in medication or interaction with other medication, either purchased over the counter or prescribed Sleep deprivation Key points of the menstrual cycle in women Effects of hunger or excessive stress Heavy use of alcohol or other drugs, or withdrawal from such use High fever from infection Severe dehydration Exposure to flashing lights Information from witnesses or family members may provide clues about whether or not one or more of these triggers were present, helping the EMS responder identify an epilepsy-related seizure. Describe the two types of epilepsyrelated seizures generalized and partial - in greater detail We touched upon this earlier. There are two types of seizures associated with epilepsy based on how much of the brain is involved in the neurological disruption. Does anyone remember the two types? The first is called a generalized seizure which involves a disruption in the entire brain. The second type is called a partial seizure. Just as the name implies, this type of seizure affects only certain parts of the brain. A generalized seizure affects the whole brain at once. This is the type of seizure that is most commonly 14

opyright 15-20 minutes 15-20 minutes Provide details Provide regarding details regarding generalized seizures generalized seizures (Pages 6-7 of the (Pages Participant s 6-7 of Guide) the Participant s Guide) Generalized Tonic Generalized Clonic Tonic Clonic Absence seizures Absence seizures PART 3: WHAT PART IS EPILEPSY? 3: 7/2010 WHAT IS EPILEPSY? encountered by EMS responders because of its encountered dramatic symptoms. by EMS It responders is often marked because by convulsions, of its dramatic and can also symptoms. be caused It is by often head marked trauma, by brain convulsions, tumors, and poisoning, can also metabolic be caused disorders by head (such trauma, as diabetes), brain tumors, poisoning, other acute metabolic conditions disorders affecting (such the brain. as diabetes), or other Under acute the category conditions of generalized affecting the seizures, brain. you may Under encounter: the category of generalized seizures, you may encounter: Generalized tonic clonic seizure: Generalized Formerly tonic called clonic grand seizure: mal seizures. Formerly Most common called grand best mal known seizures. type of generalized Most common seizure. and best known type of generalized Begins with stiffening seizure. of the limbs (the tonic Begins phase), with followed stiffening by jerking of the of limbs the limbs (the tonic and face (the phase), clonic followed phase). by jerking of the limbs and face (the clonic phase). Absence seizures: Absence Formerly seizures: known as petit mal. Marked Formerly by known lapses as of petit awareness, mal. sometimes with staring, Marked that by lapses begin of and awareness, end abruptly, sometimes lasting only with a staring, few seconds. that begin and end abruptly, lasting only a There few seconds. is no warning and no after-effect. Awareness There is no and warning the ability and no to after-effect. communicate usually Awareness quickly and return the ability after to an communicate absence seizure. usually More common quickly in return children after than absence in adults, seizure. absence More common seizures in children are frequently than in so adults, brief that absence they escape seizures detection, are frequently even if the so child brief is that experiencing they escape detection, 50 to 100 even attacks if the daily. child They is may occur experiencing for several 50 to months 100 attacks before daily. a child They is sent may occur for a medical for several evaluation. months before a child is sent for a medical evaluation. Myoclonic seizures: Myoclonic Marked seizures: by rapid, brief contractions of the Marked by rapid, brief contractions of the 15 15

opyright 15-20 minutes 15-20 minutes Myoclonic seizures Myoclonic seizures Atonic seizures Atonic seizures PART 3: WHAT PART IS EPILEPSY? 3: WHAT 7/2010 IS EPILEPSY? muscles, which usually occur at the same time muscles, on both sides which of usually the body. occur at the same time Occasionally, both sides they of the involve body. one arm or a foot. Occasionally, People usually they think involve of them one as arm sudden or a foot. jerks or clumsiness. People usually A variant think of of them experience, as sudden jerks common or clumsiness. to many people A variant who do of not the have experience, epilepsy, common is the to sudden many jerk people of a who foot do during not have sleep. epilepsy, is the sudden jerk of a foot during sleep. Atonic seizures: Atonic Create seizures: an abrupt loss of muscle tone. Create Sometimes an abrupt called loss drop of attacks, muscle astatic tone. or Sometimes akinetic seizures. called drop attacks, astatic or akinetic They result seizures. in head drops, loss of posture, or sudden They result collapse. in head drops, loss of posture, or sudden Because collapse. they are so abrupt, without any warning, and Because because they the are people so abrupt, who without experience any warning, them and fall with because force, the atonic people seizures who experience can result in them injuries fall with to force, the head atonic and seizures face. Protective can result in injuries headgear to is the sometimes head and used face. by Protective children and headgear adults. is sometimes used by children and adults. Awareness and the ability to communicate usually Awareness quickly and return the ability after to an communicate atonic seizure. This usually type quickly of generalized return after seizure an atonic tends seizure. to be This resistant type to of drug generalized therapy. seizure tends to be resistant to drug therapy. Infantile Spasms: Infantile Clusters Spasms: of quick, sudden movements that start between Clusters of 3 months quick, sudden and two movements years of age. that start between If a child is 3 months sitting up, and the two head years will of fall age. forward, and If a child the arms is sitting will flex up, the forward. head will fall forward, and the arms will flex forward. Infantile spasms Infantile spasms If lying down, the knees will be drawn up, with arms If lying and down, head the flexed knees forward will be as drawn if the up, baby with is arms and head flexed forward as if the baby is 16 16

opyright 15-20 minutes 15-20 minutes PART 3: WHAT PART IS EPILEPSY? 3: WHAT 7/2010 IS EPILEPSY? reaching for support. reaching for support. Remember, by definition, a generalized seizure means Remember, the electrical by disruption definition, involves a generalized the entire seizure brain. means the electrical disruption involves the entire brain. Provide details Provide regarding details partial regarding seizures partial seizures (Pages 7-8 of the (Pages Participant s 7-8 of Guide) the Participant s Guide) Two categories Two of categories partial of partial seizures seizures Simple Partial Simple seizure Partial seizure In partial seizures the electrical disturbance is limited to In partial a specific seizures area of the one electrical cerebral disturbance hemisphere is (side limited of to the a brain). specific Partial area of seizures one cerebral are the hemisphere most common (side type of of the seizure brain). experienced Partial seizures by people are the with most epilepsy. common Virtually type any of seizure movement, experienced sensory, by or people emotional with epilepsy. symptom Virtually can any occur movement, as part of sensory, a partial or seizure, emotional including symptom complex can visual occur as or auditory part of a hallucinations. partial seizure, including Partial seizures complex may visual spread or to auditory cause a hallucinations. generalized seizure, Partial in seizures which case may the spread classification to cause a category generalized is partial seizure, seizures in which case the secondarily classification generalized. category is partial seizures secondarily generalized. Partial seizures are subdivided into simple partial Partial seizures seizures (in which are consciousness subdivided into is simple retained); partial and complex seizures (in partial which seizures consciousness (in which is consciousness retained); and is complex impaired partial or lost). seizures (in which consciousness is impaired or lost). Simple partial seizure: Simple May partial be no seizure: more than an odd feeling, a shaking limb, May be a change no more in than how an things odd look feeling, or smell. a shaking limb, It could a change be experienced in how things as a period look or of smell. lost time It that could only be the experienced person having as a the period seizure of lost time experiences. that only the person having the seizure experiences. These episodes are unlikely to generate calls for emergency These episodes assistance are unlikely unless to they generate are calls for emergency continuous. assistance However, they unless sometimes they are precede a continuous. generalized seizure. However, they sometimes precede a generalized seizure. 17 17

