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Home , Causes of seizures

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Introduction ...... 1 About this Training ...... 1 What is a ? ...... 2 Typical Causes for ...... 3 What is Epilepsy? ...... 4 Causes of Epilepsy ...... 4 Danger of Prolonged Seizure ...... 5 Epilepsy and Seizure Triggers ...... 5 Epilepsy and Seizures: Types ...... 6 Generalized Seizures ...... 6 Partial Seizures...... 7 Special Cautions ...... 8 After a Seizure ...... 9 The Postictal Phase ...... 9 Treating Seizures ...... 10 Treatment Do’s ...... 10 Treatment Don’ts ...... 11 Treatment Guidelines ...... 12 PreHospital Treatment: Convulsive Seizure in Progress ...... 12 Patient No Longer Convulsing ...... 15 Complex Partial Seizure ...... 17 Epilepsy and Seizures: Patient Experiencing Seizure with VNS Implant ...... 18 Epilepsy and Seizures: Is Ambulance and Hospital Transport Needed? ...... 19 Epilepsy and Seizures: Antiepileptic Drugs ...... 20 PreHospital Treatment: Convulsive Seizure of Unknown Origin ...... 21 Convulsive Seizure due to CNS Injury ...... 21 Active Seizure Has Ceased ...... 23 Convulsive Seizure due to Metabolic Disorder ...... 23 Active Seizure Has Ceased ...... 25 Seizure in Progress Due to Infection ...... 25 Once Active Seizure Has Ceased ...... 25 Using SAMPLE to take a seizure history ...... 26 Glossary of Terms ...... 28 Frequently Asked Questions ...... 30 control. Where differences arise, it is hoped that EMS responders will raise Introduction the issues with their leadership to see if modifications in local practice would As EMS personnel, naturally, you are enhance patient care and outcomes. often the first responders when someone is having a seizure. The recognizes how important that EMS response can be to the health and safety of an Seizure – a sudden, brief estimated three million Americans disruption of the normal subject to seizures caused by epilepsy. functioning in the brain. Beyond that number, there are likely millions more who may experience one or more seizure episodes as a result of Normal nerve cells, or , in the trauma or other acute or chronic brain fire billions of electrical signals to illness. each other by means of tiny bursts of energy. They start and then stop, over Given the prevalence and critical and over again. Think of these bursts nature of these events, the Epilepsy as flashes of energy. Foundation has prepared this manual to provide information and training A seizure is a sudden, brief disruption crucial to an effective EMS response to of the normal functioning of neurons in seizures. The recommendations from the brain. The disruption in the the Epilepsy Foundation outlined in neurological environment causes this training are built on solid some nerve cells to fire without experience. However, the Foundation stopping and spread to involve other also recognizes that the availability of nerve cells. When this happens, a kind EMS responders, their training, of electrical pulse sweeps through the authority for their practice, and their brain and typically causes the affected utilization of medications and person to experience a variety of treatments varies from location to behaviors such as staring, falling, location. Therefore, this information repetitive motions, disorientation, or to should be regarded as guidelines. experience the massive muscular contractions generally known as With this in mind, suggested response convulsions. and treatments guidelines are divided into two categories:

All Responders/BLS Response About this Training (Basic Life Support) ALS Response (Advanced Life When an individual has a convulsive Support) seizure – that is, an alteration of brain function producing loss of EMS responders should follow local consciousness and muscle regulations, practice and/or medical contractions affecting the whole body

1 – often the first impulse on the part of the public is to call 911 for an emergency medical services (EMS) What is a Seizure? response. This training describes a variety of seizures associated with epilepsy, seizures with other potential causes, appropriate EMS response on Seizure – a sudden, brief scene, and issues to be considered disruption of the normal neuron when determining whether or not functioning in the brain. further medical care is warranted.

In general, the goals are to: Normal nerve cells, or neurons, in the

brain fire billions of electrical signals to Strengthen the knowledge of each other by means of tiny bursts of Emergency Medical Services energy. They start and then stop, over (EMS) responders in the and over again. Think of these bursts recognition, causes, as flashes of energy. A seizure is a appropriate response and sudden, brief disruption of the normal management of generalized functioning of neurons in the brain. and partial seizures and . As mentioned earlier, the disruption in Enhance the ability of EMS the neurological environment causes responders’ ability to respond some nerve cells to fire without effectively to individuals stopping and spread to involve other experiencing a seizure, with an nerve cells. When this happens, a kind emphasis on epileptic seizures. of electrical pulse sweeps through the Help the EMS responders’ brain and typically causes the affected make informed decisions person to experience a variety of regarding the proper response behaviors such as staring, falling, to seizures with respect to the repetitive motions, disorientation, or to need for additional care and experience the massive muscular ambulance transport contractions generally known as convulsions. By the end of this training, you will be able to: A seizure that involves the entire brain Define what a seizure is and list is called a generalized seizure. This various causes type of seizure generally results in Describe the basics of epilepsy, convulsions and other clearly a variety of seizures associated observable behaviors. But not all with epilepsy and other seizures are dramatic. potential causes Differentiate between the types More limited disruptions of brain of seizures function produce less dramatic Outline appropriate EMS changes in movement or behavior, responses and treatment depending on what part or how much options for those experiencing a of the brain is affected. These are seizure better known as partial seizures

2 because only part of the brain is After a seizure, recovery may occur affected. We’ll talk more about these over a matter of minutes to an hour. two types of seizures shortly. An intoxicated person takes considerably longer to become alert, A seizure usually lasts a few seconds oriented and able to speak clearly. Do to a few minutes. Return to full not rely on the smell of alcohol as a awareness may be rapid or slow. telltale sign that it is intoxication rather While seizures may take several forms, than a seizure. The person may have EMS is most likely to be called when simply had a glass of wine prior to the someone has a generalized convulsion seizure episode. (ttonic-clonic seizure) or a complex partial seizure which produces altered awareness and confused behavior inappropriate to the surroundings. EMS may also be requested by law Typical Causes for Seizures enforcement officers to medically evaluate a person exhibiting confusion, A seizure may be idiopathic - that is, it disorientation, and other possible occurs spontaneously and is of signs of seizure activity. unknown cause. Or a seizure may be

secondary to an injury, infection or other disorder affecting the brain. Be careful not to confuse a Typical causes (of the disruption in the seizure with intoxication. neurological environment making way for a seizure) include:

It may sometimes be tricky to Head trauma differentiate between someone who is Poisoning experiencing a seizure from someone Chemical imbalances who is intoxicated or reacting to legal Certain drugs or illegal substances. A seizure begins Severe infections of the brain suddenly, whereas intoxication is a High slowly building process. Information Flashing lights from bystanders, friends or family members as to the way the episode began will help identify which condition is present. During a seizure, the By age 80, nearly 10% of us will have muscles of the body alternately experienced at least one seizure. One contract and relax while the patient is of the most common causes of unconscious. This massive relaxation seizures is epilepsy - it is a of muscles may include those involved neurological disorder that has with bladder and bowel control. A recurring seizures as its primary seizure usually lasts a few seconds to symptom. a few minutes, and return to full awareness may be rapid or slow.

