TY - JOUR
AU1 - USAR, Robert Kaspar, MC
AU2 - USAR, Robert E. Buckner, II, MC
AU3 - USAR, Joseph P. McMahon, MC
AU4 - USN, Mill Etienne, MC
AU5 - USA, Alan A. Larsen, Jr., MC
AU6 - USN, Josh Duckworth, MC
AB - ABSTRACT Patients with seizures can present a common and challenging problem for medical providers in the deployed environment. Unfortunately, there is a paucity of controlled clinical trial data that can be used to formulate evidence-based guidelines for management. In an attempt to aid the non-neurologist deployed provider in the care of patients presenting with seizures, the authors describe two cases illustrative of common presentations. Thereafter, the authors address many facets of the management questions commonly raised by such cases and offer suggestions regarding such issues as initial pharmacologic management, the need for admission and evacuation, seizure precautions, differentiation from syncope and nonepileptic seizures, addressing patient and command concerns regarding evaluation and duty restrictions, and obtaining online management assistance. INTRODUCTION The incidence of seizures is difficult to define since it is highly dependent on the age and other characteristics of the population under study. Approximately 10% of the population will have at least one seizure in their lifetime, and it is estimated that 0.5 to 1% of the population has epilepsy.1,2 Seizures are not uncommon in the deployed environment. Sleep deprivation, physical exhaustion, the use of workout stimulants, and the challenge of adhering to the medication regimen are but a few of the seizure-provoking conditions commonly encountered in the deployed environment. Video games and computer viewing are often carried out in a darkened tent or barracks, which may increase the risk of seizures induced by photic stimulation.3 In one author's experience, the most common trigger for seizures in the deployed environment is sleep deprivation (A.A. Larsen, personal communication). Many deployed service members experience more sleep deprivation than they have ever experienced previously. This degree of sleep deprivation may unmask a previously existing subclinical seizure disorder. Herein we briefly present two cases of seizure disorders as they might present in the deployed environment. These cases generate questions that help to illustrate the scope and challenges presented in managing this complex condition in the deployed environment. Although there are insufficient studies to construct evidence-based guidelines, it is hoped that the experiences of the authors (three of whom are neurologists) will provide useful guidance that will be helpful for the deployed providers who manage this disorder. CASE 1 Fellow military service members were awakened at 2:00 a.m. by the noises from a 23-year-old male military service member who shared a living space with them. He was on the floor beside his cot and was described to be “shaking all over.” The shaking stopped spontaneously after several minutes, but the service member was unconscious and could not be aroused. His computer was on and was lying beside his cot. First responders were called to evaluate the service member, and they evacuated him by ambulance to the nearest medical treatment facility (MTF). The service member regained consciousness after about 15 minutes while being transported. He had no recollection of going to bed that evening, and he could not recall events such as what he had for dinner earlier that evening. On arrival at the emergency department he was fully awake and responded appropriately. Vital signs were normal. Physical examination was normal without evidence of tongue laceration but he did have urinary incontinence. He had a normal mental status and there was no focal weakness identified. He had no significant medical history, and there were no clear epilepsy risk factors including no history of febrile seizures, no history of traumatic brain injury, no history of central nervous system (CNS) infection, no perinatal complications, and no family history of epilepsy. His only medication was ibuprofen (400 mg) for muscular pain taken on an as needed basis. Laboratory studies including electrolytes, creatinine, and glucose were normal. A noncontrast CT of the head was normal. He was admitted for observation. CASE 2 A 32-year- old service member was in the barracks preparing for a mission when he suddenly fell to the ground and began having what was described by his fellow service members as a generalized convulsion. The convulsive activity ceased spontaneously after several minutes. The service member had stable vital signs, but he did not regain consciousness. Approximately 15 minutes later, while being transported to an MTF, generalized convulsive seizure activity recurred. He was given lorazepam (2 mg) intravenously. Seizure activity ceased within 5 minutes. Vital signs remained stable but the service member remained