opyright 15-20 minutes 15-20 minutes Complex Partial Complex seizure Partial seizure PART 3: WHAT PART IS EPILEPSY? 3: WHAT 7/2010 IS EPILEPSY? Family members or bystanders reporting that someone Family members experiencing or bystanders a convulsion reporting a period that of someone changed awareness experiencing first a convulsion had an odd or feeling a period is of changed helpful information awareness for first establishing had an odd a feeling diagnosis. is helpful information for establishing a diagnosis. Complex partial seizure: Complex Easily partial mistaken seizure: for an episode of mental illness, intoxication, Easily mistaken drug for use an or episode anti-social of mental behavior. illness, intoxication, Depending on drug the use function or anti-social of the affected behavior. part of the Depending brain and on how the function extensive of the disruption affected part is, of the this brain type of and seizure how extensive produces the a kind disruption of dreamstate, type in which of seizure the person produces appears a kind to of be dream- awake is, this but state, is completely in which the or person almost appears completely to be out awake of but touch is completely with his or her or almost surroundings. completely out of touch The person with his will or be her unable surroundings. to respond to directions The person and will may be unable mumble to or respond repeat to a phrase directions over and over and again. may mumble or repeat a phrase over The person and over may again. wander into traffic or other danger The person quite may oblivious wander to into the traffic risk of or harm. other danger In rare cases, quite oblivious people having to the this risk type of harm. of seizure may In rare cry cases, out, run, people flail their having arms, this or type experience of seizure extreme may cry out, fear. run, flail their arms, or experience extreme fear. Partial seizures are sometimes more difficult to recognize Partial seizures than generalized are sometimes seizures more because difficult to the recognize outwards symptoms than generalized are more seizures subtle because and they the will vary depending outwards symptoms upon which are part more of subtle the brain and is they impacted. will vary depending While the overwhelming upon which part majority of the of brain EMS is responders impacted. do While an outstanding the overwhelming job recognizing majority and of EMS handling responders citizens do experiencing an outstanding seizures, job recognizing in limited and cases handling they may citizens experiencing respond with seizures, inappropriate limited force cases to behaviors they may associated respond with with inappropriate seizures, especially force to behaviors complex partial seizures. associated These with particular seizures, especially seizures cloud complex awareness, partial seizures. These particular seizures cloud awareness, 18 18

opyright 15-20 minutes 15-20 minutes Exercise caution in Exercise making caution in assumptions making about behaviors assumptions about behaviors Recap major points Recap major points PART 3: WHAT PART IS EPILEPSY? 3: WHAT 7/2010 IS EPILEPSY? block normal communication, and produce a variety of undirected, block normal involuntary communication, and unorganized and produce movements a variety of that undirected, may be involuntary mistakenly and viewed unorganized as aggression. movements The results that may can be be mistakenly fatal, especially viewed when as aggression. dangerous The results restraint can practices be fatal, are especially used. when dangerous restraint DO NOT FORCIBLY practices are RESTRAIN used. A PERSON WHO IS DO HAVING NOT A FORCIBLY SEIZURE; RESTRAIN THIS INCLUDES A PERSON USE WHO OF IS IMMOBILIZATION HAVING A SEIZURE; TECHNIQUES THIS INCLUDES AND USE DEVICES. OF IMMOBILIZATION TECHNIQUES AND DEVICES. Let s recap a few major points before moving into Let s seizure recap treatment. a few major points before moving into seizure TRAINING treatment. TIP: If time permits, you may present the TRAINING recap as a TIP: series If time of questions permits, actually you may posed present to the recap group as to informally a series of test questions their retention actually of posed the material to the and group provide to informally a degree test of their interactivity. retention of the material and provide a degree of interactivity. Epilepsy can be defined as: Epilepsy can A brain be defined disorder as: marked by recurring seizures. There are A two brain kinds disorder of seizures: marked by recurring seizures. There are Generalized two kinds of seizures: Generalized Partial Generalized Partial seizures: Generalized Involve seizures: a disruption in the entire brain Are Involve marked a disruption by convulsions in the entire and other brain dramatic/recognizable Are marked by convulsions symptoms and other dramatic/recognizable Often result in EMS calls symptoms because of their dramatic Often result nature in EMS calls because of their dramatic nature Pages 6 and 7 of your Participant s Guide summarizes the Pages various 6 and types 7 of your of generalized Participant s seizures. Guide summarizes the various types of generalized seizures. Partial seizures: Partial seizures: Involve only a portion of the brain Involve Show different only a portion symptoms of the and brain behaviors Show different symptoms and behaviors 19 19

opyright 15-20 minutes 15-20 minutes PART 3: WHAT PART IS EPILEPSY? 3: WHAT 7/2010 IS EPILEPSY? depending upon which part of the brain is affected depending upon which part of the brain is affected Are often mistaken for intoxication or drug use Are often mistaken for intoxication or drug use TRAINING TIP: If your session is scheduled for 75-90 TRAINING minutes and TIP: you If your have session access is to scheduled a DVD player for and 75-90 TV minutes for viewing, and you you may have recap access the to material a DVD player covered and up TV to this for viewing, point by you showing may recap the first the 5 material minutes covered and 10 up to this seconds point (5:10) by showing minutes the of first the 5 video minutes entitled and A 10 Guide to seconds Seizure (5:10) Management minutes of for the Emergency video entitled Medical A Guide Responders. to Seizure Management for Emergency Medical Responders. We have already laid the foundation in this training by We describing have already what a laid seizure the foundation is and exploring this the training various by types describing of seizures. what a seizure Now let s is and switch exploring gears to the discuss various treatment types of seizures. options when Now let s you switch are called gears to to the discuss scene. treatment options when you are called to the scene. Video Recap & Video Treatment Recap Preview & (Optional) Treatment Preview (Optional) TRAINER S NOTES: TRAINER S NOTES: 20 20