3 What is Epilepsy? Causes of Epilepsy

In 70% of cases, no cause can be found for epilepsy although it is Epilepsy is one of the most estimated that genetic factors play a common , role. Known causes include: affecting an estimated 3 million Americans. It is also called a Head injuries seizure disorder. Stroke Brain tumors Poisoning Specifically, epilepsy is a neurological Problems in brain development disorder characterized by recurring before birth seizures not otherwise provoked by Serious infections such as acute injury or other health or emergency. It is one of the potential causes that should always be Among elderly people, epilepsy is most considered by EMS personnel when often caused by stroke, cardiovascular called to respond to a seizure event or disease, brain tumors or Alzheimer’s a person displaying signs of altered disease. Epilepsy is also more mental functioning (mentation). prevalent in children with mental retardation, , autism, , and other developmental disorders. Many Because of lingering stigma associated returning veterans with head injuries with the condition, some people will develop epilepsy. strongly deny having epilepsy despite the presence of seizures and a typical As epilepsy is not a specific disease, it history, but will acknowledge having “a is not contagious. It is also not a seizure disorder.” EMS responders mental illness, although a seizure may providing assistance to someone with briefly affect mental functioning. seizures should use both terms when However, people who have epilepsy taking a patient history. may, like any other person, also have mental health problems, including Except for stroke, epilepsy is the most depression and anxiety. Most are able common neurological disorder in the to prevent seizures by daily use of United States, affecting some three antiepileptic medications, also called million Americans of all ages, or . However, despite approximately one in every 100 medical therapy, seizures persist in people. approximately 20% of patients with primary (involving the whole brain at once) and 35% of those with partial epilepsy (involving only part of the brain).

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The likelihood is high is that you will one day be called to treat someone having a seizure.

If seizures happen in a public place, they are likely to generate a 911 call for emergency assistance. If seizures Epilepsy and Seizure Triggers happen at home, and there is an established diagnosis of epilepsy, EMS In many cases, there is no obvious is usually not called, as the family has trigger for a seizure in someone who experience in the progression and has been diagnosed with epilepsy. recovery phase of a typical seizure for The possibility of seizures exists that patient. despite use of seizure-preventing medication. Nevertheless, there are some key triggers that may produce seizures in people with epilepsy. Triggers include:

Danger of Prolonged Seizure Failure to take medication or running out of medication

EMS may be called, however, if Effects of a planned change in someone with epilepsy whose seizures medication or interaction with usually last only a couple of minutes other medication, either experiences a series of seizures or a purchased over the counter or single seizure that shows no sign of prescribed stopping. Prolonged seizures, those lasting longer than 5 minutes, may Key points of the menstrual progress to a condition known as cycle in women status epilepticus. Status epilepticus Effects of hunger or excessive is life threatening and requires stress immediate medical intervention. Rapid Heavy use of alcohol, other transport to a hospital or emergency drugs, or withdrawal from use care medical center may be required. High fever from infection Severe dehydration Exposure to flashing lights

Witnesses/family comments regarding the presence of one or more of these triggering factors may help the EMS responder identify an epilepsy-related seizure.

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Epilepsy and Seizures: Types Generalized Seizures

As already noted, epilepsy is one of the Generalized tonic clonic seizures - most common causes of seizures, and (formerly known as grand mal) are seizures caused by epilepsy take a the most common and best known variety of forms. Seizures in a person type of generalized seizure. This with epilepsy may be generalized or seizure affects the whole brain at partial, based on how much of the once. They begin with stiffening of brain is affected by the neurological the limbs (the tonic phase), dysfunction. followed by jerking of the limbs and face (the clonic phase). A generalized seizure is the type most likely to be encountered by GENERALIZED SEIZURE EMS responders. A generalized tonic clonic seizure can also be caused by head trauma, poisoning, brain tumors, metabolic disorders or other acute conditions affecting the brain.

An electrical disruption involving the Absence seizures – entire brain – it affects the whole brain (formerly known as petit mal) are at once lapses of awareness, sometimes

with staring, that begin and end

abruptly, lasting only a few

seconds. There is no warning and

no after-effect. Awareness and the

ability to communicate usually PARTIAL SEIZURE quickly return after an absence

seizure. More common in children

than in adults, absence seizures

are frequently so brief that they

escape detection, even if the child

is experiencing 50 to 100 attacks

daily. They may occur for several

months before a child is sent for a An electrical disruption involving only medical evaluation. parts of the brain.

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Myoclonic seizures – marked by rapid, brief contractions Partial Seizures of muscles, which usually occur at the same time on both sides of the body. Occasionally, they involve one arm or a foot. People usually In partial seizures the electrical think of them as sudden jerks or disturbance in the brain is limited clumsiness. A variant of the to a specific area of one cerebral experience, common to many hemisphere (side of the brain). people who do not have epilepsy, is the sudden jerk of a foot during sleep. Partial seizures are subdivided into simple partial seizures (in which Atonic seizures – consciousness is retained); and produce an abrupt loss of muscle complex partial seizures (in which tone. Other names for this type of consciousness is impaired or lost). seizure include drop attacks, Partial seizures may spread to cause a astatic or akinetic seizures. They generalized seizure, in which case the produce head drops, loss of classification category is partial posture, or sudden collapse. seizures secondarily generalized. Because they are so abrupt, without any warning, and because the people who experience them Partial seizures are the most common fall with force, atonic seizures can type of seizure experienced by people result in injuries to the head and with epilepsy. Virtually any movement, face. Protective headgear is sensory, or emotional symptom can sometimes used by children and occur as part of a partial seizure, adults. The seizures tend to be including complex visual or auditory resistant to drug therapy. hallucinations. Awareness and the ability to communicate usually quickly return A simple partial seizure may be no after an . more than an odd feeling, a shaking

limb, a change in how things look or

smell, or a period of lost time that only Infantile spasms – the person having the seizure clusters of quick, sudden experiences. These episodes are movements that start between 3 unlikely to generate calls for months and two years. If a child is emergency assistance unless they are sitting up, the head will fall forward, continuous. However, they sometimes and the arms will flex forward. If precede a generalized seizure. If lying down, the knees will be drawn family members or bystanders report up, with arms and head flexed that someone experiencing a forward as if the baby is reaching convulsion or a period of changed for support. awareness had one of these episodes

first, it helps to establish the diagnosis.

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A complex partial seizure is easily DO NOT FORCIBLY RESTRAIN A mistaken for an episode of mental PERSON WHO IS HAVING A illness, intoxication, use of illicit drugs SEIZURE; THIS INCLUDES USE OF or directed anti-social behavior. IMMOBILIZATION TECHNIQUES Depending on the function of the AND DEVICES. affected part of the brain, and how extensive the disruption is, this type of The Importance of Stopping seizure produces a kind of dream- Convulsions state, in which the person appears to be awake but is completely or almost Although not an actual type of completely out of touch with his or her seizure, status epilepticus is said surroundings. He will be unable to to exist after 30 minutes of respond to directions. He may continuous seizure activity. It is a mumble or repeat a phrase over and true medical emergency requiring over again. He may wander into traffic immediate treatment or rapid or other danger quite oblivious to the transport to a hospital. However, risk of harm. In rare cases, people current recommendations call for having this type of seizure may cry out, treatment to stop a convulsive run, flail their arms, or experience seizure if it has continued for more extreme fear. than 5 minutes, followed by hospital transport.

