Abstracts

Rationale: Sudden unexpected death in epilepsy (SUDEP), often unwitnessed, is estimated to occur in up to 1 in 1000 patient years in large cohorts, and up to 9 per 1000 patient years in drug resistant or surgical populations. Cardio-respiratory causes are usually implicated. Such deaths are infrequent in modern EMUs, possibly reduced by close monitoring of patients and intervention by rapid response teams. We report an unexpected death upon discharge from the EMU in a young patient with documented nonepileptic spells (NES). Methods: Review of >2000 consecutive patients admitted to the UCSD EMU revealed one sudden death. A 29 yo fully ambulatory female with developmental delay, behavioral/psychiatric disorder, obesity, childhood epilepsy, and recurrent seizures despite 3 AEDs was admitted for noninvasive diagnostic video-EEG monitoring with 10-20 and T1T2 scalp electrodes, and ECG. Standard EMU protocol was followed, with written and verbal patient education material, gentle medication taper and sleep restriction to encourage natural seizures, continuous bedside sitter and electronic EEG/ECG surveillance, and daily reminders for ambulation/up in chair/leg exercise. Over 3 days she demonstrated 3 stereotyped NES with stiffening, unresponsiveness, bicycling movements, back arching, head shaking. No ictal or interictal epileptiform discharges were found. On day 4 she and her family were counseled about the diagnosis of NES and literature was provided; she was restarted on 2 of 3 AEDs at home doses, with plans to later reduce AEDs as an outpatient if clinically indicated. On day 5, video-EEG was discontinued, electrodes were removed and she was discharged. Before leaving the hospital, she showered, and then emerged from the bathroom gasping and cyanotic. A code blue was called, but she could not be resuscitated. Results: An autopsy revealed massive pulmonary embolus as the immediate cause of death. Risk factors for venous thromboembolic disease were obesity, smoking. After death we learned she previously had superficial phlebitis at a psychiatric hospital attributed to IV infiltration. Further interview of sitters revealed she had not consistently followed recommendations for daily leg exercises. Mild complaints of leg pains were not reported to staff/physicians. Conclusions: This tragic case of sudden death from venous thromboembolic disease in a young patient with NES illustrates the importance of continually reviewing and revising EMU patient safety protocols. After a comprehensive internal review, our policies were revised to include specific DVT education by the EMU nurse coordinator upon admission, documented t.i.d. leg exercise, and enhanced screening for venous thromboembolic risk factors and symptoms in all patients, including young and fully ambulatory EMU patients. Patients sign a comprehensive consent form, specifying risks and benefits of EMU evaluation. We encourage other centers to review and report any illustrative cases related to patient safety.