opyright 20-30 minutes 20-30 minutes Introduce the idea Introduce of BLS and the ALS idea responses of BLS and ALS responses Review important treatment Review important don ts treatment don ts PART 4: 7/2010 TREATING PART SEIZURES 4: TREATING SEIZURES The recognizes that training of EMS The Epilepsy responders, Foundation authority recognizes for their practice, that training and of the utilization EMS responders, of medications authority and for treatments their practice, varies and from the utilization location to of location. medications This training and treatments should be varies viewed from as location guidelines, to location. honoring This local training protocols. should With be this viewed in mind, as guidelines, suggested response honoring and local treatments protocols. guidelines With this in are mind, divided suggested into response "All Responders/BLS and treatments Response guidelines (Basic are Life Support)", divided into and "All"ALS Responders/BLS Response (Advanced Response Life (Basic Life Support)". Support)", and "ALS Response (Advanced Life Support)". There are a number of important cautions that you There must be are aware a number of: of important cautions that you must be aware of: Treatment Don ts Treatment Don ts Don t give anything by mouth - people with epilepsy should Don t give never anything be given by epilepsy mouth - people meds and/or with epilepsy fluids until should the never seizure be is given over epilepsy and consciousness meds and/or has fluids until returned. the seizure is over and consciousness has returned. Don t restrain - The EMS responder should never attempt Don t restrain to prevent - The further EMS responder injury by restraining should never the attempt jerking movements to prevent further of someone injury having by restraining a seizure. the Restraining jerking movements involuntary of someone muscle spasms having a that seizure. produce jerking Restraining may involuntary cause muscle muscle tears spasms or even that fractures. produce It jerking is better may to cause let the muscle movements tears or take even place fractures. freely, It but is to better protect to let the the head movements from continued take place impact freely, on the but ground to protect by the placing head something from continued flat and impact soft on underneath. the ground by Make placing sure something breathing flat is unimpeded. and soft underneath. Make sure breathing is unimpeded. 21 21

opyright 20-30 minutes 20-30 minutes PART 4: TREATING PART SEIZURES 4: TREATING 7/2010 SEIZURES Don t make assumptions - EMS responders should never Don t make assume assumptions that because - EMS an alcohol responders type should odor is noted never assume on a person s that because breath, the an alcohol individual type is odor is noted intoxicated. on a person s The individual breath, may the have individual gone is out to intoxicated. dinner and had The a individual single drink may prior have to gone the seizure, out to but dinner the and two had events a single are not drink necessarily prior to the connected. seizure, but Withdrawal the two from events alcohol are not or necessarily barbiturates connected. is more Withdrawal likely to trigger from a seizure. alcohol or barbiturates is more likely to trigger a seizure. Don t allow extended seizure - although not an actual Don t allow type of extended seizure, seizure status epilepticus - although not is said an to actual exist after type 30 of minutes seizure, status of continuous epilepticus seizure is said activity. to It exist a after true 30 medical minutes emergency of continuous requiring seizure immediate activity. treatment It is a true or medical rapid transport emergency to requiring the hospital. immediate treatment However, current or rapid recommendations transport to the hospital. call for However, treatment current to stop recommendations a convulsive seizure call if for it has continued treatment to for stop more a than convulsive 5 minutes, seizure followed if it has by continued hospital transport. for more than 5 minutes, followed by hospital transport. While prolonged generalized convulsions are While regarded prolonged as being generalized of highest convulsions risk, it is also are possible to regarded experience as being prolonged of highest partial risk, seizures. it is also These possible to present experience as episodes prolonged of continual partial seizures. confusion These lasting present much longer as episodes than the of 2 continual to 3 minutes confusion that a lasting normal seizure much longer of this than type the would 2 to last. 3 minutes Because that they a normal represent seizure of continuing this type would disruption last. Because of brain activity, they they represent too require continuing emergency disruption treatment of and brain need activity, to be they stopped too require as emergency soon as possible. treatment and need to be stopped as soon as possible. Likewise, there a number actions you generally DO Likewise, want to take: there a number actions you generally DO want to take: 22 22

opyright 20-30 minutes 20-30 minutes Review general Review actions general responders DO actions want responders to take DO want to take PART 4: TREATING PART SEIZURES 4: TREATING 7/2010 SEIZURES Treatment Do s Treatment Do s Establish safety and privacy - create a safe space. Make Establish sure safety the physical and privacy area - is create safe by a safe removing space. Make objects sure that the could physical hurt the area patient. is safe Ensure by removing the scene objects is that safe could for rescuers. hurt the patient. Use appropriate Ensure the body substance scene is safe isolation for rescuers. (BSI) precautions. Use appropriate body substance Check for obvious isolation triggers (BSI) precautions. - look around for obvious seizure Check for triggers obvious such triggers as downed - look around electrical for wires obvious or chemical seizure triggers spills. such as downed electrical wires or chemical Assess the spills. patient check level of consciousness, responses, Assess the patient etc., even check look for level a medical of consciousness, ID bracelet responses, or necklace. etc., even look for a medical ID bracelet or Question necklace. witnesses attempt to find out what preceded Question witnesses the episode. attempt Try to get to find specifics out what about the patient s preceded behavior the episode. to help Try you to get understand specifics the about type the patient s of seizure behavior the person to help is experiencing. you understand the type of Establish seizure a the timeline person is find experiencing. out how long the person has Establish been a in timeline seizure. WARNING: find out how If it long has the been person more has than been 5 minutes, seizure. transport WARNING: the patient If it has to the been hospital. more than Conduct 5 minutes, a head-to-toe transport examination the patient look to the for hospital. trauma, Conduct protect a head-to-toe the person s examination head by look placing for trauma, something protect soft and the flat person s under head it, but by DO placing NOT restrain the something person, soft and and keep flat the under airway it, but clear. DO NOT restrain the Determine person, next and steps keep the determine airway clear. if the person can be Determine safely treated next steps on the determine scene or requires if the person further can medical be safely intervention. treated the Pay scene attention or requires to what further happens medical in the postictal intervention. phase Pay right attention after a seizure. to what happens in the postictal phase right after a seizure. 23 23

opyright 20-30 minutes 20-30 minutes Postictal phase Postictal phase Review specific Review situational specific situational treatments treatments PART 4: TREATING PART SEIZURES 4: TREATING 7/2010 SEIZURES The period of time after the seizure (ictus) ends and the The person s period alertness of time after and orientation the seizure returns (ictus) ends to preseizure person s state alertness is called and the orientation postictal returns period. to Although pre- and the seizure the amount state of is time called a person the postictal stays in period. this period Although varies among the amount individuals, of time the a person type and stays location in this of period the seizure, varies among medications, individuals, etc., it the can type last and from location seconds of to the several seizure, medications, hours. Usually etc., after it a can generalized last from seconds seizure or to complex several hours. partial, Usually the person after will a generalized initially appear seizure confused, or complex disoriented partial, the person and tired. will They initially may appear initially confused, feel fearful, disoriented depressed, frustrated and tired. and They even may embarrassed. initially feel fearful, depressed, frustrated and even embarrassed. Full recovery is accompanied by re-establishment of coherent Full recovery speech. is accompanied The patient by is re-establishment likely to have no of memory coherent of speech. events that The patient occurred is prior likely to to the have seizure. no memory of events that occurred prior to the seizure. However, usually within 20 minutes, most have However, regained full usually alertness within and 20 orientation. minutes, most If after have 20 minutes regained the full person alertness remains and orientation. confused, he If after or she 20 should minutes be the transported person remains to an appropriate confused, he medical or she facility should for evaluation. be transported to an appropriate medical facility for evaluation. We ve listed some general steps that you may take. Let s We ve look listed more some closely general at specific steps that guidelines you may for take. action the Let s Epilepsy look more Foundation closely at suggests, specific guidelines keeping local for action protocols the Epilepsy in mind. Foundation Also, remember suggests, keeping that the local treatment guidelines protocols in are mind. divided Also, into remember two categories that the treatment guidelines are divided into two categories All Responders/Basic Life Support (BLS) Advanced All Responders/Basic Life Support Life (ALS) Support (BLS) Advanced Life Support (ALS) 24 24

