- I WOULD LIKE TO WELCOME ALL
OF YOU TO OUR THIRD CALL OF

THE FISCAL YEAR IN THE
"INTRODUCTION TO EPILEPSY"

AUDIO CALL SERIES.

MY NAME IS SEAN GAMBLE,
AND I AM WITH THE EMPLOYEE

EDUCATION SERVICES HERE IN

ST. LOUIS, AND I AM THE PROJECT
MANAGER FOR THE SERIES.

OUR LINES ARE MUTED.

IF FOR SOME REASON
THEY ARE NOT,

GO AHEAD AND HIT MUTE
AT THIS TIME,

AND THEY WILL BE OPENED UP AT
THE END OF THE PRESENTATION

WHEN WE'RE READY FOR QUESTIONS.

PLEASE BE SURE TO COMPLETE
THE EVALUATION TO GET CREDIT

FOR THIS PROGRAM.

COMPLETE DIRECTIONS FOR
YOUR EVALUATIONS ARE FOUND

IN A BROCHURE ON THE CATALOG.

DEADLINE DATE TO COMPLETE
THE EVALUATION IS MARCH 23.

NOW LET ME WELCOME OUR GUEST
SPEAKER FOR TODAY,

JIMI FAMINU.

IT'S ALL YOURS, JIMI.

ARE YOU ON, JIMI?

- YEAH.

- OK.

- [INDISTINCT CONVERSATION]

[BEEP]

[RUSTLING]

[BEEP]

- HEY, DANA.

I DIDN'T KNOW YOU WERE COMING.

- HOW ARE YOU?

- CAN YOU PLEASE HIT YOUR
MUTE BUTTONS, WHOEVER'S GOT

THEIR PHONES...

- CAN YOU HEAR ME?

CAN YOU HEAR ME?

[INDISTINCT CHATTER]

- WE DO HAVE A LOT OF OPEN
MICROPHONES.

PEOPLE HAVE BEEN MAKING A LOT OF
NOISE INTO THE CONFERENCE.

I GUESS THEY
DON'T REALIZE THAT.

THE PERSON WHO YOU'RE
TRYING TO REACH MAY BE ONE

OF THE PARTICIPANTS WHO MUTED
THEIR MIC--WE HAD TO MUTE

THEIR MICROPHONE.

IF THEY ARE ON THE CALL,
THEY NEED TO HIT *0 IF THEY'RE

ONE OF THE PRESENTERS.

- ALL RIGHT.

- ALL RIGHT?

- I'LL LET THEM KNOW.

IF NURSE FAMINU IS ON THE
LINE, CAN YOU HIT *0, PLEASE?

- ONE OTHER THING I MIGHT
NOTE, IF YOU HIT *6, YOU CAN

MUTE YOUR MICROPHONE.

THAT'S FOR THE PARTICIPANTS THAT
ARE MAKING A LOT OF NOISE.

THANK YOU.

- HELLO?

- YES.

- HI, SEAN.

- HI. YOU CAN GO AHEAD
AND START.

EVERYBODY'S READY FOR YOU.

- OH. OK, EXCELLENT.
ALL RIGHT, THANK YOU.

SO GOOD MORNING, AND THANK
YOU ALL FOR CALLING INTO THIS

AUDIO PRESENTATION COVERING
SAFETY IN THE EPILEPSY

MONITORING UNIT.

MY NAME IS OLUJIMI FAMINU,
AND I'M THE NURSE

COORDINATOR FOR THE EPILEPSY
CENTER OF EXCELLENCE LOCATED

AT THE WEST LOS ANGELES
VA MEDICAL CENTER.

NOW, BECAUSE ALL THE LINES ARE
MUTED EXCEPT FOR MINE, I WILL

NOT BE ABLE TO TAKE ANY
QUESTIONS DURING THE

PRESENTATION, BUT PLEASE WRITE
YOUR QUESTIONS DOWN, AND I'LL

BE MORE THAN HAPPY TO ANSWER
THEM BEFORE THE HOUR ENDS.

OK, SO WE'RE GONNA
START THE PRESENTATION.

LET'S GO OUT TO THE NEXT PAGE.

SO LET'S START OFF BY
DISCUSSING WHAT EPILEPSY

MONITORING UNITS, OR
EMUs, ARE FOR.

SIMPLY PUT, EMUs ARE
SPECIALIZED UNITS DESIGNED

FOR PATIENTS UNDERGOING
VIDEO EEG MONITORING, OR VEM.

BY DEFINITION, VEM IS A
SIMULTANEOUS RECORDING OF BOTH

A PATIENT'S BEHAVIOR AND
EEG OVER A PROLONGED PERIOD.

THE USE OF VEM HAS SEVERAL
INDICATIONS, AND ITS USE

IN PATIENTS WITH EPILEPSY
HAS EXPEDITED THE DIAGNOSIS

AND TREATMENT OF
THESE PATIENTS.

INDICATIONS FOR VEM COULD
BE DIAGNOSTIC OR EVALUATIVE

IN NATURE.

THE DIAGNOSTIC VEM IS
INDICATED TO CHARACTERIZE

SEIZURE TYPES OR
EPILEPSY SYNDROMES.

THE DIAGNOSTIC VEM IS
ALSO INDICATED TO RESOLVE

AN EPILEPTIC VERSUS
NONEPILEPTIC

DIFFERENTIAL DIAGNOSIS.

AN EVALUATIVE VEM, ON THE
OTHER HAND, IS INDICATED TO

DETERMINE THE LOCATION OF A
PATIENT'S EPILEPTOGENIC ZONE.