unconscious with no response to painful stimuli. Thirty minutes later, while being brought into the emergency department, a third generalized convulsive seizure occurred. He was given two additional 2 mg doses of lorazepam intravenously and loaded with 20 mg/kg of phenytoin equivalent infused at 100 mg/min. The convulsion stopped, but it recurred 20 minutes later while the service member was being evaluated in the emergency department. The physician in charge made a decision to treat the patient with a continuous propofol infusion, since this was the agent with which the physician was most familiar. A 100 mg loading dose followed 4 mg/kg/h by continuous infusion of propofol was initiated. Mechanical ventilation was instituted. Laboratory studies including electrolytes, creatinine, and glucose were normal. A noncontrast CT of the head was normal. FOLLOWING ARE QUESTIONS THAT COMMONLY ARISE REGARDING THE MANAGEMENT OF SEIZURE DISORDERS IN THE DEPLOYED ENVIRONMENT What Types of Seizures are Likely to be Encountered in the Deployed Environment? There are many types of seizures. Seizure activity can be classified as partial or primary generalized. Partial seizures have onset in one part of the brain and are further subdivided into simple partial and complex partial seizures. Complex partial seizures involve an impairment in consciousness whereas patients with simple partial seizures retain consciousness and thus remain fully aware during the event. There are many subtypes of primary generalized seizures including, absence (petit mal), myoclonic, atonic (drop attacks), or tonic–clonic (grand mal). Although it is important to recognize the many seizure types mentioned above, the generalized tonic–clonic seizure is by far the most common concern in the deployed environment. Do All Patients with Possible Seizure Activity in the Deployed Environment Require Admission? Patients presenting with a suspected seizure in the deployed environment require admission. Admission decreases the provider's liability and removes considerable pressure for continued observation from the service member's unit. Usually the Joint Patient Movement Requirements Center (JPMRC) guidance will be that the patient be seizure-free for 24 hours before evacuation. This guidance may have to be modified for patients with status epilepticus or recurrent seizures despite available therapy. What Precautions Should be Taken for Patients Admitted with a Possible Seizure? Patients are at risk for recurrent seizures and should be protected from injury or harm while hospitalized. At minimum these patients should have a saline lock intravenous access placed and ready for administration of emergency antiseizure medication. Beds should be placed in a low position with wheels locked. Both side rails should be up. Activity out of bed should be supervised. Patients should ambulate with assistance. The patient should shower with someone in attendance. Patients should be monitored if they have not fully returned to their preseizure condition, including their baseline mental status and motor function. The patient should be placed in an area where line of sight observation is available. Was the Event the Patient Experienced Truly a Seizure? When attempting to determine whether the event the service member experienced was truly a seizure accurate description of the event is of the utmost importance. The episode may only occur once. Further testing such as electroencephalogram (EEG) and neuroimaging may be normal even though a seizure disorder is present. A CT scanner has been available in theater for many years and EEG capability recently became available at one MTF in Afghanistan. Such assets can be used when available. It is important to interview those accompanying the patient or immediately “reach back” to those who may have witnessed the event. Medical personnel who may provide the initial care should make every effort to obtain the information that will help ascertain whether the episode experienced by the patient was truly a seizure. Table I presents a list of key questions that help determine whether the event was truly a seizure, and, if so, information that may help determine the etiology. TABLE I. Critical Questions About the “Seizure” Event 1. Did you see the beginning of the event? If so, what was the patient doing (sitting, standing, lying down)? Was there an associated scream or moan?  2. Were the patient's arms and/or legs shaking? Were the movements synchronous or asynchronous? Were the arms/legs stiffened up? How long did the shaking/stiffness last?  3. Was the head rotated to one side or the other?  4. Were the patient's eyelids opened or closed? If open, were the eyes looking straight ahead, rolled upward, or deviated to one side?  5. Was the patient responsive during the episode?  6. How long did it take for the patient to become responsive? When the patient became responsive was the patient coherent? Was the patient oriented to time or place?  