Special Cautions

Use of force

While the overwhelming majority of EMS responders do an outstanding

job recognizing and handling While prolonged generalized citizens experiencing seizures, in convulsions are regarded as being limited cases they may respond of highest risk, it is also possible to with inappropriate force to experience prolonged partial behaviors associated with seizures, seizures. These present as especially complex partial seizures. episodes of continual confusion These particular seizures cloud lasting much longer than the 2 to 3 awareness, block normal minutes that a normal seizure of communication, and produce a this type would last. Because they variety of undirected, involuntary represent continuing disruption of and unorganized movements that may be erroneously viewed as brain activity, they too require emergency treatment and need to aggression. The results can be be stopped as soon as possible. fatal, especially when dangerous restraint practices are used.

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Most seizures due to epilepsy After a Seizure: resolve safely and do not result The Postictal Phase in death or serious injury. However, there are exceptions. The period of time after the seizure (ictus) ends and the person’s alertness and orientation returns to

their pre-seizure state is called the The generalized tonic clonic postictal period, also spelled post- seizurez places substantial strain on ictal. Although the amount of time the cardiovascular system and, in rare a person stays in this period varies cases, may be fatal. between individuals, the type and location of the seizure, If a seizure is triggered by a non- medications, etc., it can last from epileptic,e life-threatening event (such seconds to several hours. Usually as acute poisoning, severe injury, or after a generalized seizure or hypoxia from any cause) the seizure complex partial, the person will may result in death. initially appear confused,

disoriented and tired, and may feel Death may result if a seizure fearful, depressed, frustrated and occurs in a potentially dangerous even embarrassed. Full recovery is environment, such as at heights, in accompanied by re-establishment water, or while driving. Occasionally, a of coherent speech. The patient is seizure while eating will lead to likely to have no memory of events aspiration of food or vomit into the that occurred prior to the seizure. lungs, which is one reason why the airway should always be checked by

EMS. Suffocation during a seizure sometimes occurs if the seizure However, usually within 20 happens during sleep. minutes, most have regained full

alertness and orientation. If after

20 minutes the person remains

confused, the person should be

transported to an

appropriate medical facility for evaluation.

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TREATING SEIZURES

At a very high level, there are several basic actions you will need to take to understand the situation when coming upon a seizure call.

Treatment Do’s

Establish safety and privacy - create a safe space. Make sure the physical area is safe by removing

objects that could hurt the patient. Ensure the scene is safe for WARNING: If it has been more than 5 rescuers. Use appropriate body minutes, transport the patient to the substance isolation (BSI) hospital. precautions.

Check for obvious triggers – look around for obvious seizure Conduct a head-to-toe triggers such as downed electrical examination– wires or chemical spills. look for trauma, protect the person’s head by placing Assess the patient – something soft and flat under it but check level of consciousness, DO NOT restrain the person, and responses, etc., even look for a keep the airway clear. medical ID bracelet or necklace. Determine next steps – Question witnesses – decide if the person can be safely attempt to find out what preceded treated on the scene or requires the episode. Try to get specifics further medical intervention. Pay about the patient’s behavior to attention to what happens in the help you understand the type of postictal phase. seizure the person is experiencing.

Establish a timeline – find out how long the person has been in seizure.

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Don’t make assumptions - EMS responders should never assume that because an alcohol type odor is noted on a person’s breath, that the individual is intoxicated. The individual may have gone out to dinner and had a single drink prior to the seizure, but the two events are not necessarily connected. Withdrawal from alcohol or There are a number of important is more likely to trigger cautions that you must be aware of. a seizure.

Don’t allow extended seizure - Treatment Don’ts although not an actual type of seizure, status epilepticus is said Don’t give anything by mouth - to exist after 30 minutes of people with epilepsy should never continuous seizure activity. It is a be given epilepsy meds and/or true medical emergency requiring fluids until the seizure is over and immediate treatment or rapid consciousness has returned. transport to hospital. However, current recommendations call for Don’t restrain - the EMS responder treatment to stop a convulsive should never attempt to prevent seizure if it has continued for more further injury by restraining the than 5 minutes, followed by jerking movements of someone hospital transport. having a seizure. Restraining involuntary muscle spasms that While prolonged generalized produce jerking may cause muscle convulsions are regarded as being tears or even fractures. It is better of highest risk, it is also possible to to let the movements take place experience prolonged partial freely, but to protect the head from seizures. These present as continued impact on the ground by episodes of continual confusion placing something flat and soft lasting much longer than the 2 to 3 underneath. Make sure breathing minutes that a normal seizure of is unimpeded. this type would last. Because they represent continuing disruption of brain activity, they too require emergency treatment and need to be stopped as soon as possible.

11 the mouth to drain and keep airway clear. Treatment Guidelines Place something soft and flat PREHOSPITAL TREATMENT: under the head to protect against CONVULSIVE SEIZURE IN PROGRESS injury.

Protect patient’s privacy by All Providers/BLS Response: removing nonessential bystanders. }

Clear surrounding area of items Assure scene safety, utilize BSI that could injure patient. precautions, and advocate for patient respect, rights and privacy. Institute active seizure

management with the goal of Do not restrain movements. protecting life and safety until the seizure ends, as follows: Assess level of consciousness (LOC). ¾ Make sure the mouth and airway are clear of any items Ask witnesses how long the seizure that well meaning but has been under way, precipitating misguided bystanders may factors, witnessed injury, and if have inserted. Do not attempt they gave any medication or tried to secure the tongue. any treatments to stop the seizure prior to your arrival. Determine if ¾ Loosen restraining garments they witnessed any blank stare, cry, around the neck and airway. fall, loss of consciousness, shaking or shaking on one side of the body ¾ Determine need for airway that progressed to full blown support (breathing may be seizure, staring, chewing arrested at the start of the movements of the mouth, followed seizure as muscles contract, by confusion and loss of awareness resulting in a bluish tinge to of environment. tissues, and may be shallow during the postictal phase). If Time the seizure from the airway is compromised by beginning point supplied by secretions, blood or vomit, bystanders. If the time extends suction to remove. beyond five minutes, transport actively convulsing patient to ¾ Maintain an open airway and hospital, with or without ALS, and administer oxygen using notify receiving hospital. appropriate delivery device, such as a non-rebreather mask If trauma is not suspected, turn with 100% supplemental patient on one side into the oxygen at 12-15LPM. recovery position to allow fluids in (If ventilations require assist, consider inserting a

12 nasopharyngeal airway (NPA) history of abnormal ingestion, and maintain until patient can or known . Use control his or her own airway.) SAMPLE as an aid (page 26).

¾ Assess presence of pulse and Were any of the following noted by closely monitor pulse rate. This witnesses prior to the seizure? is of critical importance in an ¾ Blank stare, cry, fall, loss of actively seizing patient because consciousness, shaking OR of the risk of cardiac arrest due ¾ Shaking on one side of the body to low oxygen levels (hypoxia). that progresses to full blown seizure OR ¾ Initiate and monitor ventilatory ¾ Staring, chewing movements of and cardiac status. If available, the mouth, followed by utilize BP, EKG, pulse-oximetry, ¾ Confusion and loss of eTCO2 and/or other approved awareness of environment methods of monitoring the effectiveness of the cardio- Conduct a physical head-to-toe exam, pulmonary systems. including: ¾ Lung sounds, pupil response, ¾ Look for medical ID bracelet or trauma to head and tongue, necklace on patient or in etc. patient’s wallet if authorized ¾ Pay particular attention to (“epilepsy”, “seizures”, “seizure possible need for spinal disorder”, "diabetic", etc.). Lack immobilization. of medical history ID does not ¾ Presence of antiepileptic rule out epilepsy. medication on individual (see list on pages 20 and 21). ¾ Check patient's blood level and treat as authorized.