SO LET'S GO ON
TO THE NEXT SLIDE.

SO WE CAN SEE IT'S A
USEFUL TOOL IN THE TREATMENT

OF PATIENTS WITH EPILEPSY,
BUT IT DOES HAVE SOME RISKS.

THERE WAS A RECENT STUDY
BY DOBESBERGER, ET AL.,

THAT ANALYZED THE RATE OF
ADVERSE EVENTS DURING VEM.

THE STUDY EVALUATED
596 SESSIONS OF VEM

AND 507 PATIENTS.

9% OF THE PATIENTS HAD
53 ADVERSE EVENTS.

TO BREAK IT DOWN, 20 HAD
PSYCHIATRIC EVENTS,

SPECIFICALLY POSTICTAL
PSYCHOSIS,

PANIC ATTACKS,
AND INTERICTAL PSYCHOSIS.

15 HAD INJURIES, AND THE
INJURIES IN THIS GROUP RANGE

FROM MINOR INJURIES
TO FRACTURES

AND EPIDURAL HEMATOMAS.

10 PATIENTS HAD STATUS
EPILEPTICUS, SOME

WITH REPEATED EPISODES.

AND FINALLY, ONE PATIENT
HAD VALPROIC

ACID-INDUCED ENCEPHALOPATHY.

WITH REGARDS TO SUDDEN
UNEXPECTED DEATH IN EPILEPSY,

OR SUDEP, VERY FEW CASES
HAVE BEEN REPORTED

IN THE EMU SETTING.

LET'S GO ON TO THE NEXT SLIDE.

ANOTHER STUDY BY LEE, ET AL.,
ANALYZES THE BENEFITS OF VEM.

CHANGES IN DIAGNOSIS WERE
MADE IN APPROXIMATELY 41%

OF PATIENTS IN THE STUDY.

FOR EXAMPLE, A CHANGE IN THE
TYPE OF EPILEPSY SYNDROME.

40% OF THE PATIENTS HAD THEIR
MANAGEMENT REGIMEN CHANGED--FOR

EXAMPLE, A CHANGE
IN MEDICATION.

SO BASED ON WHAT WE JUST
REVIEWED, WE CAN SAY THE

BENEFITS OF VEM SIGNIFICANTLY
OUTWEIGH THE RISKS, BUT IT'S

OUR DUTY TO ENSURE NO
HARM COMES TO THE PATIENT.

THIS PRESENTATION PROVIDES
GENERAL GUIDELINES ON HOW

TO DO THIS.

LET'S GO ON TO THE NEXT SLIDE.

WE'LL BE DISCUSSING IN THIS
PRESENTATION THE ENVIRONMENT

OF EPILEPSY MONITORING UNIT,
OF THE EPILEPSY MONITORING

UNIT; PRE-ADMISSION
SCREENING; SEIZURE PROVOCATION

TECHNIQUES; SEIZURE
PRECAUTIONS; SEIZURE RESPONSE

PROTOCOLS AND RESCUE
MEDICATIONS; POSTICTAL

AGGRESSION AND POSTICTAL
PSYCHOSIS; INTRACRANIAL

ELECTRODE SAFETY; AND
DISCHARGE PRACTICE.

BEFORE WE GO ON, I WANT
TO EMPHASIZE THAT THERE IS

VARIABILITY IN THE ITEMS
I JUST MENTIONED.

DIFFERENT CENTERS HAVE
DIFFERENT SCHOOLS OF THOUGHT

WITH REGARD TO VEM SET UP AND
HOW TREATMENT IS PROVIDED.

THIS PRESENTATION GIVES A
SOLID FOUNDATION FROM WHICH

ONE CAN ESTABLISH
SAFE PRACTICE.

SO LET'S GO ON TO
THE NEXT SLIDE.

NOW LET'S REVIEW WHAT A
SAFE EMU ENVIRONMENT WOULD

LOOK LIKE.

IN THE PATIENT ROOM, EQUIPMENT
AND FURNITURE SHOULD BE

LIMITED AS THEY ARE
POTENTIAL FALL HAZARDS.

THE AMPLIFIER BOX SHOULD BE
EASY TO ACCESS IN THE EVENT

A QUICK DISCONNECTION
IS NECESSARY.

OBJECTS SUCH AS KNITTING
NEEDLES, HOT LIQUIDS,

AND SHARP METAL OBJECTS
SHOULD BE REMOVED.

LIMIT THE PATIENTS' OFF-CAMERA
TIME, AND USE CHAIRS

WITH HEAVY AND HIGH BACKS SO
THE PATIENT IS NOT IN DANGER

OF TILTING OVER
DURING A SEIZURE.

LET'S GO ON TO THE NEXT PAGE.

NEXT, LET'S REVIEW THE
BATHROOM, WHICH HAPPENS TO BE

A HIGH-RISK AREA FOR FALLS.

BATHROOM DOORS SHOULD HAVE
AN OUT-SWING DESIGN.

WHAT DO I MEAN BY THIS?

THE DOOR OPENS TOWARDS YOU
AND NOT TOWARDS THE PATIENT,

WHO MAY POTENTIALLY BE LYING
UNCONSCIOUS ON THE OTHER SIDE

OF THE DOOR.

ALTERNATIVELY, A CURTAIN CAN
BE USED FOR PRIVACY INSTEAD

OF A DOOR.

PADDED SINK EDGES AND TOILET
SEATS SHOULD BE USED TO

MINIMIZE TRAUMA SHOULD
THE PATIENT FALL.

HANDICAP RAILS SHOULD BE
POSITIONED IN SUCH A WAY THAT

THEY DO NOT CAUSE INJURY
IF THE PATIENT FALLS.