7. Had the patient bitten their tongue, cheek, or been incontinent? If the tongue was bitten, was it the tip or the side?  8. Was one side of the body weaker after the seizure?  9. Was there any language impairment during or after the seizure?  1. Did you see the beginning of the event? If so, what was the patient doing (sitting, standing, lying down)? Was there an associated scream or moan?  2. Were the patient's arms and/or legs shaking? Were the movements synchronous or asynchronous? Were the arms/legs stiffened up? How long did the shaking/stiffness last?  3. Was the head rotated to one side or the other?  4. Were the patient's eyelids opened or closed? If open, were the eyes looking straight ahead, rolled upward, or deviated to one side?  5. Was the patient responsive during the episode?  6. How long did it take for the patient to become responsive? When the patient became responsive was the patient coherent? Was the patient oriented to time or place?  7. Had the patient bitten their tongue, cheek, or been incontinent? If the tongue was bitten, was it the tip or the side?  8. Was one side of the body weaker after the seizure?  9. Was there any language impairment during or after the seizure?  View Large TABLE I. Critical Questions About the “Seizure” Event 1. Did you see the beginning of the event? If so, what was the patient doing (sitting, standing, lying down)? Was there an associated scream or moan?  2. Were the patient's arms and/or legs shaking? Were the movements synchronous or asynchronous? Were the arms/legs stiffened up? How long did the shaking/stiffness last?  3. Was the head rotated to one side or the other?  4. Were the patient's eyelids opened or closed? If open, were the eyes looking straight ahead, rolled upward, or deviated to one side?  5. Was the patient responsive during the episode?  6. How long did it take for the patient to become responsive? When the patient became responsive was the patient coherent? Was the patient oriented to time or place?  7. Had the patient bitten their tongue, cheek, or been incontinent? If the tongue was bitten, was it the tip or the side?  8. Was one side of the body weaker after the seizure?  9. Was there any language impairment during or after the seizure?  1. Did you see the beginning of the event? If so, what was the patient doing (sitting, standing, lying down)? Was there an associated scream or moan?  2. Were the patient's arms and/or legs shaking? Were the movements synchronous or asynchronous? Were the arms/legs stiffened up? How long did the shaking/stiffness last?  3. Was the head rotated to one side or the other?  4. Were the patient's eyelids opened or closed? If open, were the eyes looking straight ahead, rolled upward, or deviated to one side?  5. Was the patient responsive during the episode?  6. How long did it take for the patient to become responsive? When the patient became responsive was the patient coherent? Was the patient oriented to time or place?  7. Had the patient bitten their tongue, cheek, or been incontinent? If the tongue was bitten, was it the tip or the side?  8. Was one side of the body weaker after the seizure?  9. Was there any language impairment during or after the seizure?  View Large What Features May Help Differentiate Syncope and Nonepileptic Seizures from True Seizure Activity? There are many types of events that have “seizure-like” activity but may not be classified as true seizures. Syncopal episodes and nonepileptic seizures, which can both be seen in the deployed environment, are two conditions that often may be challenging to differentiate from seizures. Syncopal episodes may have posturing that resembles seizure activity. Although there are many causes for syncope, in the deployed setting vasovagal syncope is the most common. Vasovagal syncope is usually preceded by one or more prodromal symptoms such as “light-headedness”, “tunneling” of vision, dizziness, nausea, and diaphoresis. Often vasovagal syncope occurs during conditions such as prolonged standing, dehydration, fear, stressful situations, and pain. Twitching and jerking movements may accompany syncopal episodes, but these movements usually lack the rhythmic movements seen with seizures. Loss of bowel and bladder control is unusual in syncope. Seizures may last several minutes or longer, whereas the twitching movements that accompany syncope usually last only a few seconds. Disorientation and sleepiness often last many minutes or even hours following a generalized seizure, but rarely lasts more than 5 minutes after a syncopal event. In addition, some patients may have nonepileptic seizures, which are not uncommon in the deployed environment. Nonepileptic seizures are sudden changes in behavior that may resemble epileptic seizures but are not accompanied by the cortical electrographic changes that characterize epileptic seizures.4,5 Although many clinical features