opyright 20-30 minutes 20-30 minutes Read pages 12-15 Read pages of the 12-15 Participant s of the Participant s Guide Guide Review treatment Review guidelines treatment for generalized guidelines for tonic generalized clonic - convulsive tonic seizure clonic - convulsive in progress seizure in progress PART 4: TREATING PART SEIZURES 4: TREATING 7/2010 SEIZURES Take a few minutes to read over pages 12-15 in your Take Participant s a few minutes Guide. to It read outlines over the pages treatment 12-15 for in your a Participant s person who is Guide. actively It outlines convulsions the treatment (also known for a as a generalized person who tonic is actively clonic in seizure) convulsions when (also EMS known personnel as a generalized arrive at the tonic scene. clonic seizure) when EMS personnel arrive at the scene. TRAINING TIP: Give them 3-5 minutes to review the material TRAINING in TIP: their Give guides. them The 3-5 information minutes to review is duplicated the below material for in your their convenience. guides. The It information is important is duplicated to provide time below for for the your trainees convenience. to interact It is important with the participant s to provide guide time for as the it confirms trainees that to interact the document with the contains participant s the level guide of as detail it confirms they need. that the In addition, document the contains interaction the increases level of detail the they likelihood need. that In addition, they will the reference interaction the document increases the in the likelihood future. that they will reference the document in the future. PREHOSPITAL TREATMENT: CONVULSIVE SEIZURE IN PROGRESS PREHOSPITAL (GENERALIZED TREATMENT: TONIC CONVULSIVE CLONIC) SEIZURE IN PROGRESS (GENERALIZED TONIC CLONIC) All Providers/BLS Response: All Providers/BLS Response: Assure scene safety, utilize body substance isolation (BSI) Assure precautions, scene safety, and utilize advocate body for substance patient respect, isolation (BSI) rights precautions, and privacy. and advocate for patient respect, Do rights not and restrain privacy. movements. DO Do not NOT restrain FORCIBLY movements. RESTRAIN A PERSON WHO IS DO HAVING NOT A FORCIBLY SEIZURE; RESTRAIN THIS INCLUDES A PERSON USE WHO OF IS IMMOBILIZATION HAVING A SEIZURE; TECHNIQUES THIS INCLUDES AND USE DEVICES. OF IMMOBILIZATION Assess level of consciousness TECHNIQUES (LOC). AND DEVICES. Ask Assess witnesses level of how consciousness long the seizure (LOC). has been under way, Ask witnesses precipitating how factors, long the witnessed seizure has injury, been and under if way, they gave precipitating any medication factors, or witnessed tried any injury, treatments and if to they stop gave the seizure any medication prior to your or tried arrival. any Determine treatments if to they stop witnessed the seizure any prior blank to your stare, arrival. cry, fall, Determine loss of if they witnessed any blank stare, cry, fall, loss of 25 25

opyright 20-30 minutes 20-30 minutes PART 4: TREATING PART SEIZURES 4: TREATING 7/2010 SEIZURES consciousness, shaking or shaking on one side of the consciousness, body that progressed shaking or to shaking full blown on seizure, one side of staring, the body chewing that progressed movements to full of the blown mouth, seizure, followed by staring, confusion chewing and movements loss of awareness of the mouth, of environment. followed by Time confusion the seizure and from loss of the awareness beginning of point environment. supplied by Time bystanders. the seizure If from time the extends beginning beyond point five supplied minutes, by transport bystanders. actively If convulsing time extends patient beyond to the five hospital, minutes, transport with without actively ALS, convulsing and notify patient receiving to the hospital. hospital, If with trauma or without is not ALS, suspected, and notify turn receiving patient on hospital. one side into If trauma the recovery is not suspected, position to turn allow patient fluids on in the one side into mouth the to recovery drain and position keep the to allow airway fluids clear. in the mouth Place something to drain and soft keep and the flat airway under clear. the head to protect Place something against injury. soft and flat under the head to protect Protect against patient s injury. privacy by removing nonessential bystanders. Protect patient s privacy by removing nonessential bystanders. Clear surrounding area of items that could injure the patient. Clear surrounding area of items that could injure the Institute patient. active seizure management with the goal of protecting Institute active life and seizure safety management until the seizure with the ends, goal as of follows: protecting life and safety until the seizure ends, as follows: o Make sure the mouth and airway are clear of o any Make items sure that the well mouth meaning and airway but misguided are clear of any bystanders items that may well have meaning inserted. but Do misguided not attempt to bystanders secure the may tongue. have inserted. Do not attempt o to Loosen secure restraining the tongue. garments around the neck o Loosen and airway. restraining garments around the neck o and Determine airway. need for airway support (breathing o may Determine be arrested need for at the airway start support of the seizure (breathing as muscles may be arrested contract, at resulting the start in of a the bluish seizure tinge as to muscles tissues, and contract, may be resulting shallow in during a bluish the tinge to postictal tissues, and phase). may be shallow during the o postictal If airway is phase). compromised by secretions, blood o If or airway vomit, is suction compromised to remove. by secretions, blood or vomit, suction to remove. 26 26

opyright 20-30 minutes 20-30 minutes PART 4: TREATING PART SEIZURES 4: TREATING 7/2010 SEIZURES o Maintain an open airway and administer o oxygen Maintain using an open appropriate airway and delivery administer device, such oxygen as a non-rebreather using appropriate mask delivery with 100% device, such supplemental as a non-rebreather oxygen mask at 12-15LPM. with 100% o supplemental If ventilation requires oxygen assistance, at 12-15LPM. consider o inserting If ventilation a nasopharyngeal requires assistance, airway consider (NPA) and inserting maintain a until nasopharyngeal the patient can airway control (NPA) his/her and maintain own airway. until the patient can control his/her o Assess own airway. presence of pulse and closely monitor o pulse Assess rate. presence This is of of pulse critical and importance closely monitor in an actively pulse rate. seizing This patient is of critical because importance of the risk in of an actively cardiac arrest seizing due patient to low because oxygen of levels the risk of cardiac (hypoxia). arrest due to low oxygen levels o Initiate (hypoxia). and monitor ventilatory and cardiac o Initiate status. If and available, monitor utilize ventilatory BP, EKG, and pulseoximetry, status. If available, etco2 and/or utilize other BP, EKG, approved pulse- cardiac oximetry, methods of etco2 monitoring and/or the other effectiveness approved of the methods cardio-pulmonary of monitoring systems. the effectiveness of o the Look cardio-pulmonary for medical ID bracelet systems. or necklace on o patient Look for or medical in patient s ID bracelet wallet if or authorized necklace on patient ( epilepsy, or in seizures, patient s wallet seizure if authorized ( epilepsy, disorder,"diabetic", seizures, etc.). seizure Lack of medical history disorder,"diabetic", ID does not rule etc.). out Lack epilepsy. of medical o history Check patient's ID does not blood rule glucose out epilepsy. level and treat o as Check authorized. patient's blood glucose level and treat o as Check authorized. patient's temperature. Ensure o hyperthermic Check patient's patient temperature. (infant, child Ensure and adult) experiencing hyperthermic seizure patient is (infant, not excessively child and adult) dressed experiencing or bundled. seizure is Cool not using excessively approved dressed methods. or Do bundled. not allow Cool patient using to approved shiver thus increasing methods. Do metabolic not allow rate patient and body to shiver thus increasing temperature. metabolic rate and body temperature. 27 27