¾ Check patient's temperature. Ensure hyperthermic patient (infant, child and adult) experiencing seizure is not excessively dressed or bundled. Cool using approved methods. Do not allow patient to shiver thus increasing metabolic rate and body temperature.

¾ Obtain a focused history from witnesses, family or accompanying individuals about any diagnosis of epilepsy and/or other precipitating Monitor vital signs and LOC until patient event, history of pregnancy, is fully awake, alert and oriented. , alcohol/drug use,

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Activate ALS and/or rapidly transport patient to an appropriate receiving facility ~ ALS Response to convulsive if the patient: seizure in progress:

¾ Continues to seize after 5 ¾ Follow All Providers/BLS minutes OR Response guidelines as described above. ¾ Experiences a second seizure shortly after the first OR ¾ Follow local protocols if convulsive seizure lasts beyond ¾ Remains unconscious OR 5 minutes.

¾ After 20 minutes, remains ¾ Prepare for medication delivery confused OR to stop seizure activity.

¾ Is pregnant OR ¾ Obtain circulatory access.

¾ Has a co-morbid condition such ¾ Continue to monitor patient's as diabetes OR cardiac and respiratory status, level of consciousness and ¾ Experienced the seizure while observe for any changes in in water OR neurological status.

¾ Has been injured during or prior to the seizure or other event OR ALS Response to convulsive seizure continuing beyond 5 minutes: ¾ Is experiencing severe headache or other symptoms Most seizures caused by epilepsy end different from those usually after a couple of minutes. Extended associated with his or her seizures from any cause, lasting more seizures. than 5 minutes and continuing, stresses neurological, respiratory, and cardiovascular systems. If seizures are prolonged, there is a marked increase in metabolic rate which may lead to such serious conditions as hypoxia, hypercapnia, , metabolic acidosis and electrolyte disturbances. It is therefore important to institute PEDIATRICS: active treatment to bring the seizure to For pediatric patients with seizures, an end as soon as possible. drugs have been the follow pertinent protocols above. In addition: cornerstone of emergency treatment of seizures for years. Diazepam (Valium) If the patient is less than 12 months old, or appears ill, strongly urge parents to is the most widely used drug of this type. Other benzodiazapines are have the child transported to hospital and/or to be promptly evaluated by a available and may be authorized. physician. 14

Diazepam (Valium) is delivered and ventilate as needed to maintain primarily by IV, but is poorly normal SaO2 and eTCO2 levels. absorbed and may be Overdoses of benzodiazapines may be unreliable if given treated by (Romazicon), a intramuscularly. specific benzodiazepine receptor antagonist with a very short half-life. Midazolam (Versed) has a The onset of reversal is usually evident much shorter half-life and may within 1 to 2 minutes after IV injection be administered by IV, IM and is completed. Caution should be Buccal. exercised with initial and/or repeated dosing to patients with liver disease. Lorazepam (Ativan) has a Caution should also be used with longer duration of action (up to flumazenil (Romazicon) due to the 90 minutes) and may be possibility of eliciting symptoms of considered as another IV or IM benzodiazepine withdrawal, including alternative agent to stop seizures. seizures.

PREHOSPITAL TREATMENT: PATIENT Diazepam rectal gel (Diastat) NO LONGER CONVULSING may also be available for EMT.

Epilepsy medications administered intranasally are also available; use per local protocol. } All Providers/BLS Response:

Monitor vital signs and level of consciousness (a slow return to full awareness may be expected, but confusion may persist). Breathing is likely to be labored and shallow at first, therefore:

¾ All seizure patients should be placed on a non- rebreather mask with 100% supplemental oxygen at 12- Effective duration of action varies 15 LPM. depending on drug, dose and route of administration. Recurrence of seizures ¾ Continue to monitor should be watched for. Administer and patient’s pulse, blood re-administer approved pressure and respiratory benzodiazapine per local protocol. status.

Watch for respiratory depression ¾ Monitor breathing closely associated with benzodiazapine use and be ready to assist with

15 positive-pressure ventilation if needed. consciousness may Consider a nasopharyngeal fracture bones or cause airway as needed. head injuries. Manage any injuries found and ¾ Look for medical ID bracelet continue to monitor the or necklace on patient or in patient’s airway, patient’s wallet if authorized breathing, circulation (“epilepsy”, “seizures”, and vital signs. Pay “seizure disorder”, particular attention to "diabetic", etc.). Lack of possible need for spinal medical history ID does not immobilization. rule out epilepsy. ¾ Monitor vital signs and LOC ¾ Check patient's blood until patient is fully awake, glucose level and treat as alert and oriented. authorized. ~ Activate ALS and/or rapidly ¾ Obtain a focused history transport patient to an from witnesses, family or appropriate receiving facility if: accompanying individuals A second seizure occurs about any diagnosis of shortly after the first OR epilepsy and/or other The patient remains precipitating event, missed unconscious OR medications, sleep After 20 minutes, deprivation, excessive patient remains hunger or stress, history of confused OR pregnancy, diabetes, alcohol/drug use, history of Patient is pregnant OR abnormal ingestion, or Has a co-morbid known head injury. Use condition such as SAMPLE (page 26). diabetes OR Experienced the seizure ¾ Conduct a physical head-to- while in water OR toe exam, including: Has been injured during Lung sounds, pupil or prior to the seizure or response, trauma to other event OR head and tongue, etc. Is experiencing severe headache or other A rapid, head to toe symptoms different from physical exam to check those usually associated for any injuries the with his or her seizures patient may have sustained during the seizure is advised. Sudden falls with complete loss of

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PREHOSPITAL TREATMENT: COMPLEX PARTIAL SEIZURE MARKED BY AUTOMATIC BEHAVIOR, CONFUSION, INABILITY TO COMMUNICATE

PEDIATRICS: If witness descriptions include an For pediatric patients abrupt start, with stare, mumbling, experiencing a seizure, follow picking at clothes, and subsequent pertinent protocols above. wandering, running, or disturbed

In addition: If the patient is behavior, the event is most likely to less than 12 months old, or be a complex partial seizure. appears ill, strongly urge parents to have the child transported to hospital All Responders/BLS Response: and/or to be promptly } evaluated by a physician. ¾ Ask witnesses when and how the episode began.

¾ Calmly reassure patient that all is well and he or she is ~ALS Response to patient no safe. longer convulsing: ¾ Establish level of Follow protocols as described above, consciousness with questions with addition of the following: such as name, location, date. While placement of a nasopharyngeal airway is ¾ Block patient’s access to usually sufficient to doors, open windows or other maintain the airway, in rare hazards such as busy streets cases an advanced airway may by standing in front of patient. be required, i.e., ET, Combitube, However, do not grab hold LMA, King Airway, etc. unless immediate danger threatens. Patients in the If an advanced airway is throes of a complex partial utilized, eTCO2 monitoring is seizure may unknowingly flail encouraged. against restraint.