can help differentiate a seizure disorder from nonepileptic seizures, many testing modalities that aid in making the diagnosis, such as EEG and video EEG monitoring, are not readily available in the deployed environment. Thus, even when nonepileptic seizures seem likely, evacuation to an appropriate higher level of care is usually required. Many patients with a true seizure disorder may also have nonepileptic seizures, further complicating the evaluation. In addition, patients with nonepileptic seizures require referral to behavioral health since the nonepileptic seizure may be a presenting symptom of post-traumatic stress disorder, adjustment disorder, or other behavioral health condition. What Underlying Conditions May Provoke or Cause Seizures? A number of underlying conditions can produce seizures. In susceptible individuals seizures can be provoked by sleep deprivation or by repetitive flashing lights of particular colors or flash frequencies. Metabolic abnormalities such as hyponatremia, hypoglycemia, hypomagnesemia, and hypercalcemia can produce seizures. CNS injury because of acute trauma, previous brain injury, CNS infections, cerebrovascular events (ischemic stroke, intracerebral hemorrhage, subarachnoid, or subdural hemorrhage), brain tumors, and autoimmune disorders may cause seizures. Numerous drugs or substances may cause seizures (Table II). Two prescription medications that have been of particular concern in the deployed environment have been tramadol and buproprion. Heavy use of or withdrawal from alcohol may increase the risk of seizures as well. TABLE II. Drugs and Substances Encountered in the Deployed Environment that may Provoke/Cause Seizures14,15 Chloroquine  Mefloquine  Beta lactam antibiotics (usually in high doses)  Acyclovir  Quinolones  Isoniazid (INH)  Tramadol  Dietary supplements  Antidepressants  Antipsychotics  Amphetamines  Cocaine  Phencyclidine  Methylphenidate  Additional Provocations:  Withdrawal from alcohol, short acting benzodiazepenes or barbiturates  “Spice”  Bath salts  “Huffing”  Chloroquine  Mefloquine  Beta lactam antibiotics (usually in high doses)  Acyclovir  Quinolones  Isoniazid (INH)  Tramadol  Dietary supplements  Antidepressants  Antipsychotics  Amphetamines  Cocaine  Phencyclidine  Methylphenidate  Additional Provocations:  Withdrawal from alcohol, short acting benzodiazepenes or barbiturates  “Spice”  Bath salts  “Huffing”  View Large TABLE II. Drugs and Substances Encountered in the Deployed Environment that may Provoke/Cause Seizures14,15 Chloroquine  Mefloquine  Beta lactam antibiotics (usually in high doses)  Acyclovir  Quinolones  Isoniazid (INH)  Tramadol  Dietary supplements  Antidepressants  Antipsychotics  Amphetamines  Cocaine  Phencyclidine  Methylphenidate  Additional Provocations:  Withdrawal from alcohol, short acting benzodiazepenes or barbiturates  “Spice”  Bath salts  “Huffing”  Chloroquine  Mefloquine  Beta lactam antibiotics (usually in high doses)  Acyclovir  Quinolones  Isoniazid (INH)  Tramadol  Dietary supplements  Antidepressants  Antipsychotics  Amphetamines  Cocaine  Phencyclidine  Methylphenidate  Additional Provocations:  Withdrawal from alcohol, short acting benzodiazepenes or barbiturates  “Spice”  Bath salts  “Huffing”  View Large What is the Best Initial Treatment for Seizure Control in a Patient with Seizures? The initial management of seizures has not been well studied in randomized controlled trials and is thus not standardized.6,–8 Management differs between institutions and even within institutions. Thus, many approaches can be considered acceptable. Management in the deployed setting may sometimes differ from that in the nondeployed setting. Despite the lack of an evidence-based comprehensive approach, we present an algorithm that the authors believe might serve as a useful framework (Fig. 1). Once it has been determined that the event was likely a seizure, a decision must be made about the need for seizure control medications. An important consideration is the likelihood that the patient has epilepsy. Table III lists some of the factors one may consider when determining the likelihood of epilepsy in patients who present with a seizure. The more epilepsy risk factors the service member has, the more likely it is that the member should be treated with antiseizure medications. Patients evacuated for evaluation of a possible seizure do not need to be routinely placed on seizure control medications. Since current theaters of operations require long evacuation flights to level 4 care, antiseizure medications to reduce the likelihood of recurrent seizures during transport are sometimes requested by JPMRC. FIGURE 1. View largeDownload slide In theater seizure management algorithm. FIGURE 1. View largeDownload slide In theater seizure management algorithm. TABLE III. Epilepsy Risk Factors History of:  • Traumatic brain injury  • Intracranial events (ischemic/hemorrhagic, subarachnoid, or