BEDSIDE BATHS, OR BIRDBATHS,
SHOULD BE ENCOURAGED AS

OPPOSED TO SHOWERS, WHICH
INCREASE THE PATIENTS'

OFF-CAMERA TIME.

LET'S GO ON TO THE NEXT SLIDE.

WITH REGARDS TO UNIT STAFFING,
THE NATIONAL ASSOCIATION

OF EPILEPSY CENTERS RECOMMENDS
A HIGH PATIENT/NURSE RATIO

RELATIVE TO A STANDARD WARD.

THE PRACTICE OF HAVING A
CENTRALIZED MONITORING STATION

WITH ALL THE PATIENTS IN
VIEW BY A VIDEO MONITORING

TECHNICIAN IS SO WIDESPREAD,
I'M WILLING TO LABEL IT AS

A MINIMUM REQUIREMENT
FOR AN EPILEPSY CENTER.

SOME CENTERS HAVE 24-HOUR
VIDEO OBSERVATION BY

A MONITORING TECHNICIAN
WITH A SITTER

AT BEDSIDE, WHICH
IS PREFERABLE.

OTHER CENTERS HAVE 24-HOUR
VIDEO OBSERVATIONS BY

A MONITORING TECHNICIAN WITH A
FAMILY MEMBER AT BEDSIDE

TO ALERT NURSES IN THE
EVENT OF A SEIZURE.

THE PATIENT SHOULD HAVE A
DESIGNATED SEIZURE BUTTON

IN ADDITION TO THE CALL LIGHT,
NOT ONLY TO MARK THE SEIZURES

ON THE EEG, BUT TO SENSITIZE
STAFF MEMBERS TO WHEN

THE PATIENT IS ABOUT
TO HAVE A SEIZURE.

LET'S GO ON TO THE NEXT SLIDE.

IT'S A GOOD IDEA TO DO
SOME FORM OF PRE-ADMISSION

SCREENING SO THAT SEIZURE
PRECAUTIONS CAN BE CUSTOMIZED

TO THE PATIENT.

SCREENING QUESTIONS ASKED
WOULD INCLUDE IF THE PATIENT'S

SEIZURES ARE CYCLIC IN NATURE,
SO THAT THE EMU ADMISSION IS

TIMED FOR WHEN SEIZURES ARE
AT THEIR GREATEST FREQUENCY.

SEIZURE FREQUENCY AND
SEMIOLOGY IS IMPORTANT TO KNOW

SO STAFF MEMBERS KNOW
WHAT TO EXPECT.

AWARENESS OF THE ICTAL AND
POSTICTAL BEHAVIORS ALLOW

SEIZURE AND SAFETY
PRECAUTIONS TO BE CUSTOMIZED

FOR THE PATIENT.

FOR EXAMPLE, ONE OF OUR
PATIENTS HERE AT WEST L.A.

WAS KNOWN TO ATTEMPT SELF-
GAGGING PRIOR TO GENERALIZED

TONIC CLONIC SEIZURES, SO THE
PATIENT COULD ONLY EAT SMALL

MEALS AT A TIME.

ANOTHER PATIENT WAS KNOWN
TO SIMPLY GET UP, SNATCH

ELECTRODES OFF HIS HEAD,
AND WALK AWAY.

THIS IS WHY EARLIER ON I
EMPHASIZED THE AMPLIFIER BOX

BEING ACCESSIBLE IN CASE
THE PATIENT HAD TO BE

QUICKLY DISCONNECTED.

MOST ESPECIALLY, BEHAVIORS
THAT PUT STAFF MEMBERS AT RISK

SHOULD BE NOTED
AND COMMUNICATED.

LET'S GO ON TO THE NEXT SLIDE.

STUDIES HAVE SHOWN THAT
PATIENTS WHO EXPERIENCE

SEIZURES IN CLUSTERS ARE
AT HIGHER RISK FOR STATUS

EPILEPTICUS, SO IT IS
IMPORTANT TO DETERMINE IF

THE PATIENT EXPERIENCES
SEIZURES IN CLUSTERS.

IF THE PATIENT SMOKES,
THE NEED FOR A NICOTINE PATCH

SHOULD BE ASSESSED, AS THIS
COULD INCREASE COMPLIANCE

ON THE PATIENT'S PART
AND REDUCE THE POTENTIAL

FOR MISSING SEIZURES.

DURING THE PRE-ADMISSION
SCREENING, IT SHOULD ALSO BE

DETERMINED WHETHER ANY
CONTRAINDICATIONS TO

VEM EXIST.

SOME EPILEPSY CENTERS CONSIDER
PREGNANCY A CONTRAINDICATION.

POOR HEALTH IS A
DEFINITE CONTRAINDICATION,

AS EXACERBATION OF PRE-
EXISTING HEALTH CONDITIONS

SHOULD BE AVOIDED.

FOR EXAMPLE, ONE OF OUR
PATIENTS HAD AN EPISODE

OF COPD EXACERBATION,
SO MONITORING HAD TO

BE DISCONTINUED.

FINALLY, AFTER A LONG PERIOD
OF SEIZURE FREEDOM, VEM IS

NOT RECOMMENDED.

LET'S GO ON TO THE NEXT SLIDE.

CONSENT FOR VEM IS GOOD
PRACTICE AND PROVIDES

AN OPPORTUNITY FOR THE PATIENT
TO BE INFORMED ON WHAT IS TO

BE EXPECTED.