opyright 20-30 minutes 20-30 minutes Discuss reactions Discuss to treatment reactions to guidelines treatment for tonic clonic guidelines seizures for tonic clonic seizures Highlight ALS Highlight circumstances ALS circumstances PART 4: TREATING PART SEIZURES 4: TREATING 7/2010 SEIZURES o Obtain a focused history from witnesses, o family Obtain or a focused accompanying history individuals from witnesses, about any diagnosis family or accompanying of epilepsy and/or individuals other about any diagnosis precipitating of epilepsy event, history and/or of other pregnancy, diabetes, precipitating alcohol/drug event, history use, of history pregnancy, of diabetes, abnormal alcohol/drug ingestion, or known use, history head of injury. o Use abnormal SAMPLE ingestion, as a guide or known for taking head the injury. history o (page Use SAMPLE 26). as a guide for taking the history o (page Conduct 26). a physical head-to-toe exam, o including Conduct a lung physical sounds, head-to-toe pupil response, exam, trauma including to head and lung tongue, sounds, etc. pupil response, trauma o to Check head for and the tongue, presence etc. of antiepileptic o medication Check for the on presence the individual. of antiepileptic o medication Monitor vital on signs the individual. and LOC until patient is o fully Monitor awake, vital alert signs and and oriented. LOC until patient is fully awake, alert and oriented. How would you summarize treatment for a tonic clonic How seizure would that you is, summarize a convulsive treatment seizure for in progress? a tonic clonic seizure What lingering that is, questions a convulsive do you seizure have in about progress? these guidelines? What lingering Again, questions the Foundation do you have urges about you these to discuss guidelines? with your supervisor Again, the any Foundation differences urges in these you guidelines to discuss with and your local supervisor protocols. any differences in these guidelines and your local protocols. Note that ALS (Advanced Life Support) techniques and/or Note that rapid ALS transport (Advanced to Life the hospital Support) are techniques indicated if ANY and/or of the rapid circumstances transport to the noted hospital on pages are indicated 14 and 15 if is ANY present. of the Initiate circumstances ALS if the noted person: pages 14 and 15 is present. Initiate ALS if the person: Continues to seize after 5 minutes OR Experiences Continues to a seize second after seizure 5 minutes shortly OR after the first OR Experiences a second seizure shortly after the first OR 28 28

opyright 20-30 minutes 20-30 minutes Reference the Reference SAMPLE patient the SAMPLE history tool patient history tool PART 4: TREATING PART SEIZURES 4: TREATING 7/2010 SEIZURES Remains unconscious OR Remains After 20 minutes, unconscious remains OR confused OR Is After pregnant 20 minutes, OR remains confused OR Has Is pregnant a co-morbid OR condition such as diabetes OR Has Experienced a co-morbid the seizure condition while such in as water diabetes OR OR Has Experienced been injured the seizure during while or prior in to water the seizure OR or other Has been event injured OR during or prior to the seizure or other Is experiencing event OR severe headache or other symptoms different Is experiencing from those severe usually headache associated or other with symptoms his or her different seizures. from those usually associated with his or her seizures. Page 15 of the Participant s Guide lists some of the Page medications 15 of the used Participant s to stop a seizure: Guide lists some of the medications used to stop a seizure: Diazepam (Valium) Midazolam Diazepam (Valium) (Versed) Lorazepam Midazolam (Versed) (Ativan) Diazepam Lorazepam rectal (Ativan) gel (Diastat) Diazepam Epilepsy medications rectal gel (Diastat) administered intranasally are Epilepsy also available; medications use administered per local protocol. intranasally are also available; use per local protocol. Gather as much information as possible from the postictal Gather as patient much information (who may still as be possible fatigued from and the postictal somewhat patient confused), (who witnesses may still be or fatigued family members. and somewhat The commonly confused), mnemonic witnesses SAMPLE or family is members. an efficient way The commonly to gather data used mnemonic it s found on SAMPLE page 26 is an of your efficient participant s way to gather guide: data it s found on page 26 of your participant s S signs and guide: symptoms A S allergies signs and symptoms A M allergies medications M P pertinent medications medical history P L last pertinent oral intake medical history E L last events oral leading intake up to the seizure events leading up to the seizure E 29 29

opyright 20-30 minutes 20-30 minutes PART 4: TREATING PART SEIZURES 4: TREATING 7/2010 SEIZURES Signs and Symptoms that may range from postictal Signs confusion and Symptoms a bleeding that tongue may range bitten from during postictal the seizure, confusion to to bystander a bleeding reports tongue of bitten how the during seizure the seizure, progressed, to bystander to types of reports injury of if trauma how the is seizure suspected as a progressed, cause. Remember to types of that injury people if trauma often is think suspected that a as a seizure cause. episode Remember lasted that longer people than often it actually think did. that a seizure episode lasted longer than it actually did. Allergies to any substance ingested prior to the seizure, including Allergies to medications, any substance foods, ingested animals, prior dyes, to the or other seizure, sources. including medications, It is possible foods, that an animals, allergic reaction dyes, or other triggered sources. the It is seizure. possible that an allergic reaction triggered the seizure. Medications that the patient is taking. The presence of Medications seizure-preventing that the medications patient is taking. (see list The on pages presence 20 of seizure-preventing and 21 of your guide) medications or a VNS implant (see list under on pages the chest 20 wall and 21 is a of strong your guide) indication or a that VNS the implant seizure under is the the result chest of wall an is ongoing a strong epileptic indication condition. that the Withdrawal seizure is the from result of seizure an ongoing medications, epileptic or condition. an abrupt drop Withdrawal in therapeutic from blood seizure level medications, due to missed or an doses, abrupt are drop common in therapeutic causes of blood seizures level due in people to missed with epilepsy. doses, are Changes common in causes medications of seizures in can people also with cause epilepsy. breakthrough Changes seizures. in medications Seizures may can also also be caused breakthrough as a side effect seizures. of certain Seizures prescription may drugs also be or caused of illegal as a side drugs effect such of as certain cocaine prescription or PCP. drugs or use of illegal drugs such as cocaine or PCP. Pertinent medical history which indicates that the patient Pertinent has medical a history history of epilepsy which indicates (seizure disorder), that the brain patient injury, has a hypoglycemia, history of epilepsy diabetes, (seizure recent disorder), illness, brain other injury, health hypoglycemia, conditions associated diabetes, with recent seizures, illness, or other recent health changes conditions in his/her associated daily routine. with seizures, or recent changes in his/her daily routine. Last oral intake to assess the likelihood of vomiting and Last aspiration oral intake as a complication to assess the of likelihood the seizure. of vomiting and aspiration as a complication of the seizure. 30 30