subdural hematoma)  • Perinatal insults, ICU stays (reason for if known)  • Epilepsy or sudden death of unclear etiology in family members  • Abnormal development (late milestones, trouble getting through school)  • Epilepsy as a child (granted waiver to enter military because “outgrew them”)  • Brain abnormalities such as arteriovenous malformation, neurofibroma  • Central nervous system infection or injury  History of:  • Traumatic brain injury  • Intracranial events (ischemic/hemorrhagic, subarachnoid, or subdural hematoma)  • Perinatal insults, ICU stays (reason for if known)  • Epilepsy or sudden death of unclear etiology in family members  • Abnormal development (late milestones, trouble getting through school)  • Epilepsy as a child (granted waiver to enter military because “outgrew them”)  • Brain abnormalities such as arteriovenous malformation, neurofibroma  • Central nervous system infection or injury  The more risk factors a patient has, the higher the risk of recurrent seizure and need to start seizure control medications. View Large TABLE III. Epilepsy Risk Factors History of:  • Traumatic brain injury  • Intracranial events (ischemic/hemorrhagic, subarachnoid, or subdural hematoma)  • Perinatal insults, ICU stays (reason for if known)  • Epilepsy or sudden death of unclear etiology in family members  • Abnormal development (late milestones, trouble getting through school)  • Epilepsy as a child (granted waiver to enter military because “outgrew them”)  • Brain abnormalities such as arteriovenous malformation, neurofibroma  • Central nervous system infection or injury  History of:  • Traumatic brain injury  • Intracranial events (ischemic/hemorrhagic, subarachnoid, or subdural hematoma)  • Perinatal insults, ICU stays (reason for if known)  • Epilepsy or sudden death of unclear etiology in family members  • Abnormal development (late milestones, trouble getting through school)  • Epilepsy as a child (granted waiver to enter military because “outgrew them”)  • Brain abnormalities such as arteriovenous malformation, neurofibroma  • Central nervous system infection or injury  The more risk factors a patient has, the higher the risk of recurrent seizure and need to start seizure control medications. View Large In the nondeployed setting many patients are not placed on medication for a single seizure until further evaluation has been completed. Since placement on seizure control medications can hinder further evaluation of the patient and make a premature judgment on the need for medication, patients should not routinely be placed on seizure control medications for evacuation without consulting the theater neurologist or obtaining a neurology consult via the military online consultation service (neuron.consult@us.army.mil). It is, however, mandatory to write for seizure control medications on the patient movement request orders so that these medications are readily available for the patient should a seizure occur during transport. How are Recurrent Seizures Best Managed? As previously noted there are no evidence-based comprehensive guidelines for seizure management. Approaches may differ between institutions and even among individuals within the same institution. Characteristics of seizure control medications commonly available in the deployed setting are summarized in Table IV. TABLE IV. Pros and Cons of Seizure Control Medications Likely to be Available in Deployed Settings Drug  Onset of Action  Duration  Pros  Cons  Diazepam (Valium)  20 seconds  15–20 minutes  Readily available at all levels of care; multiple routes of administration; most providers familiar with drug  Higher incidence of ventilatory suppression; short duration of action  Lorazepam (Ativan)  2–5 minutes  4–14 hours  Long duration of action  Slower onset  Midazolam (Versed)  90 seconds  30 minutes  Perceived high effectiveness with less side effects; preferred by many for continuous infusion  Tachyphylaxis within 48 hours  Propofol (Diprivan)  1 minute  3–10 minutes  Short half-life allows smooth and rapid titration  Hypotension; propofol infusion syndrome  Fosphenytoin (Cerebyx)  15 minutes  24 hours  Perceived advantages of faster administration rate, fewer side effects  Much more costly than phenytoin; need to calculate phenytoin equivalents when dosing  Drug  Onset of Action  Duration  Pros  Cons  Diazepam (Valium)  20 seconds  15–20 minutes  Readily available at all levels of care; multiple routes of administration; most providers familiar with drug  Higher incidence of ventilatory suppression; short duration of action  Lorazepam (Ativan)  2–5 minutes  4–14 hours  Long duration of action  Slower onset  Midazolam (Versed)  90 seconds  30 minutes  Perceived high effectiveness with less side effects; preferred by many for continuous infusion  Tachyphylaxis within 48 hours  Propofol (Diprivan)  1 minute  3–10 minutes  Short half-life allows smooth and rapid titration  