A STANDARD VEM CONSENT
FORM CONTAINS THE INDICATIONS

FOR MONITORING, ADVANTAGES AND
DISADVANTAGES OF MONITORING,

THE METHODS OF SEIZURE
PROVOCATION THAT ARE GOING TO

BE USED, RESTRICTION OF
MOBILITY OUTSIDE THE ROOM,

USE OF RESTRAINTS FOR SAFETY
PURPOSES, PATIENT RIGHT TO

REQUEST CESSATION OF
MONITORING, RECORDING OF VIDEO

AND VOICE CONSENT, TELLING
THE PATIENT USE OF RECORDING

FOR ACADEMIC AND EDUCATIONAL
RESEARCH AND PUBLICATION

PURPOSES MAY HAPPEN.

LET ME GO BACK TO THE
ISSUE OF RESTRAINTS.

SOME CENTERS PRE-EMPTIVELY HAVE
THE PATIENT WEAR A POSEY VEST,

WITH THEIR CONSENT, OF COURSE.

OTHER CENTERS CHOOSE TO
UTILIZE RESTRAINTS ONLY WHEN

THE PATIENT BECOMES A DANGER
TO THEMSELVES OR OTHERS.

SO LET'S GO ON TO
THE NEXT SLIDE.

WHEN IT COMES TO THE
TAPERING OF ANTIEPILEPTIC

DRUGS, OR AEDs,
FOR VEM, THERE ARE NO SET

RULES BECAUSE TAPERING
TECHNIQUES VARY.

THE PRACTICE OF USING TAPERING
PROTOCOLS IN EPILEPSY IS NOT

WIDESPREAD, BUT STUDIES SHOW
IT DOES HELP TO LIMIT

THE OCCURRENCE OF
STATUS EPILEPTICUS.

TO DEMONSTRATE THE VARIABILITY
OF HOW AEDs ARE TAPERED OFF,

LET ME GIVE YOU
3 EXAMPLES.

IN EXAMPLE 1, SUBTHERAPEUTIC
CONVENTIONAL AEDs WOULD BE

DISCONTINUED FIRST.

RECENTLY APPROVED AEDs WOULD
BE THE NEXT SET OF AEDs TO BE

DISCONTINUED, AND THEN THE
REMAINING AEDs WOULD BE

TAPERED OFF AT A RATE OF
ONE THIRD OF THE ORIGINAL

MAINTENANCE DOSE
OVER 3 DAYS.

IN EXAMPLE 2, ONE AED AT A
TIME COULD BE TAPERED OFF.

TAPERING RATE WOULD BE NO
MORE THAN HALF OF THE AED

EVERY 24 HOURS.

IN EXAMPLE 3, SUBTHERAPEUTIC
AEDs WOULD BE STOPPED FIRST,

AND THEN THE AED WITH THE
SHORTEST HALF-LIFE WOULD BE

WITHDRAWN NEXT.

IF THE PATIENT WERE ON ONE
AED, THEN THE TAPERING RATE

WOULD BE NO MORE THAN 1/3
TO 1/4 OF THE ORIGINAL DOSE

EVERY 24 HOURS.

WITH RESPECT TO SPECIAL
CONSIDERATIONS, WHICH IS

ON THE NEXT SLIDE, ABRUPT
WITHDRAWAL OF CERTAIN AEDs

IS CONTRAINDICATED.

BARBITURATES AND
BENZODIAZEPINES FALL

IN THIS CATEGORY.

WHEN WE TAPER OFF THE AEDs,
YOU WANT TO MONITOR

FOR WITHDRAWAL SEIZURES,
NEW ONSET OF SEIZURE CLUSTERS,

AND NEW ONSET OF GENERALIZED
TONIC CLONIC SEIZURES.

WE WANT TO MONITOR FOR
SIDE EFFECTS OF WITHDRAWAL,

AND ALSO WANT TO APPLY CAUTION
WITH WITHDRAWING PRIOR TO

ADMISSION UNLESS THE PATIENT
HAS MILD SEIZURES AND/OR HAS

ADEQUATE HOME SUPERVISION.

LET'S GO ON TO THE NEXT SLIDE.

ANOTHER FACTOR TO CONSIDER
WHEN TAPERING OFF THE AEDs IS

THE LOCATION OF THE
SUSPECTED EPILEPTOGENIC ZONE.

FOR EXAMPLE, EXTRATEMPORAL
SEIZURES OCCUR QUICKER USING

THE SAME TAPERING TECHNIQUES
DESCRIBED PREVIOUSLY.

APPLY CAUTION IF SEIZURES
APPEAR AS CLUSTERS OR IF PHASE 2

MONITORING IS IN PROGRESS.

LET'S GO ON TO THE NEXT SLIDE.

SLEEP DEPRIVATION IS A COMMON
PRACTICE USED TO PROVOKE

SEIZURES DURING
VIDEO EEG MONITORING.

SOME EPILEPSY CENTERS
HAVE PROTOCOLS FOR SLEEP

DEPRIVATION, AND IF
THEY DO, THEY VARY.

ON A SIDE NOTE, I WILL ADD
THAT A STUDY DONE BY MALLOW

SHOWED THAT USE OF SLEEP
DEPRIVATION DURING VEM HAS

LITTLE EFFECT ON THE NUMBER
OF SEIZURES THAT

THE PATIENT HAS.

LET'S GO ON TO THE NEXT SLIDE.

SO NOW WE'RE TALKING ABOUT
HYPERVENTILATION AND HOW IT'S

COMMONLY USED TO INDUCE
SEIZURES DURING VEM.

AND THE RESPONSE COMMONLY
SEEN TO THIS TECHNIQUE IS

THE GENERALIZED
SLOWING OF THE EEG.