¾ Seek information from accompanying individuals regarding any existing epilepsy or seizure disorder diagnosis.

17 ¾ Monitor recovery and arrange for safe passage home for patient once he or she is fully aware of surroundings.

¾ If safe to do so, check patient's blood glucose level but be aware that a person in the throes of a complex partial seizure may The stimulated nerve carries a small unknowingly flail against electrical charge into the brain on a restraint. Treat as authorized. regular, programmed basis. The charge originates in a small disc battery implanted on the left side of the chest wall. Additional charges may be generated by means of a ALS Response: ~ magnet, worn on the patient’s wrist, Treat per ALS Response Seizure being passed over the battery. in Progress on page 14 and 15 Some patients find they can abort an impending seizure or shorten a seizure in progress by generating an Obtain a focused history from additional electrical pulse in this way. witnesses, family or accompanying individuals. ¾ Treatment of someone who has a VNS and is having a seizure includes moving the patient’s EPILEPSY AND SEIZURES: wrist magnet in a single pass over the implanted battery on a PATIENT EXPERIENCING A slow count of 1-3. The implant CONVULSIVE OR COMPLEX PARTIAL area may be visible as a small SEIZURE WHO HAS A VAGUS NERVE elevated oval area of the upper STIMULATION (VNS) IMPLANT left chest wall.

¾ Assist the patient by passing the magnet over the VNS } All Responders/BLS battery once every 3-5 minutes, Response: up to three times.

Some patients with epilepsy are NOTE: If the VNS does not stop being treated with an implanted and/or control the seizure activity, device called a Vagus Nerve treat per guidelines as listed under Stimulator (VNS) designed to prevent PREHOSPITAL TREATMENT: seizures through electrical CONVULSIVE SEIZURE IN PROGRESS. stimulation of the vagus nerve in the neck.

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Epilepsy and Seizures: Patient or legal guardian Is Ambulance and Hospital understands and assumes risk Transport Needed? for declining transport

} All Responders/BLS Response:

A seizure in an individual who does not have epilepsy is likely to be the result of an acute, serious, even life-threatening condition. Rapid transport to a hospital or appropriate facility is advisable in such cases. However, a seizure in someone who has epilepsy, while If transport is declined: potentially serious, is much more likely to resolve without further ¾ Secure appropriate signature problems. In such cases, transport on release form or waiver per to hospital may be unnecessary local protocol. unless there are complications. ¾ If possible, contact and secure Some localities mandate hospital an agreement from family evaluation for all emergency calls. member, friend or taxi service Others allow the patient to decline to assure that patient returns ambulance transport. Wherever home safely. possible, post-ictal (post-seizure) patients with epilepsy should have ¾ A person who just experienced the option to decline. a generalized tonic clonic or complex partial seizure should not be allowed to drive. A If local protocols permit, transport of family member, friend, or taxi someone with a history of epilepsy should be called to take the may NOT be necessary if: seizure patient home. Not only may there be some residual Breathing is unimpaired AND confusion or slowed response on the part of the patient, but Patient appears fully awake driving privileges in many states and oriented AND require a person to be seizure free for a set period of time, usually a matter of months or Is under medical supervision for seizures AND even years.

Is taking medications as

prescribed AND

19 However, if in doubt as to the patient’s post-seizure level of recovery or post- seizure condition, err on the side of Epilepsy and Seizures: caution, and transport. Antiepileptic () Drugs

A number of drugs are used in the treatment of epilepsy. Their primary role is to prevent seizures and their effectiveness depends largely on whether they are taken regularly in the appropriate dose. However, a seizure is still possible even when all regimens are followed. Transport to an appropriate medical facility IS appropriate if: Presence of one or more of these medications on an individual who is ¾ The patient remains having a seizure increases the unconscious OR likelihood that the seizure is due to epilepsy, although some of the drugs ¾ Experiences a second seizure have other indications as well. shortly after the first OR The following medications can be ¾ After 20 minutes, patient prescribed for epilepsy: remains confused OR

¾ Patient is pregnant OR (Tegretol, Tegretol XR, Carbatrol) ¾ Has a co-morbid condition such Clonazepam (Klonopin) as diabetes OR Ethosuximide (Zarontin) Felbamate (Felbatol) ¾ Experienced the seizure while Gabapentin (Neurontin) in water OR Lacosamide (Vimpat) Lamotrigine (Lamictal) ¾ Has been injured during or prior Levetiracetam (Keppra) to the seizure or other event OR Oxcarbazepine (TTrileptal) Phenobarbital ¾ Is experiencing severe Phenytoin (Dilantin, Phenytek) headache or other symptoms Pregabalin (Lyrica) different from those usually Primidone (Mysoline) associated with his or her Rufinamide (Banzel) seizures. Tiagabine (Gabitril) Topiramate (Topamax)

20

Valproate (Depakote, Depakene) Whatever the cause, the Vigabatrin (SSabril) immediate physical management Zonisamide (Zonegran) of the seizure is the same as the management of a generalized Lorazepam (AAtivan), diazepam (VValium) convulsive seizure in someone with and midazolam (VVersed) may also be epilepsy (see pages 12-14). prescribed for emergency treatment to halt an extended seizure. While initial EMS management may be the same, identification of the Rectal diazepam gel (DDiastat) may be underlying cause is important, prescribed for emergency use by non- since prompt treatment of the medical personnel to bring prolonged underlying cause may in some or cluster seizures to a close. cases help bring the seizure to an end while preserving the health of Fosphenytoin (CCerebyx) is used in the patient. hospital settings to stop episodes of status epilepticus.

PREHOSPITAL TREATMENT: PREHOSPITAL TREATMENT: CONVULSIVE SEIZURE DUE TO CNS CONVULSIVE SEIZURE IN PROGRESS INJURY/DISORDER SEIZURE OF UNKNOWN CAUSE

These include:

} All Providers/BLS Response: ¾ Trauma to the brain: structural damage, free blood, scar tissue If there is no evidence of a formation and hypoxia due to previous diagnosis of epilepsy or medical causes and/or blow to seizure disorder, EMS personnel the head responding to an individual undergoing a convulsive seizure ¾ must consider other potential underlying causes. Since prompt ¾ Scar on the brain from a treatment of that underlying cause previous injury may in some cases help bring the seizure to an end while preserving ¾ Stroke the health of the patient, identification of the underlying ¾ Alzheimer’s disease/dementia cause is important. Seizures may result from a CNS injury/disorder, ¾ Changes in cardiac rate or metabolic changes, severe rhythm abnormalities that may infection, Alzheimer’s affect cerebral blood flow disease/dementia or other and/or flow of oxygen to the conditions causing disruption in brain brain activity.

21

Identifying factors: PREHOSPITAL TREATMENT: ¾ No diagnosis or history of CONVULSIVE SEIZURE DUE TO CNS epilepsy INJURY/DISORDER

¾ History of recent head injury, falls, stroke or TIA } All Providers/BLS Response: ¾ Diagnosed brain tumor or Treat following guidelines on pages other disorder 12-14.