Hypotension; propofol infusion syndrome  Fosphenytoin (Cerebyx)  15 minutes  24 hours  Perceived advantages of faster administration rate, fewer side effects  Much more costly than phenytoin; need to calculate phenytoin equivalents when dosing  View Large TABLE IV. Pros and Cons of Seizure Control Medications Likely to be Available in Deployed Settings Drug  Onset of Action  Duration  Pros  Cons  Diazepam (Valium)  20 seconds  15–20 minutes  Readily available at all levels of care; multiple routes of administration; most providers familiar with drug  Higher incidence of ventilatory suppression; short duration of action  Lorazepam (Ativan)  2–5 minutes  4–14 hours  Long duration of action  Slower onset  Midazolam (Versed)  90 seconds  30 minutes  Perceived high effectiveness with less side effects; preferred by many for continuous infusion  Tachyphylaxis within 48 hours  Propofol (Diprivan)  1 minute  3–10 minutes  Short half-life allows smooth and rapid titration  Hypotension; propofol infusion syndrome  Fosphenytoin (Cerebyx)  15 minutes  24 hours  Perceived advantages of faster administration rate, fewer side effects  Much more costly than phenytoin; need to calculate phenytoin equivalents when dosing  Drug  Onset of Action  Duration  Pros  Cons  Diazepam (Valium)  20 seconds  15–20 minutes  Readily available at all levels of care; multiple routes of administration; most providers familiar with drug  Higher incidence of ventilatory suppression; short duration of action  Lorazepam (Ativan)  2–5 minutes  4–14 hours  Long duration of action  Slower onset  Midazolam (Versed)  90 seconds  30 minutes  Perceived high effectiveness with less side effects; preferred by many for continuous infusion  Tachyphylaxis within 48 hours  Propofol (Diprivan)  1 minute  3–10 minutes  Short half-life allows smooth and rapid titration  Hypotension; propofol infusion syndrome  Fosphenytoin (Cerebyx)  15 minutes  24 hours  Perceived advantages of faster administration rate, fewer side effects  Much more costly than phenytoin; need to calculate phenytoin equivalents when dosing  View Large If the patient has recurrent seizures, repeated doses of benzodiazepenes can be used for short-term control. A possible practical choice is lorazepam (2 mg intravenous) every 2 to 3 minutes until seizures are controlled or a total dose of 8 to 10 mg is reached. Careful observation for respiratory depression is necessary. If there are recurrent seizures, fosphenytoin is added by some to try to reduce the risk of seizure recurrence. As noted, many other approaches are acceptable 9,–12 (see Table IV), and there is a paucity of literature involving evidence-based comparisons. How is Status Epilepticus Defined and How is it Best Managed? There appear to be various definitions of status epilepticus. Workable definitions for the deployed environment are 5 minutes of persistent generalized seizures or 2 or more discrete seizures between which there is incomplete recovery of consciousness. Another acceptable definition is persistent seizure activity after administration of adequate doses of first- and second-line antiseizure medications. This usually consists of benzodiazepenes and fosphenytoin in the deployed environment. Propofol has emerged as a popular alternative for control of status epilepticus. As noted previously, there is little scientific evidence regarding the best treatment regimen, and providers rely on medications and treatment algorithms with which they are familiar. The authors suggest one possible algorithm for the management of seizures and status epilepticus based on agents typically available in theater (Fig. 1). What is the Suggested Workup for Seizures in the Deployed Environment? As previously mentioned, a thorough description of the event with particular emphasis on the questions noted in Table I is of critical importance. A general physical examination with particular emphasis on a search for injuries (including tongue laceration), signs of infection, fundoscopic changes (blurred optic disk or retinal hemorrhages), or neurologic abnormalities (especially localizing findings) should be performed. A temporary focal paralysis following the seizure (Todd's paralysis) may give clues as to the anatomical localization of the seizure. It should be noted that a transient positive Babinski's sign is not unusual after a generalized seizure and may not necessarily be indicative of other CNS pathology. When available, laboratory examinations should include complete blood count, metabolic panel (blood urea nitrogen, creatinine, electrolytes), glucose, liver function tests, and creatine phosphokinase. When available, a non-contrast CT of the head should be obtained as part of the initial evaluation. This is recommended even if there appears to be a metabolic cause. If EEG is available, that should be obtained as well. Do Seizures Always Require Evacuation for Evaluation? Owing to the need for testing modalities