opyright 20-30 minutes 20-30 minutes Recap major points Recap major points Video Recap Video (Optional) Recap (Optional) PART 4: TREATING PART SEIZURES 4: TREATING 7/2010 SEIZURES Events leading up to the incident which may prove to be Events important. leading Have up the to the patient incident describe, which as may best prove s/he to be can, important. what s/he Have was the doing patient before describe, the seizure as best began, s/he or can, if s/he what cannot s/he remember was doing (not before unusual), the seizure see if began, friends or or witnesses if s/he cannot remember provide that (not information. unusual), see Exposure if friends to or witnesses flashing lights, can provide for example, that information. may be a seizure Exposure trigger to for flashing some people. lights, for In young example, children may be a sudden a seizure rise trigger in fever for some may trigger people. what In is young called children a febrile a (fever) sudden seizure. rise in fever may trigger what is called a febrile (fever) seizure. Let s briefly recap a few major points: Let s briefly recap a few major points: TRAINING TIP: If your session is scheduled for 75-90 TRAINING minutes and TIP: you If your have session access is to scheduled a DVD player for and 75-90 TV minutes for viewing, and you you may have recap access the to material a DVD player covered and up TV to this for viewing, point by you showing may recap the video the material entitled A covered Guide up to to this Seizure point Management by showing the for Emergency video entitled Medical A Guide to Responders Seizure Management minutes for 5:10 Emergency - 9:42. Medical Responders minutes 5:10-9:42. Otherwise, you may present the recap as a series of statements Otherwise, you as noted may present below. the For recap greater as interactivity a series of statements and to informally as noted test below. retention, For consider greater interactivity actually posing and to informally the information test retention, below as consider questions actually to the group rather posing than the information simply sharing below statements. as questions to the group rather than simply sharing statements. When responding to someone experiencing a seizure, When don t: responding to someone experiencing a seizure, don t: Give anything by mouth Give Restrain anything by mouth Make Restrain assumptions about behavior Allow Make the assumptions extended seizure about behavior Allow the extended seizure 31 31

opyright 20-30 minutes 20-30 minutes PART 4: TREATING PART SEIZURES 4: TREATING 7/2010 SEIZURES The things you do want to do include: The things Establishing you do want a to safe do area include: and privacy Establishing Check for obvious a safe triggers area and privacy Assess Check for the obvious patient triggers carefully Assess Question the witnesses patient carefully Question Establish witnesses a timeline Conduct Establish a head-to-toe timeline examination Conduct Determine a head-to-toe if hospital transport examination is necessary Determine if hospital transport is necessary One warning related to the length of the seizure is: One warning Transport related the to patient the length to the of the hospital seizure if the is: seizure Transport lasted the patient more than to the 5 minutes hospital or if another seizure lasted started more shortly than after 5 minutes the first or one. another seizure started shortly after the first one. In addition, transport to the hospital is always indicated In when: addition, transport to the hospital is always indicated when: The seizure continues for more than 5 The minutes seizure OR continues for more than 5 minutes The person OR experiences another seizure shortly The person after experiences the first one another OR seizure shortly The person after remains the first unconscious one OR OR The person remains confused unconscious after OR 20 minutes The person OR remains confused after 20 minutes There is some OR other medical condition such as diabetes There is some OR other medical condition such as diabetes The seizure OR happened in water OR There seizure has been happened an injury water either OR before or during There has the been seizure an OR injury either before or during The person the seizure is experiencing OR headaches or other The person symptoms is experiencing not usually headaches associated or with other his or symptoms her seizures. not usually associated with his or her seizures. 32 32

opyright 20-30 minutes 20-30 minutes PART 4: TREATING PART SEIZURES 4: TREATING 7/2010 SEIZURES The postictal phase is: The postictal The phase period is: right after a seizure. The person The may period still be right somewhat after a confused, seizure. The feel person tired, may etc. Full still recovery be somewhat often confused, happens within feel tired, about etc. 20 minutes. Full recovery If that often doesn t happens happen, within consider about 20 transport minutes. to the If that hospital. doesn t happen, consider transport to the hospital. An easy way to remember what to ask regarding the person s An easy way history remember is: what to ask regarding the person s history is: S - signs and symptoms A S - signs allergies and symptoms A M medications allergies P M medications pertinent history L P last pertinent oral intake history L E last events oral leading intake up to the seizure E events leading up to the seizure Reference the Reference Participant s the Guide Participant s Guide Before we move to the last portion of this training, take a Before few minutes we move to to thumb the last through portion your of this Participant s training, take Guide. a few minutes You will to notice thumb that through there are your treatment Participant s Guide. guidelines You for will various notice that seizure there scenarios, are treatment beginning with page guidelines 12, which for various we have seizure already scenarios, looked at beginning detail. with page 12, which we have already looked at in detail. Page 17 and 18 notes treatment guidelines for a complex Page 17 partial and 18 seizure. notes treatment guidelines for a complex partial seizure. Also pay particular attention to pages 19 and 20 which Also summarize pay particular factors attention that help to determine pages 19 when and transport 20 which to summarize the hospital factors may that be indicated. help determine when transport to the hospital may be indicated. 33 33

opyright 20-30 minutes 20-30 minutes PART 4: TREATING PART SEIZURES 4: TREATING 7/2010 SEIZURES TRAINING TIP: If time permits, have the participants TRAINING read and discuss TIP: If time the treatment permits, have guidelines the participants for a complex read and partial discuss seizure the treatment (pages 17 guidelines and 18 in for the a complex Particpant s partial Guide). seizure In addition, (pages 17 review and 18 the in section the titled Particpant s Epilepsy Guide). and Seizures: In addition, Is Ambulance review the section and Hospital titled Epilepsy Transport and Seizures: Needed? (pages Is Ambulance 19 and and 20 of the Hospital Participant s Transport Guide). Needed? Otherwise, (pages simply 19 and provide 20 of a few the minutes Participant s for the Guide). participants Otherwise, to thumb simply through provide the a few guide minutes on their own for the as participants noted below. to thumb through the guide on their own as noted below. Take a few minutes now to review the material in the Participant s Take a few minutes Guide. now Then to we review will wrap the material up the session. in the In Participant s particular, Guide. read pages Then 17 we and will 18 wrap which up the details session. In treatment particular, guidelines read pages for a 17 complex and 18 partial which seizure. details treatment guidelines for a complex partial seizure. Video Recap Video (Optional) Recap (Optional) TRAINING TIP: If your session is scheduled for 75-90 TRAINING minutes and TIP: you If your have session access is to scheduled a DVD player for and 75-90 TV minutes for viewing, and you may have recap access the to material a DVD player covered and up TV to this for viewing, point by you showing may recap the video the material entitled A covered Guide up to to this Seizure point Management by showing the for Emergency video entitled Medical A Guide to Responders Seizure Management minutes for 9:42 Emergency to 14:20 Medical or the end. Responders minutes 9:42 to 14:20 or the end. TRAINER S NOTES: TRAINER S NOTES: 34 34