IT IS IMPORTANT TO NOTE THAT
HYPERVENTILATION IS KNOWN TO

ESPECIALLY TRIGGER SEIZURES
STEMMING FROM IDIOPATHIC

GENERALIZED EPILEPSY AND
SOME FOCAL EPILEPSIES.

LET'S GO ON TO THE NEXT SLIDE.

THERE ARE SOME
CONTRAINDICATIONS TO

HYPERVENTILATION THAT WE
NEED TO BE AWARE OF, AND THEY

INCLUDE ACUTE STROKE, RECENT
INTRACRANIAL HEMORRHAGE,

LARGE VESSEL STENOSIS, RECENT
TIA, MOYAMOYA DISEASE, SEVERE

CARDIOPULMONARY DISORDERS,
AND SICKLE CELL

DISEASE OR TRAIT.

LET'S GO ON TO THE NEXT SLIDE.

THE NEXT SLIDE SHOULD BE
ON PHOTIC STIMULATION.

SO PHOTIC STIMULATION
IS ANOTHER

SEIZURE-INDUCING TECHNIQUE.

THE IMPORTANT THING TO
REMEMBER IS THAT THE PHOTIC

LIGHT SHOULD BE TURNED UP
ABSENT OF THE PHOTO PROXIMAL

RESPONSES OBSERVED.

AND PROCEED WITH CAUTION IF
FACIAL TWITCHING OR UPPER BODY

JERKS ARE OBSERVED INITIALLY.

LET'S GO ON TO THE NEXT SLIDE.

WITH REGARDS TO CARDIAC
MONITORING DURING VEM, SINGLE

LEAD MONITORING, WHICH COMES
WITH THE EEG MONITORING

SOFTWARE, IS ADEQUATE.

IT SHOULD BE USED FOR TWO
REASONS: ONE, TO CAPTURE ANY

POTENTIAL ICTAL ASYSTOLE EVENTS,
AND TWO, WHEN

THE PATIENT EXPERIENCES LATE
HYPERTENSION DURING

STATUS EPILEPTICUS.

EVEN THOUGH ONLY 0.27% OF
PATIENTS WITH EPILEPSY HAVE

BEEN REPORTED TO HAVE ICTAL
ASYSTOLE, IT IS IMPORTANT

TO MONITOR FOR THIS
PHENOMENON, AS IT IS SUSPECTED

TO HAVE A ROLE IN SUDEP.

LET'S GO ON TO THE NEXT SLIDE.

SO WE SHOULD BE ON
SEIZURE PRECAUTIONS NOW.

STANDARD SEIZURE
PRECAUTIONS IN THE EMU

INCLUDE [INDISTINCT]

WITH CUSTOMIZED PADDING TO
ENCOURAGE COMPLIANCE, AS SOME

SEIZURE PACKS DID NOT ALLOW
THE PATIENT TO ACCESS THE BED

CONTROL PANEL ON
THE SIDE RAILS.

LOW BED HEIGHT.

TRIPS OFF THE WARD
SHOULD BE LIMITED.

SUCTION WITH A YANKAUER
TIP SHOULD BE AVAILABLE

IN ADDITION TO NASAL
CANNULA OXYGEN.

LET'S CONTINUE ON TO
THE NEXT SLIDE.

IV ACCESS SHOULD BE IN PLACE
PRIOR TO TAPERING OF THE MEDS.

CONTINUOUS PULSE OXIMETRY
IS AN OPTION.

FREQUENT ATTENTION SHOULD BE
PAID TO WHETHER OR NOT

THE CAMERA IS FOCUSED ON THE
PATIENTS, WHO TEND TO MOVE

AROUND THE ROOM A LOT.

AND ALWAYS INSTRUCT A PATIENT
TO PRESS THE SEIZURE BUTTON IF

AN AURA IS SENSED.

SO LET'S GO ON TO THE SLIDE
TITLED "SEIZURE RESPONSE

AND RESCUE MEDICATION."

SEIZURE RESPONSE IS
MAINLY ABOUT PREPARATION.

WHEN I SAY PREPARATION, I
MEAN HAVING A PHYSICIAN WHO IS

FAMILIAR WITH THE PATIENT
AVAILABLE IN-HOUSE, HAVING

RESCUE MEDICATIONS READILY
AVAILABLE ON THE UNIT,

AND HAVING A PROTOCOL FOR
BENZODIAZEPINE TO TREAT

PATIENTS HAVING A SEIZURE
BEFORE BEGINNING

WITHDRAWAL OF AEDs.

LET'S GO ON TO THE NEXT SLIDE.

A SOLID SEIZURE RESPONSE
PROTOCOL WOULD CONTAIN WRITTEN

ORDERS CUSTOMIZED TO REASON
FOR MONITORING AND THE TYPE

OF SEIZURE AND THE NUMBER OF
SEIZURES THAT SHOULD OCCUR

BEFORE TREATMENT.

FOR EXAMPLE, GIVE 5 MILLIGRAMS
OF DIAZEPAM IV PUSH IF PATIENT

HAS 3 COMPLEX PARTIAL
SEIZURES WITHIN 24 HOURS.

ALSO, THE SEIZURE RESPONSE
PROTOCOL WOULD SPECIFY THE

TYPE OF SEIZURE AND THE NUMBER
OF SEIZURES THAT SHOULD OCCUR

BEFORE CALLING THE PHYSICIAN.

IT IS ALSO IMPORTANT TO NOTE
THAT THE AREA OF CARE THAT THE

EMU IS SITUATED IN MAY NOT BE
PREPARED FOR RAPID INTUBATION.