that are usually not available in the deployed environment (EEG, MRI, video/EEG monitoring, special tests of blood, or CSF for infection or autoimmune disorders), almost all patients who present with a seizure will require evacuation to a higher level of care for evaluation. As noted previously, suspected nonepileptic seizures also require evacuation. Are There Ever Any Special Circumstances Under Which a Patient with Suspected Seizure Would Not be Evacuated? If a neurologist evaluates the patient and is certain that the event was not a seizure, evacuation may not be necessary. If the service member has a known seizure disorder, is on waiver after a physical evaluation board, is taking antiepileptic drugs, the seizure was provoked by something other than noncompliance, the service member's command wishes to have the service member remain in theater, and the consulting neurologist agrees, the service member may be allowed to remain. However, it should be noted that it would be a rare exception for a service member who has had a seizure to be allowed to remain in theater. The final decision on service member evacuation remains with the service member's command. Under What Category Should Patients be Evacuated? When patients can be promptly evacuated from theater and placed on a direct flight to a level 4 or 5 MTF, patients without recurrent seizures may be evacuated under the routine/ambulatory category. If there is concern for recurrent seizure activity, patients may require routine/litter for safety. If available medical evacuation flights will be indirect because of numerous stops, it may take many days to complete the evacuation process. In such instances it may be safer to work with JPMRC and evacuate the patient as a priority. This requires judgment based on all the data gathered regarding the event and the condition of the patient. Patients requiring frequent doses or infusion of control medications require urgent or priority evacuation. Many of these patients will require mechanical ventilation during evacuation. Careful coordination with JPMRC and, if available, a consulting neurologist can optimize care. How Does Whether a Seizure is Provoked or Unprovoked Affect Management and Prognosis? It is important to differentiate between a provoked and an unprovoked seizure for clinical reasons,13 but this difference is irrelevant to initial management in the deployed setting. Whether the seizure was provoked or not, the service member must be evacuated out of theater (except in the case of rare exceptions noted above). However, whether the seizure was provoked remains an important part of the history. Once in a garrison setting, the question of provoked versus unprovoked becomes relevant and will determine the severity and duration of subsequent restrictions. For example, a service member who had no history of seizures and no predisposing condition, but engaged in an activity while downrange that may have resulted in a seizure would be evacuated out of theater for the seizure and have a seizure workup in garrison. The service member would probably be placed on 6-month seizure restrictions with a temporary P3 profile (in the army). If the workup was unremarkable, and the service member had no further seizures at the end of 6 months, the service member might be removed from all restrictions and profiles. This decision would be strongly influenced by how strongly the neurologist felt the event was provoked. The service member's Military Occupational Specialty and branch of service also effects what restrictions may be placed on the service member. Note that there are interservice differences and the appropriate service regulations should be consulted. What are Some Points for Discussion When the Patient and Command Have Questions Regarding What Workup Will Ensue and Whether the Patient is Likely to Return to Duty? It is likely that at a minimum the patient will get an MRI and EEG upon evacuation from theater. Once evacuated from theater it is extremely unlikely that the service member will return to theater for the remainder of the deployment. Service branches may vary in approaches to management. According to AR 40-501 (the Army Standards for Fitness) the patient must be seen by a neurologist for consultation and further evaluation. The neurologist will make recommendations regarding treatment and duty restrictions. Since there are so many factors that affect the decisions regarding the need for referral to the medical evaluation board (MEB) and duty restrictions, the neurologist is given considerable latitude for clinical decision making in AR 40-501. There are some circumstances that require an MEB; these may vary among service branches and Military Occupational Specialties. What Duty Restrictions Will be Placed and for How Long? As noted above, ongoing restrictions will vary depending on a number of factors. In some patients there may be a question as to whether