First Responders: EMS Personnel Trainer s Guide opyright 5-10 20-30 minutes Activity Ask for Parking Lot questions and/or other urgent issues PART 5: 4: 7/2010 TREATING Wrap-Up SEIZURES The things you do want to do include: We have covered Establishing a great a safe deal area of content and privacy in a short period of time. Check for obvious triggers Assess the patient carefully Are there any Question questions witnesses that you would like to raise? Establish a timeline TRAINING Conduct TIP: Oftentimes, a head-to-toe the answers examination are in the room. An experienced co-facilitator, colleague or even Determine if hospital transport is necessary participant may be able to answer a question that you may not be able to fully address. One warning related to the length of the seizure is: Transport the patient to the hospital if the Please be sure to discuss issues with your supervisor seizure lasted more than 5 minutes or another as necessary, or call the for further seizure started shortly after the first one. information. In addition, transport to the hospital is always indicated Ask for suggestions What suggestions would you offer to make this training when: for improvement more effective? (Optional) The seizure continues for more than 5 TRAINING minutes TIP: You OR may also use a more formal evaluation The form. person experiences another seizure shortly after the first one OR The person remains unconscious OR Thank the Thank you The for person your time, remains attention, confused and participation. after 20 participants Most importantly, minutes thank OR you for dedication to offering the best possible There is response some other for medical people who condition suffer such from as seizures. diabetes OR The seizure happened in water OR TRAINER S NOTES: There has been an injury either before or during the seizure OR The person is experiencing headaches or other symptoms not usually associated with his or her seizures. 35 32

36 32 250 mg 4 mg 12 mg 500 mg 600 mg 400 mg 2 mg 30 mg 500 mg 125 mg 50 mg 500 mg 250 mg 125 mg Sprinkles 200 mg 16 mg 750 mg 100 mg 250 mg 300 mg 2 mg 1000 mg 500 mg Also available as oral solution 1200 mg 3600 mg 36 mg 56 mg 1000 mg 3000 mg GABITRIL (tiagabine) KEPPRA (levetiracetam) 200 mg 400 mg 250 mg 1000 mg 2000 mg 3500 mg 1750 mg 3000 mg 1750 mg 3000 mg 600 mg 1200 mg 3200 mg 1 mg 10 mg Actual doses for a person with epilepsy may be higher or lower than the doses listed. AVERAGE ADULT DAILY DOSE FELBATOL (felbamate) DILANTIN (phenytoin) DIAMOX SEQUELS (extended release acetazolamide) DEPAKOTE ER (extended release divalproex sodium) DEPAKOTE (divalproex sodium) DEPAKENE (valproate) CARBATROL (extended release carbamazepine) BANZEL (r namide) *ATIVAN (lorazepam) BRAND NAME (generic name) Give your memory some help if you have trouble remembering to take your medication. Reminders include daily or weekly pill boxes, watches with alarms, notes where you can see them, and computer calendar reminders. It may be helpful to take your medication at the same time you regularly perform other daily tasks, such as brushing your teeth, after meals or before bedtime. Be cautious when starting a new medication or making a major change in dose. Do not drive until you know how the new dr er ect you. It may make you drowsy. Never mix large amounts of alcohol with medication. Ask your doctor if it would be safe for you to consume small amounts of alcoholic beverages. Remember to tell all your doctors, as well as dentists and pharmacists, that you are taking an antiepileptic medication. It is a good idea to bring all your medication bottles with you to doctor visits. Keep all epilepsy medications away from direct sunlight, dampness and high humidity. A bathroom cabinet or windowsill over the kitchen sink are usually not good places to keep medicines. Know the name, strength of pills and dosage of your medication. Write it down so you can refer to it. If you are unhappy with your level of seizure control or are having unpleasant side e ects from the medication, do not assume you have to put up with it. Tell your doctor. Ask about other medications or treatments which may be appropriate for you. PART 4: 7/2010 SEIZURES TREATING 250 mg 400 mg 1 mg One warning related to the length of the seizure is: Transport the patient to the hospital if the seizure lasted more than 5 minutes or another seizure started shortly after the first one. Do not try other people s pills, even if a friend says they are working well for her. Instead, get the name of the medication and ask your doctor if it might be right for you. Keep all medications out of reach of young children. Keep medication in the drug store bottle with a childproof cap and label on it. If using a pill box, keep it in a safe place if there are children around. Grandparents and others should remember that toddlers can be very curious. Sleepiness, fatigue, poor coordination, loss of strength, dizziness Tremor, dizziness, nervousness, di culty concentrating, sleepiness, weakness Anorexia, vomiting, insomnia, nausea, headache, liver and blood toxicity Clumsiness, insomnia, motor twitching, nausea, rash, gum overgrowth, hairiness, thickening of features Appetite loss, frequent urination, drowsiness, confusion, numbness of extremities, kidney stones Upset stomach, altered bleeding time, liver toxicity, hair loss, weight gain, tremor Upset stomach, altered bleeding time, liver toxicity, hair loss, weight gain, tremor Upset stomach, altered bleeding time, liver toxicity, hair loss, weight gain, tremor Dizziness, drowsiness, blurred or double vision, nausea, skin rashes, abnormal blood counts (rare) Drowsiness vomiting, headache, fatigue, loss of appetite and dizziness Drowsiness, sleepiness, fatigue, poor coordination, unsteadiness, behavior changes SOME SIDE EFFECTS 100 mg 200 mg 0.5 mg FORM (of brand name product) Do learn about your medication. Ask your doctor or pharmacist for information about the medication and possible side e ects. If you obtain information from other sources, such as friends or the Internet that causes you concern, check with your doctor or pharmacist. Do take your medication regularly. ere are several important things people with epilepsy can do to give their treatment the best chance of success. Taking Control Any change in physical or mental health in someone taking these medications should be reported promptly to the doctor. Safety in pregnancy has not been established for any of these medications. Questions about their use in pregnancy should be discussed with the doctor. Take enough medication with you when going on vacation to last until you return. Carry a separate copy of your prescription and the phone number of your doctor so you can easily replace any medicine that gets lost. Do not keep pills in checked baggage when traveling by plane. Take them with you. The things you do want to do include: Establishing a safe area and privacy Check for obvious triggers Assess the patient carefully Question witnesses Establish a timeline Conduct a head-to-toe examination Determine if hospital transport is necessary Do ask your doctor what to do if you miss a dose of medication. Do not assume if you miss a few doses that you can make them up by taking them all at once, or when you feel a seizure coming on. What you need is a certain amount of medication, taken regularly, to keep a constant level of medication in your blood. In addition, transport to the hospital is always indicated when: The seizure continues for more than 5 minutes OR The person experiences another seizure shortly after the first one OR The person remains unconscious OR The person remains confused after 20 minutes OR There is some other medical condition such as diabetes OR The seizure happened in water OR There has been an injury either before or during the seizure OR The person is experiencing headaches or other symptoms not usually associated with his or her seizures. f not complete because of space limitations. For a complete list, consult your doctor, nurse, or pharmacist. More detailed sources of information on side e ects include the drug s prescribing information sheet, or the Physician s Desk Reference. ctures are of brand name drugs as of the printing date. However, drugs may change in appearance from time to time. Generic versions of these drugs (listed under the brand name) will look di erent from the brand name drugs. Be honest. If you have been missing doses or having side effects, say so. If you are not honest with your doctor, he or she cannot properly help you. more familiar with the medications they are taking. It is not designed for use by health or other professionals to identify drugs. Other drugs not listed here may also be prescribed to prevent seizures. Do not run out of medication. Set up a schedule for reordering so it becomes automatic. Request re several days in advance. If ordering medication by mail, leave enough time for delays in delivery. 20-30 minutes copyright Do not ever stop your medication abruptly. is can result in a dramatic increase in your seizures, which can be dangerous to you. Do not change the dose without consulting your doctor. Too much medication may lead to side e ects. Too little medication may increase your seizures. Epilepsy Medication Medicines for Epilepsy