¾ Signs of acute injury to the If head injury is possible and signs head of increasing intracranial pressure are observed (increased BP, ¾ Signs of neurological decreased pulse rate, rapid and/or dysfunction: change in deep irregular respirations, mental status, respiratory unilateral dilated pupil, posturing, pattern, pupil focal neurological findings, etc.) size/reactivity/orientation, slightly hyperventilate patient (age or posturing variable) with bag-valve mask and 100% O2 and/or utilize eTCO2 ¾ Droop of facial tissues, monitor to maintain CO2 between slurred speech, paralysis or 30-35. weakness on one side of the body ALS Response: If seizure ¾ Advanced age ~ has lasted longer than 5 minutes,

¾ Alzheimer’s diagnosis follow ALS Response on pages 14- 15.

¾ Administer medications per local protocols.

¾ Limit fluid administration except as indicated by signs of hypovolemia.

¾ Provide rapid transport to

nearest appropriate facility.

22

¾ Increased blood levels of PRE-HOSPITAL TREATMENT: ACTIVE sodium, glucose, or calcium SEIZURE HAS CEASED ¾ Pre-/eclampsia of pregnancy

} All Providers/BLS Response: ¾ Liver or kidney failure Treat following guidelines on pages 15 -16. ¾ Sudden withdrawal from heavy alcohol, , or benzodiazepine use Activate ALS and/or rapidly ~ ¾ Side effects of legal or transport patient to an appropriate illegal drugs, including receiving facility. , , , Treatments for certain types of stroke physostigmine, tricyclic patients include fibrinolytic therapy antidepressants, certain and the use of neuroprotective antihypertensive medications administered in a timely medications, , PCP manner, usually within 2-3 hours from and time of onset, in a hospital setting. Check local protocols. ¾ Electrolyte imbalance,

sometimes associated with

diuretic use

PREHOSPITAL TREATMENT: ¾ High temperature, humidity CONVULSIVE SEIZURE DUE TO or over exertion (e.g. during METABOLIC DISORDER or after running)

A variety of metabolic irregularities can produce a chemical imbalance in the brain sufficient to produce a generalized convulsive seizure. Susceptible individuals include those with diabetes or other metabolic disorder, or women who are pregnant and subject to pre-eclampsia.

Potential causes also include:

¾ Low blood levels of oxygen or sodium.

¾ Decreased blood levels of calcium, magnesium,

potassium, or glucose.

23

Identifying factors: } All Providers/BLS Response: ¾ No diagnosis or history of Treat following guidelines on pages epilepsy 12-14.

¾ Medical ID for diabetes ALS Response: Treat ~ BLS Response above. If ¾ Low blood sugar level per blood following B the seizure duration is longer than glucose test 5 minutes, follow ALS response on pages 14-16. ALS treatment to ¾ History of liver or kidney correct underlying cause, if not disease or diabetes already performed, includes the ¾ Headache following:

¾ Visual disturbances Medication delivery:

Hypoglycemic patient: Administer ¾ Altered respiratory pattern glucose and possibly thiamine, ¾ Evidence of legal or illegal drug depending on local protocol. Follow local protocol for glucose dose for use children and infants. ¾ Pregnancy Decreased LOC and respiratory rate:

Administer naloxone (Narcan) if ¾ Elevated body temperature decreased sweating decreased LOC and respiratory rate from possible opiate overdose. Follow local protocol for dose and route. PREHOSPITAL TREATMENT: Narcan may be administered by a CONVULSIVE SEIZURE DUE TO variety of routes, including METABOLIC DISORDER intravenous, intramuscular, subcutaneous, sublingual, intralingual, tracheal and intranasal using a mucosalatomizer device.

Pregnant Patent: For seizures in a pregnant patient, treat as above, establish vascular access, and provide rapid transport to appropriate facility. Treat per local protocols, consider administration of magnesium sulfate.

Overdose: For seizures caused by an overdose of tricyclic antidepressents or sodium channel blockers, follow local protocols for possible administration of sodium bicarbonate or other reversal agents.

24

¾ History of infection Hyperthermia/Heat Stroke: For seizures caused by hyperthermia/heat stroke, initiate rapid Pre-hospital treatment: cooling methods, seizure in progress due to administer IV fluids Infection and electrolyte replacement and provide rapid } All Providers/BLS transport. Response: Take appropriate body substance isolation (BSI) PRE-HOSPITAL precautions to protect EMS TREATMENT: ACTIVE providers and the patient. SEIZURE HAS CEASED Treat following All Responder/BLS Response on pages 12-14. Obtain a focused history. It is ALS Response: Treat important to find and ~ bring any medications or other drugs following BLS Response above. that the patient may have taken to the If seizure lasts longer than 5 minutes, follow ALS Response on pages 14-15. emergency department for further evaluation.

Pre-hospital treatment once active Cause of Seizure: SEIZURE DUE TO seizure has ceased INFECTIOUS DISEASE:

Certain serious infections of the brain } All Responders/BLS Response: produce conditions that lead to seizures or create high that ¾ Take appropriate body trigger seizures. Potential causes substance isolation precautions include meningitis, encephalitis, and to protect EMS providers and other childhood illnesses associated the patient. with high fever. ¾ Administer high-flow, high concentration oxygen by non- Identifying factors: rebreather mask. ¾ Initiate and maintain ¾ No diagnosis or history of appropriate cardiac and epilepsy respiratory monitoring. ¾ Hyperthermia ¾ Check blood sugar levels and ¾ Headache, stiff neck treat per local protocols. ¾ Photophobia ¾ Dehydration ¾ Confusion or unconsciousness

25

¾ For pediatric patients, follow medications, foods, animals, dyes, or local protocols for possible other sources. It is possible that an administration of allergic reaction triggered the seizure. acetaminophen or ibuprofen. Medications that the patient is ¾ Transport to appropriate taking. The presence of seizure- receiving facility and notify prior preventing medications (see list on pp. to arrival of possible infectious 20-21) or a VNS implant under the patient. chest wall is a strong indication that the seizure is the result of an ongoing ~ ALS Response: epileptic condition. Withdrawal from seizure medications, or an abrupt drop Follow All Responders/BLS Guidelines above: in therapeutic blood level due to ¾ Obtain vascular access for missed doses, is a common cause of seizures in people with epilepsy. possible medication or fluid administration, if not already Changes in medications can also started. cause breakthrough seizures. Seizures may also be caused as a side ¾ Treat shock and hyperthermia effect of certain prescription drugs or per local protocols. use of illegal drugs such as cocaine or PCP. Epilepsy and Seizures: All Responders Using SAMPLE to take a seizure history Pertinent medical history. Determine if the patient has a history of epilepsy Gather as much information as (seizure disorder), brain injury, possible from the postictal patient hypoglycemia, diabetes, recent illness, (who may still other health conditions associated be fatigued and with seizures, or recent changes in somewhat their daily routine. confused), witnesses or Last oral intake to assess the family likelihood of and aspiration members. The as a complication of the seizure. commonly used mnemonic SAMPLE is an efficient way to gather data: Events leading up to the incident. These are important. Have the patient Signs and Symptoms. These may describe, as best s/he can, what s/he range from postictal confusion to a was doing before the seizure began or, bleeding tongue bitten during the if s/he cannot remember (not seizure, to bystander reports of how unusual), see if friends or witnesses the seizure progressed, to types of can provide that information. injury if trauma is suspected as a Exposure to flashing lights, for cause. Remember that people often example, may be a seizure trigger for think that a seizure episode lasted some people. In young children a longer than it actually did. sudden rise in fever may trigger what is called a febrile (fever) seizure. llergies to any substance ingested A prior to the seizure, including

26

Glossary of Terms Glossary of Terms

Absence Seizure – (formerly known as Fibrinolytic Therapy - The goal of petit mal) lapses of awareness, fibrinolytic (thrombolytic) therapy is to sometimes with staring, that begin and dissolve occlusive clots in specific end abruptly, lasting only a few arteries. seconds, with no warning and no after- effect. Awareness and the ability to Generalized Seizure - a seizure that communicate usually quickly return involves the entire brain is called a after an . generalized seizure. These seizures may cause loss of consciousness, falls, ALS - Advanced Life Support or massive muscle spasms.