the event was truly a seizure. After evaluation the conclusion may be that a true seizure probably did not occur. In such cases no treatment or duty restrictions may be required, although this depends on the final diagnosis. If it is determined that it is likely that a seizure occurred, the circumstances surrounding the seizure help define what restrictions will be needed. For example, a single seizure provoked by sleep deprivation that resolved spontaneously may not require extensive restrictions. On the other hand, multiple unprovoked seizures may require quite stringent duty restrictions, even if the seizures have not recurred after evacuation. In most instances, service members are initially placed on duty restrictions for 6 months. The restrictions include no driving, no handling firearms or other weapons, no climbing to heights, no operation of heavy machinery, no swimming, and no sleeping on a top bunk. In addition, any other activity that could cause harm to the patient or others if seizure should recur may be precluded. The stringency of preclusion may vary. For instance, some might preclude the carrying of small infants, while others would not. The 6 month time period is due to the fact that most seizure recurrences will occur within the first 6 months. If the service member is returning to garrison, recommendations on driving personal vehicles should be made taking into account individual state laws. However, the service member is usually restricted from driving government vehicles for 6 months. Physical training is usually allowed although swimming is, as noted previously, often precluded. Weight lifting, particularly with the use of free weights, may be precluded. If there is only a single seizure no MEB is required. A second seizure requires an MEB. If the neurologist elects to place the service member on a trial of duty, the service member will receive a temporary P3 profile. The service member is considered nondeployable. If the service member has another seizure after 6 months, AR 40-501 states that the service member must be referred to an MEB. If the service member remains seizure-free for 1 year, the profile can be reduced to a P2 with a profile restriction “specifying no assignment to an area where medical treatment is not available.” Should seizures recur at a later time, referral to an MEB is at the discretion of the physician. Once a service member has been seizure-free for 36 months, the service member may be removed from profile restrictions. Where Can Deployed Providers Obtain Online Assistance Regarding Management? Deployed providers may often obtain valuable assistance by accessing the neurology section of the United States Military online consultation system for deployed providers at neuron.consult@us.army.mil. REFERENCES 1. Up To Date. Evaluation of the first seizure in adults . Available at http://www.uptodate.com/contents/evaluation-of-the-first-seizure-in-adults; accessed September 8, 2012. 2. Berg AJ, Shinnar S The risk of seizure recurrence following a first unprovoked seizure: a quantitative review. 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Postgrad Med J  2009; 85: 667– 73. Google Scholar CrossRef Search ADS PubMed  9. Rossetti AO, Reichart MD, Schuller M, Despland P, Bogouslavsky J Propofol treatment of refractory status epilepticus: a study of 31 episodes. Epilepsia  2004; 45: 757– 63. Google Scholar CrossRef Search ADS PubMed  10. Prasad A, Worrall BB, Bertram EH, Bleck TP Propofol and midazolam in the treatment of refractory status epilepticus. Epilepsia  2001; 42: 380– 6. Google Scholar CrossRef Search ADS PubMed  11. Costello DJ, Cole AJ Treatment of acute seizures and status epilepticus. J Intensive Care Med  2007; 22: 319– 47. Google Scholar CrossRef Search ADS PubMed  12. Up to Date. Status epilepticus in adults . Available at http://www.uptodate.com/contents/status-epilepticus-in-adults; accessed September 8, 2012. 13. Berg AT Risk of recurrence after a first unprovoked seizure. Epilepsia  2008; 49( Suppl 1): 13– 18. Google Scholar CrossRef Search ADS PubMed  14. Shandia S, Brent J, Mousavi-Fatemi K, Hafezi P, Soltaninejad K Recurrent seizures in tramadol intoxication: implications for therapy based on 100 patients. Basic Clin Phar Toxicol  2012 August; 111( 2): 133– 6. 15. Thundiyil JG, Kearny TE, Olson KR Evolving epidemiology of drug-induced seizures reported to a Poison Control Center System. J Med Toxicol  2007 March; 3( 1): 15– 19. Google Scholar CrossRef Search ADS   Reprint & Copyright © Association of Military Surgeons of the U.S.
TI - Management of Seizure Disorders in the Deployed Environment: A Treatment Guide for the Non-Neurologist in Theater
JF - Military Medicine
DO - 10.7205/MILMED-D-12-00526
DA - 2013-08-01
UR - https://www.deepdyve.com/lp/oxford-university-press/management-of-seizure-disorders-in-the-deployed-environment-a-GK8u1HQzwM
SP - 907
EP - 913
VL - 178
IS - 8
DP - DeepDyve
ER -