Anorexia, vomiting, insomnia, nausea, headache, liver and blood toxicity 1200 mg 3600 mg FELBATOL (felbamate) 400 mg 600 mg Tremor, dizziness, nervousness, di culty concentrating, sleepiness, weakness 36 mg 56 mg GABITRIL (tiagabine) 4 mg 12 mg 16 mg 2 mg Sleepiness, fatigue, poor coordination, loss of strength, dizziness 1000 mg 3000 mg KEPPRA (levetiracetam) Also available as oral solution 750 mg 1000 mg 500 mg 250 mg Sleepiness, fatigue, poor coordination, loss of strength, dizziness 1000 mg 3000 mg KEPPRA XR (extended release levetiracetam) 750 mg 500 mg Drowsiness, sleepiness, fatigue, poor coordination, unsteadiness, behavior changes 1.5 mg 20 mg KLONOPIN (clonazepam) 0.5 mg 1 mg 2 mg Orally Disintegrating Tablets Chewable Dispersible Dizziness, headache, blurred vision, clumsiness, sleepiness, nausea, skin rash 100 mg 500 mg LAMICTAL (lamotrigine) 200 mg 100 mg 50 mg 25 mg 200 mg 150 mg 100 mg 25 mg 25 mg 5 mg 2 mg Dizziness, headache, blurred vision, double vision, trouble with balance and coordination, anxiety, tremor, nausea, vomiting, skin rash 200 mg 600 mg LAMICTAL XR (extended release lamotrigine) 25 mg 50 mg 100 mg 200 mg Dizziness, blurred vision, weight gain, sleepiness, di culty concentrating, swelling of hands and feet, dry mouth 150 mg 600 mg LYRICA (pregabalin) 225 mg 300 mg 50 mg 75 mg 100 mg 150 mg 200 mg 25 mg Clumsiness, dizziness, appetite loss, fatigue, drowsiness, hyperirritability, insomnia, depression, hyperactivity (children) 250 mg 1000 mg MYSOLINE (primidone) 50 mg 250 mg Sleepiness, dizziness, clumsiness, fatigue, twitching 900 mg 3600 mg NEURONTIN (gabapentin) 400 mg 600 mg 800 mg 100 mg 300 mg * opyright 20-30 minutes Drowsiness, irritability, hyperactivity (children), behavorial problems, di culty concentrating, depression 15 mg 100 mg PHENOBARBITAL (phenobarbital) 100 mg 60 mg 30 mg 15 mg Clumsiness, insomnia, motor twitching, nausea, rash, gum overgrowth, hairiness, thickening of features 200 mg 400 mg PHENYTEK (extended phenytoin sodium) 200 mg 300 mg Permanent vision loss, abnormal MRIs, anemia, sleepiness, fatigue, numbness of extremities, weight gain, swelling, hyperactivity 2,000 mg 4,000 mg (adults) 50-150mg/kg/day (children with infantile spasms) (can be divided into 2 doses per day) SABRIL (vigabatrin) Also available as powder for oral solution PART 4: 500 mg Dizziness, drowsiness, blurred or double vision, nausea, skin rashes, abnormal blood counts (rare) 600 mg 1200 mg TEGRETOL (carbamazepine) 200 mg 100 mg Dizziness, drowsiness, blurred or double vision, nausea, skin rashes, abnormal blood counts (rare) TREATING 7/2010 SEIZURES 600 mg 1200 mg TEGRETOL XR (extended release carbamazepine) 100 mg 200 mg 400 mg Confusion, sleepiness, dizziness, clumsiness, di culty thinking or talking, tingling sensation of the skin, nausea, decreased appetite Sprinkles 200 mg 400 mg TOPAMAX (topiramate) 100 mg 200 mg 15mg 25 mg 25 mg 50 mg T-Tabs Drowsiness, sleepiness, fatigue, poor coordination, unsteadiness, behavior changes 15 mg 45 mg TRANXENE (clorazepate) 15 mg 7.5 mg 3.75 mg Di culty concentrating, sleepiness, fatigue, dizziness, double vision, nausea, unsteadiness, rash The things you do want to do include: Establishing a safe area and privacy 600 mg 2400 mg TRILEPTAL (oxcarbazepine) 600 mg 150 mg 300 mg Dizziness, headache, nausea, vomiting, double vision, blurred vision, walking di culty, drowsiness, diarrhea, falls, unintentional rapid eye movement, tremor 200 mg 400 mg VIMPAT (lacosamide) Also available as oral solution 50 mg 100 mg 150 mg 200 mg Appetite loss, nausea, drowsiness, headache, dizziness, fatigue, rash, abnormal blood counts (rare) Check for obvious triggers Assess the patient carefully Question witnesses Establish a timeline Conduct a head-to-toe examination Determine if hospital transport is necessary One warning related to the length of the seizure is: Transport the patient to the hospital if the seizure lasted more than 5 minutes or another seizure started shortly after the first one. In addition, transport to the hospital is always indicated when: The seizure continues for more than 5 minutes OR 500 mg 1500 mg ZARONTIN (ethosuximide) The person experiences another seizure shortly after the first one OR The person remains unconscious OR The person remains confused after 20 minutes OR There is some other medical condition such as diabetes OR The seizure happened in water OR There has been an injury either before or during the seizure OR The person is experiencing headaches or other symptoms not usually associated with his or her seizures. 250 mg Sleepiness, dizziness, loss of appetite, headache, nausea, irritability, culty concentrating, unsteadiness, fever, kidney stones, rash (should not be used in individuals allergic to sulfa drugs) 100 mg 600 mg ZONEGRAN (zonisamide) 100 mg 25 mg e following medicine is not prescribed for daily, long-term use, but to stop episodes of prolonged or cluster seizures. Drowsiness, sleepiness, fatigue, poor coordination, unsteadiness, behavior changes Average Single Dose 0.2 mg. 0.5 mg./kg. DIASTAT ACUDIAL TM (diazepam rectal gel) 2.5 mg 20 mg use. that FDA-approved for not but epilepsy, Sometimes prescribed for 37 32

NOTES: 32

NOTES: 32

2010 copyright 7/2010 This publication was made possible with funding from the Centers for Disease Control and Prevention (CDC) under cooperative agreement number 5U58DP000606-05. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the CDC. iii 604EMT Rev. 5/2011