Atonic seizures – seizures producing Generalized Tonic Clonic Seizure - an abrupt loss of muscle tone. Other (formerly known as grand mal) the names for this type of seizure include most common type of generalized drop attacks, astatic or akinetic seizure, affecting the whole brain at seizures. They produce head drops, once, and beginning with stiffening of loss of posture, or sudden collapse. the limbs (the tonic phase), followed by Atonic seizures can result in injuries to jerking of the limbs and face (the the head and face. clonic phase). A generalized tonic clonic seizure can be caused by head - any of a group of trauma, poisoning, brain tumors, aromatic lipophilic amines (as metabolic disorders or other acute diazepam and chlordiazepoxide) used conditions affecting the brain. especially as tranquilizers. Grand Mal Seizure – see Generalized BLS - Basic Life Support Tonic Clonic Seizure

BSI – body substance isolation which Hyperthermic – exceptionally high means precautions taken to prevent fever. exposure to a patient’s possibly contaminated body fluids. Infantile spasms – clusters of quick, sudden movements that start between Complex Partial Seizures - partial 3 months and two years. If a child is seizures in which consciousness is sitting up, the head will fall forward, impaired or lost. and the arms will flex forward. If lying down, the knees will be drawn up, with Convulsions - massive muscular arms and head flexed forward as if the contractions baby is reaching for support.

Epilepsy - a neurological disorder that Mentation - altered mental functioning has recurring seizures as its primary symptom. Epilepsy is one of the most common causes of seizures, affecting QHDUO\PLOOLRQ$PHULFDQV,WLV also called a seizure disorder.

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29 may be appropriatemay you.for ect sunlight, dampness and high away from dir sleepiness, weakness liver and blood toxicity SOME SIDE EFFECTS loss of appetite and dizziness hair loss, weight gain, tremor hair loss, weight gain, tremor hair loss, weight gain, tremor some side effects individuals may experience. unsteadiness, behavior changes Drowsiness vomiting, headache, fatigue, Drowsiness vomiting, headache, fatigue, skin rashes, abnormal blood counts (rare) Not all individuals experience side effects. This partial list names Appetite loss, frequent urination, drowsiness, Anorexia, vomiting, insomnia, nausea, headache, Anorexia, vomiting, insomnia, nausea, headache, gum overgrowth, hairiness, thickening of features Drowsiness, sleepiness, fatigue, poor coordination, confusion, numbness of extremities, kidney stones Upset stomach, altered bleeding time, liver toxicity, Upset stomach, altered bleeding time, liver toxicity, Upset stomach, altered bleeding time, liver toxicity, Clumsiness, insomnia, motor twitching, nausea, rash, Clumsiness, insomnia, motor twitching, nausea, rash, Dizziness, drowsiness, blurred or double vision, nausea, Tremor, dizziness, nervousness, difficulty concentrating, Tremor, dizziness, nervousness, difficulty concentrating, it in a safe place if there are children around. Grandparents and others should Grandparents around. children are place if there it in a safe that toddlers can be veryremember curious. Know the name, strength of pills and dosage your medication. Write it down so Keep of young children. Keep all medications out of reach medication in the cap and label on it. If using a pill box, keep bottle with a childproof drug store you can refer to it. Keep all epilepsy medications cabinet or windowsill over the kitchen sink are usually not A bathroom humidity. good places to keep . thatRemember to tell all your doctors, as well dentists and pharmacists, you are taking an antiepileptic medication. It is a good idea to bring all your medication bottles with you to doctor visits. unpleasant side having or are control If unhappy with your level of seizure you are Do not run so it becomes reordering out of medication. Set up a schedule for If in advance. days medication by mail, ordering several automatic. Request refills in delivery. delays enough time for leave your to put up with it. the medication, do not assume you have Tell effects from Ask about other medications or treatments which doctor. so you can easily replace any that gets lost.so you can easily any Do not keep pills in checkedreplace them with you. by plane. Take baggage when traveling Take enough medication with you when going on vacation to last until you return. enough medication with you when going on vacation to last until Take Carry copy of your prescription and the phone number of your doctor a separate > > > > > > > 3200 mg 1 mg–10 mg 36 mg–56 mg 200 mg–400 mg 600 mg–1200 mg 250 mg–1000 mg 1750 mg–3000 mg 1750 mg–3000 mg 2000 mg–3500 mg 1200 mg–3600 mg higher or lower than the doses listed. Actual doses for a person with epilepsy may be AVERAGE ADULT DAILY DOSE DAILY ADULT AVERAGE ® ® ® ® ® ® ® ER ® ® SEQUELS ® (tiagabine) () *ATIVAN BANZEL™ (felbamate) (phenytoin) (lorazepam) GABITRIL (rufinamide) DILANTIN FELBATOL DEPAKENE DEPAKOTE CARBATROL (extended release (extended release BRAND NAME (generic name) DEPAKOTE divalproex sodium) (divalproex sodium) Do not change the dose without consulting your doctor. Too much medication may Too Do not change the dose without consulting your doctor. lead to side effects. Too little medication may increase your seizures. little medication may increase Too lead to side effects. Be say so. If honest. not side effects, you are If been missing doses or having you have honest with your doctor, he or she cannot properly help you. he or she cannot properly honest with your doctor, in increase This in a dramatic can result Do not ever stop your medication abruptly. Instead, get the name of medication and ask your doctor if it might be right you. for mix large amounts of alcohol with medication. AskNever your doctor if it would be you to consume small amounts of alcoholic beverages. for safe Be cautious when starting a new medication or making major change in dose. Do regularly, to keep a constant level of medication in your blood. regularly, her. Do not try working well for pills, even if a friend they are says other people’s you. It maynot drive dose will affect until you know how the new drug or different your seizures, which can be dangerous to you. Do ask your doctor what to do if you miss a dose of medication. not assume doses that you can make them up by taking all at once, or when miss a few coming on. What a seizure feel you need is a certain amount of medication, taken bedtime. brushing your teeth, after meals or before make you drowsy. make you drowsy. Give your memory remembering to take your some help if you have trouble medication. Reminders include daily or weekly pill boxes, watches with alarms, watches medication. Reminders include daily notes or weekly pill boxes, be helpful to take It may reminders. you can see them, and computer calendar where your medication at the same time you regularly perform other daily tasks, such as DIAMOX > > > > > > > > (extended release acetazolamide) (extended release carbamazepine) Medicines for Epilepsy for Medicines 500 mg 300 mg 2 mg 16 mg 250 mg 500 mg 12 mg 200 mg 125 mg 600 mg 4 mg 400 mg 100 mg 250 mg 500 mg Sprinkles 250 mg 125 mg with your doctor or pharmacist. Do take your medication regularly. Do take your medication Do learn information about your medication. Ask your doctor or pharmacist for about the medication and possible side effects. If you obtain information from such as friends or the Internetother sources, that causes you concern, check 400 mg 0.5 mg 1 mg 2 mg 50 mg 30 mg 100 mg The pictures are of brand name drugs as the printing date. However, may The list of side effects is not complete because space limitations. For a list, Any change in physical or mental health someone taking these medications This chart is designed to help people with epilepsy (seizure disorders) become important several There are things people with epilepsy can do to give their > > 200 mg FORM (of brand name product) 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. change in appearance from time to time. Generic versions of these drugs (listed under the brand name) will look different from the name drugs. consult your doctor, nurse, or pharmacist. More detailed sources of information on side effects include the drug’s prescribing information sheet, or Physician’s Desk Reference. should be reported promptly to the doctor. Safety in pregnancy has not been estab- lished for any of these medications. Questions about their use in pregnancy should be discussed with the doctor. Epilepsy Medication Epilepsy Control Taking treatment the best chance of success. treatment