SO PLAN ACCORDINGLY.

LET'S GO ON TO THE NEXT SLIDE,
WHICH SHOULD BE TITLED

"MANAGEMENT OF GENERALIZED
TONIC CLONIC SEIZURES."

FOR LISTENERS IN THIS
PRESENTATION WHO MIGHT BE

UNFAMILIAR WITH THE MANAGEMENT
OF GENERALIZED TONIC CLONIC

SEIZURES, LISTED ARE THE
IMPORTANT STEPS TO TAKE.

SO STEP ONE, MAINTAIN
PATIENT'S AIRWAY.

POSITION ON SIDE TO
AVOID ASPIRATION.

LOOSEN DOWN AROUND
THE PATIENT'S NECK.

PROTECT HEAD AND APPLICABLE
INTRACRANIAL ELECTRODES

FROM TRAUMA.

REMOVE POTENTIALLY
HAZARDOUS OBJECTS FROM

IMMEDIATE ENVIRONMENT.

MONITOR PULSE OXIMETRY,
AND PROVIDE OXYGEN TO MAINTAIN

AN OXYGEN SATURATION
GREATER THAN 92%.

DO NOT FORCEFULLY
HOLD ONTO THE PATIENT.

DO NOT ATTEMPT TO FORCE
ANY OBJECT INTO

THE PATIENT'S MOUTH.

DO NOT FORCE A
SUCTIONING DEVICE INTO

THE PATIENT'S MOUTH.

WAIT UNTIL THE MOUTH
IS OPEN AND RELAXED.

LEAVE PATIENT IN RECOVERY
POSITION ONCE PATIENT IS

NO LONGER CONVULSING
AND IS RELAXED.

WE'RE ON STEP 10 NOW, WHICH
SAYS SUCTION AS NEEDED.

REORIENT PATIENT'S
ENVIRONMENT UPON

REGAINING CONSCIOUSNESS.

ADMINISTER ORAL HYGIENE AS
NECESSARY TO REMOVE SECRETIONS

AND BLEEDING.

AND NOTIFY THE COVERING
PHYSICIAN AS SOON AS POSSIBLE.

SO LET'S GO ON TO THE SLIDE
TITLED "RESPONSE TO TONIC

CLONIC STATUS EPILEPTICUS."

DURING THE INITIAL STAGES
OF STATUS EPILEPTICUS, APPLY

CAUTION IN THE AMOUNT OF
BENZODIAZEPINE ADMINISTERED.

AS I MENTIONED EARLIER,
THE AREA OF CARE THE EMU IS

SITUATED IN MAY NOT BE
PREPARED FOR RAPID INTUBATION.

IT IS IMPORTANT TO KEEP IN
MIND THAT DIAZEPAM WARDS OFF

STATUS EPILEPTICUS FOR
A SHORTER PERIOD OF TIME

COMPARED TO LORAZEPAM.

IN THE ESTABLISHED STATE
OF STATUS EPILEPTICUS, IV

FOSPHENYTOIN AND
VALPROIC ACID ARE

THE FIRST-LINE AEDs AND
ARE LESS LIKELY TO CAUSE

CARDIORESPIRATORY DEPRESSION.

IV PHENOBARBITAL CAN CAUSE
CARDIORESPIRATORY DEPRESSION,

AND THIS MIGHT MEAN A
TRANSFER TO THE ICU.

SO KEEP THIS IN MIND.

OTHER OPTIONS FOR THE
TREATMENT OF STATUS

EPILEPTICUS INCLUDE IV
LEVITERACETAM.

BUT NOTE ITS USE FOR
STATUS EPILEPTICUS IS OFF LABEL.

LET'S GO ON TO THE NEXT SLIDE.

WE SHOULD BE ON
POSTICTAL AGGRESSION NOW.

SO POSTICTAL AGGRESSION IS
ONE OF THE POTENTIAL ADVERSE

EVENTS OCCURRING DURING VEM
THAT COULD BE PARTICULARLY

CHALLENGING IF ONE DOESN'T
KNOW HOW TO MANAGE THEM.

POSTICTAL AGGRESSION IS
BASICALLY A RESPONSE TO

PERCEIVED THREAT OR INTENT TO
HARM IN A POSTICTAL STATE

ON THE PART OF THE PATIENT.

SOME PEOPLE USE THE TERM
"RESISTIVE VIOLENCE" TO

DESCRIBE THE
PATIENT'S BEHAVIOR.

ONE PROPOSED CAUSE OF PIA,
OR POSTICTAL AGGRESSION,

IS CEREBRAL EXHAUSTION.

THE PATIENT'S BEHAVIOR DURING
POSTICTAL AGGRESSION IS

BRIEF, UNDIRECTED,
AND REACTIVE IN NATURE.

POSTICTAL AGGRESSION TENDS
TO OCCUR SHORTLY AFTER ONE OR

MORE SEIZURES OR AFTER
A CLUSTER OF SEIZURES.

LET'S GO ON TO THE NEXT SLIDE,
WHICH DISCUSSES THE MANAGEMENT

OF POSTICTAL AGGRESSION.

THE AGGRESSION TENDS TO
RESOLVE ITSELF QUICKLY.

ONE SHOULD LIMIT PATIENT
CONTACT AND INTERVENE ONLY IF

THE PATIENT OR ANOTHER
INDIVIDUAL IS AT RISK

FOR PHYSICAL HARM.

AND FINALLY, TRY NOT TO
RESTRAIN THE PATIENT, AS THIS

CAUSES THE PATIENT TO
BECOME MORE AGGRESSIVE.