30 fatigue, twitching loss of strength, dizziness loss of strength, dizziness unsteadiness, behavior changes Drowsiness, sleepiness, fatigue, Drowsiness, sleepiness, fatigue, Sleepiness, dizziness, clumsiness, sleepiness, difficulty concentrating, Dizziness, headache, blurred vision, Drowsiness, sleepiness, fatigue, poor Drowsiness, sleepiness, fatigue, poor difficulty thinking or talking, tingling difficulty thinking or talking, tingling swelling of hands and feet, dry mouth Dizziness, blurred vision, weight gain, Dizziness, blurred vision, weight gain, Sleepiness, fatigue, poor coordination, Sleepiness, fatigue, poor coordination, Sleepiness, fatigue, poor coordination, Sleepiness, fatigue, poor coordination, clumsiness, sleepiness, nausea, skin rash double vision, nausea, unsteadiness, rash fatigue, rash, abnormal blood counts (rare) skin rashes, abnormal blood counts (rare) skin rashes, abnormal blood counts (rare) Confusion, sleepiness, dizziness, clumsiness, coordination, unsteadiness, behavior changes Drowsiness, irritability, hyperactivity (children), Drowsiness, irritability, hyperactivity (children), sensation of the skin, nausea, decreased appetite gum overgrowth, hairiness, thickening of features Drowsiness, sleepiness, fatigue, poor coordination, poor coordination, unsteadiness, behavior changes (should not be used in individuals allergic to sulfa drugs) Clumsiness, dizziness, appetite loss, fatigue, drowsiness, Clumsiness, dizziness, appetite loss, fatigue, drowsiness, Appetite loss, nausea, drowsiness, headache, dizziness, Appetite loss, nausea, drowsiness, headache, dizziness, Clumsiness, insomnia, motor twitching, nausea, rash, Difficulty concentrating, sleepiness, fatigue, dizziness, Difficulty concentrating, sleepiness, fatigue, dizziness, Dizziness, drowsiness, blurred or double vision, nausea, Dizziness, drowsiness, blurred or double vision, nausea, Dizziness, drowsiness, blurred or double vision, nausea, Dizziness, drowsiness, blurred or double vision, nausea, behavorial problems, difficulty concentrating, depression hyperirritability, insomnia, depression, hyperactivity (children) difficulty concentrating, unsteadiness, fever, kidney stones, rash difficulty concentrating, unsteadiness, fever, kidney stones, rash numbness of extremities, weight gain, swelling, hyperactivity and coordination, anxiety, tremor, nausea, vomiting, skin rash Sleepiness, dizziness, loss of appetite, headache, nausea, irritability, Permanent vision loss, abnormal MRIs, anemia, sleepiness, fatigue, Dizziness, headache, blurred vision, double trouble with balance Dizziness, headache, nausea, vomiting, double vision, blurred vision, walking Dizziness, headache, nausea, vomiting, double vision, blurred walking difficulty, drowsiness, , falls, unintentional rapid eye movement, tremor

15 mg–45 mg 1.5 mg–20 mg 15 mg–100 mg 200 mg–400 mg 100 mg–600 mg 200 mg–400 mg 200 mg–400 mg 200 mg–600 mg 100 mg–500 mg 150 mg–600 mg 600 mg–1200 mg 600 mg–2400 mg 500 mg–1500 mg 600 mg–1200 mg 250 mg–1000 mg 900 mg–3600 mg 1000 mg–3000 mg 1000 mg–3000 mg Average Single Dose 0.2 mg. – 0.5 mg./kg. (can be divided into 2 doses per day) 2,000 mg–4,000 mg (adults) 50-150mg/kg/day (children with infantile spasms) TM ® ® ® ® ® ® ® ® ® ® ® ® ® XR™ ® ® ® ACUDIAL ® SABRIL LYRICA KEPPRA (primidone) (vigabatrin) VIMPAT® (pregabalin) (topiramate) (gabapentin) (zonisamide) (clorazepate) (lamotrigine) TOPAMAX LAMICTAL (clonazepam) (lacosamide) TEGRETOL MYSOLINE ZARONTIN KLONOPIN TRANXENE PHENYTEK TRILEPTAL ZONEGRAN (ethosuximide) (levetiracetam) KEPPRA XR™ (phenobarbital) NEURONTIN (oxcarbazepine) (carbamazepine) TEGRETOL XR LAMICTAL (diazepam rectal gel) PHENOBARBITAL DIASTAT (extended phenytoin sodium) (extended release lamotrigine) (extended release levetiracetam) (extended release carbamazepine) 200 mg 300 mg 100 mg 50 mg oral solution Orally Disintegrating Tablets Also available as 225 mg 25 mg 800 mg Sprinkles oral solution Also available as 200 mg 1000 mg 600 mg 150 mg 200 mg 400 mg 750 mg 100 mg 200 mg 100 mg The following medicine is not prescribed for daily, long-term use, but to stop episodes of prolonged or cluster seizures. 600 mg for oral solution 400 mg 25 mg Also available as powder 750 mg 75 mg 100 mg 150 mg 200 mg 100 mg 200 mg 15mg 25 mg 60 mg 500 mg 15 mg 200 mg 100 mg 25 mg 200 mg 1 mg 2 mg 50 mg 100 mg 30 mg 50 mg 250 mg T-Tabs 7.5 mg 5 mg 2.5 mg—20 mg 500 mg 250 mg 500 mg 250 mg 25 mg 25 mg 200 mg 300 mg 0.5 mg Chewable Dispersible 50 mg 100 mg 150 mg 100 mg 100 mg 150 mg 300 mg 50 mg 25 mg 100 mg 300 mg 25 mg 50 mg 15 mg 2 mg 3.75 mg * Sometimes prescribed for epilepsy, but not FDA-approved that use. *

31 This Publication was made possible with funding from the Center for Disease Control (CDC) and Prevention under Cooperative agreement number 5U58DP000606-05. Its contents are solely the responsibility of the authors and do not necessarily represent the RIÀFLDOYLHZVRIWKH&'&

iii www.epilepsyfoundation.org 800-332-1000

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