LET'S GO ON TO THE NEXT SLIDE,
WHICH SHOULD BE

ON POSTICTAL PSYCHOSIS.

NOW, ON THE OTHER HAND,
POSTICTAL PSYCHOSIS IS

PSYCHOSIS COMMONLY ASSOCIATED
WITH PATIENTS DIAGNOSED

WITH INTRACTABLE EPILEPSY.

THE ONSET OF THIS TYPE OF
PSYCHOSIS IS LESS THAN A WEEK

POSTICTALLY.

THE PATIENT MAY APPEAR CLEAR-
HEADED BUT MAY EXPERIENCE

IRRITABILITY, MOOD
LABILITY, AND INSOMNIA.

THE PSYCHOSIS PERIODS CAN BE
AS SHORT AS 15 HOURS OR AS

LONG AS TWO MONTHS.

DELIRIUM, PARANOID DELUSIONS,
AUDITORY AND VISUAL

HALLUCINATIONS ARE THE
SYMPTOMS COMMONLY OBSERVED.

AND LIKE POSTICTAL AGGRESSION,
IT TENDS TO OCCUR SHORTLY

AFTER ONE OR MORE SEIZURES OR
AFTER A CLUSTER OF SEIZURES.

LET'S GO ON TO THE NEXT
SLIDE, WHICH SHOULD DISCUSS

THE MANAGEMENT OF
POSTICTAL PSYCHOSIS.

AS FOR MANAGEMENT, POSTICTAL
PSYCHOSIS IS SELF-LIMITING.

THE PSYCHOSIS SHOULD BE
TREATED WITH TRANQUILIZERS

AND SEDATIVES IF THE PSYCHOSIS
GETS PROGRESSIVELY WORSE,

AND BENZODIAZEPINES ARE THE
DRUG OF CHOICE FOR DELIRIUM.

IF NECESSARY,
NEUROLEPTICS CAN BE USED.

AND FINALLY, IT IS IMPORTANT
TO BALANCE PATIENT SAFETY

AND THE NEED FOR DATA.

LET'S GO ON TO THE NEXT SLIDE,
WHICH DISCUSSES INTRACRANIAL

ELECTRODE SAFETY.

PATIENTS WITH INTRACRANIAL
ELECTRODES ARE AT A HIGHER

RISK FOR INJURY THAN PATIENTS
WHO COME IN FOR ROUTINE VEM,

OR VIDEO EEG MONITORING.

IF POLICY ALLOWS AND IF THE
PATIENT CONSENTS, RESTRAINTS

SHOULD BE APPLIED.

AN ALTERNATIVE IS TO HAVE A
ONE-TO-ONE SITTER AT BEDSIDE

WITHIN ARM'S REACH.

THIS WOULD BE PREFERABLE.

[INDISTINCT]
PATIENT AT ALL TIMES.

SECURE EXTRA WIRING
TO AVOID FALLS.

MONITOR FOR SIGNS
OF INFECTION.

AND PERFORM FREQUENT
NEUROLOGICAL CHECKS.

LET'S GO ON TO THE NEXT SLIDE,
WHICH DISCUSSES THE SAFE

DISCHARGE OF THE PATIENT.

SO IN REGARDS TO THE SAFE
DISCHARGE, IF THE PATIENT HAS

HAD A SEIZURE WITHIN 24 HOURS
BEFORE DISCHARGE, CONSIDER THE

BENZODIAZEPINES SUCH AS DIASTAT
FOR BREAK FOR SEIZURES

UNTIL ALL AEDs
ARE THERAPEUTIC.

YOU WANT TO REVIEW WITH THE
PATIENT AND FAMILY THE SUMMARY

OF THE FINDINGS DURING THE VEM
STATE, OR THE VIDEO EEG

MONITORING STATE.

EDUCATE THE PATIENT AND
FAMILY ON THE SEIZURES.

UPDATE THE FAMILY AND THE
PATIENT ON ANY MEDICATION

CHANGES, AND GIVE THEM
A TITRATION PLAN.

ALSO, EDUCATE THEM ON
THE SYMPTOMS OF POSTICTAL

PSYCHOSIS, AND DIRECT THEM TO
THE ER IF THAT WERE TO HAPPEN.

ALSO, LET THEM KNOW ABOUT
THEIR FOLLOW-UP APPOINTMENTS

SO THERE'S CONTINUITY OF CARE.

HOPEFULLY THIS WAS EDUCATIONAL
FOR ALL OF YOU, AND THANK YOU

VERY MUCH.

- I'M GONNA GET THE
LINES OPENED UP.

ALL RIGHT, LINES SHOULD
BE OPENED IF THERE ARE

ANY QUESTIONS.

- I HAVE A QUESTION
FROM SAGINAW.

- HI. WHAT'S YOUR NAME?

- HI. THIS IS GAIL LeCLAIR.

I'M WITH PEOPLE WITH
DISABILITIES, AND I WANTED TO

GET SOME INFORMATION IN
OUR NEUROLOGY CLINIC,

AND IN TALKING WITH ALL THE
NURSES AND EVERYBODY HERE,

THEY SAID, "WE CAN'T HAVE
ANYTHING THAT SUPPORTS

A MEDICINE, A COMPANY."

DO YOU KNOW IF THERE'S SOME
PLACE BESIDES THAT [INDISTINCT],

WHICH IS VERY OLD INFORMATION,
THAT I CAN GET SOMETHING

FOR MY PATIENTS?

- WELL,
WHAT INFORMATION ARE YOU

SPECIFICALLY LOOKING FOR--

- OH,
JUST LIKE GENERAL FIRST AID

FOR THE FAMILY--YOU KNOW,
TYPES OF SEIZURES, THAT KIND

OF THING I WAS LOOKING FOR.

- AH, I SEE.

NOW, OUR EPILEPSY CENTER
OF EXCELLENCE DOES HAVE

AN AFFILIATION WITH THE
EPILEPSY FOUNDATION.

- YOU DO?

- YES.

- OK,
BECAUSE I KNOW THEY HAVE A LOT

OF GREAT INFORMATION THERE,
BUT I WOULD PROBABLY HAVE TO

GET PERMISSION FROM SOMEBODY,
YOU KNOW, TO DO THAT.

I'M NOT REALLY SURE WHO,
BUT I CAN FIND OUT.

- NOW,
WHERE IS YOUR FACILITY?

- IN SAGINAW, MICHIGAN.

- AW, OK.

- WERE NOT AN EOC.

I WANTED TO GET JUST SOME
GENERAL INFORMATION UP THERE

FOR THE FAMILY MEMBERS
AND FOR THE PATIENTS.

- A SECOND THING I COULD
ALSO DO IS LOOK INTO WHAT

INFORMATION IS THERE AND SEND
IT TO THE SAN FRANCISCO VA

AND SEE WHAT INFORMATION THEY
HAVE, ALSO, BECAUSE THAT'S OUR

SISTER ECE.

SO, YEAH, I WILL LOOK
INTO THAT FOR YOU.

- YOU WILL? OK.

AND THEN I'LL GET WITH THE
NURSE HERE THAT DOES ALL

THE EDUCATION STUFF.

THAT I WOULD VERY MUCH
APPRECIATE, BUT THAT WAS

VERY INTERESTING.

I HAD MY DAUGHTER AT AN
EPILEPSY CENTER OF EXCELLENCE.

IT WASN'T TOO LONG AGO,
PROBABLY ABOUT 6 YEARS AGO

AT HENRY FORD
HOSPITAL IN DETROIT.

SO IT SOUNDS LIKE VA
IS RIGHT ON LINE.

- OK, VERY GOOD.

NOW, PLEASE FILL OUT THE
EVALUATION FORM SO WE CAN KIND

OF GET IN TOUCH
WITH YOU, OK?

- OK. THANKS. I WILL. OK.

- IS THERE ANY
MORE QUESTIONS?

WELL, I DON'T THINK
THERE'S ANY MORE QUESTIONS.

- YEAH,
I DON'T BELIEVE SO.

- OH, OK.

I WONDER HOW MANY
PARTICIPANTS THEY HAD.

- WE'LL FIND OUT
AFTER IT'S OVER.

- OK.

I WAS JUST CURIOUS BECAUSE I
WENT TO MY DIRECTOR, AND SHE'S

LIKE, "YEAH, GO AHEAD, GAIL,
IF YOU WANT TO GET SOME

INFORMATION," AND IT'S JUST
SOMETHING THAT I WANTED TO DO

FOR A LONG TIME HERE, WAS
GET THAT KIND OF INFORMATION.

ALL RIGHT.

WELL, HAVE A NICE DAY.
THANK YOU.

- THANKS, GAIL.
APPRECIATE IT.

- THANK YOU FOR EVERYBODY
FOR JOINING OUR CALL TODAY.

- THANK YOU ALL.

- THANK YOU.

- I HAD A QUICK QUESTION.

- YES. GO FOR IT.

- WHERE CAN I FIND THE
EVALUATION FORM FOR THE POST--

- YOU CAN FIND THE EVALUATION
FORM ON THE EPILEPSY WEBSITE.

AT THE VA EPILEPSY WEBSITE,
THEY HAVE IT POSTED THERE.

PLUS YOU CAN FIND IT IN
THE EES CATALOGUE.

IF YOU CAN'T FIND IT FOR
SOME REASON, YOU CAN GO AHEAD

AND SEND ME AN E-MAIL AT
SEAN.GAMBLE@VA.GOV, AND I CAN

SEND YOU ONE.

- THANK YOU.

I SHOULDN'T HAVE ANY TROUBLE.

THANK YOU.

- SO HOW DO WE GET THE FORM
TO FILL OUT FOR CONTINUING

EDUCATION CREDITS?

- WELL,
ONCE YOU TAKE THE SURVEY,

IT'S GONNA GO AHEAD AND GIVE
YOU--ONCE YOU SUBMIT IT,

AT THE END, IT'S GONNA
SAY "PRINT CERTIFICATE."

YOU NOW PRINT THEM YOURSELF.
WE DON'T SEND THEM OUT.

- OH, OK. YEAH.

SO I SHOULD--I'M AT
THE--HOW DO I GET THE SURVEY

SHEETS, NOW?

- ARE YOU VA?

- NO.

- OK/ GO TO
WWW.EPILEPSY.VA.GOV, AND UNDER

ANNOUNCEMENTS, YOU'LL
SEE THERE'S GOING TO BE

A HARD [INDISTINCT] ON THERE.

- OH, OK.

- THAT YOU CAN JUST PRINT OUT.
THEN YOU WOULD SEND IT IN.

- OH, OK. ALL RIGHT.
THANK YOU VERY MUCH.

- THANK YOU.

- BYE-BYE, NOW.

- IS THERE ANY
OTHER QUESTIONS?

ALL RIGHT, THANK YOU,
EVERYBODY,

FOR JOINING US TODAY.

- THANK YOU, EVERYONE.
THANK YOU, SEAN.

- THANK YOU.
- BYE.