# 43 Y/O female seizure



## rhan101277 (Sep 11, 2013)

Call comes in as a possible seizure for a patient with seizure hx.  Patient currently is not seizing is alert and breathing.

Upon arriving at the residence you find the patient lying on the couch.  She seems postictal, a small sign of dried blood is noted on the lower lip.  Pt alert but confused and is grabbing at things, just wondering what things are.  Checking a quick radial pulse you find her skin to be hot and make a mental note of this.  Her radial pulse is very fast.  Pt has nystagmus.  Family denies drug use, denies pt has had any n/v/d, mucus membranes moist.

Vitals:

RR: 26
HR: 175
SpO2: 90%
B/P: 180 palpated (unable to obtain electronic or manual b/p)
12 Lead: no STEMI, most likely sinus tach

How do you treat assuming a fluid bolus has no effect on reducing HR?


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## DesertMedic66 (Sep 12, 2013)

A little bit if O2 and pop a line in just incase the patient seizes again. Vitals, Oxygen, Monitor, IV, Transport. 

I'm trained to the EMT level so Medics may do some different things.


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## Rialaigh (Sep 12, 2013)

BP stays stable and work of breathing doesn't increase then line, some fluids, and a nice slow relaxing ride to the hospital. 

If RR increase some or she seems anxious at all I would be tempted to do a little Ativan to slow the RR and prevent another seizure.


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## mike1390 (Sep 12, 2013)

Pt with a known seizure hx has a normal postictal state... my old protocol states I can BLS this pt.


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## DesertMedic66 (Sep 12, 2013)

mike1390 said:


> Pt with a known seizure hx has a normal postictal state... my old protocol states I can BLS this pt.



Must not be referring to RivCo protocols lol


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## mike1390 (Sep 12, 2013)

Nope VenCo

Although since this is a ALOC pt lets get a BGL too.


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## rmabrey (Sep 12, 2013)

DesertEMT66 said:


> A little bit if O2 and pop a line in just incase the patient seizes again. Vitals, Oxygen, Monitor, IV, Transport .



This


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## Anjel (Sep 12, 2013)

rhan101277 said:


> Call comes in as a possible seizure for a patient with seizure hx.  Patient currently is not seizing is alert and breathing.
> 
> Upon arriving at the residence you find the patient lying on the couch.  She seems postictal, a small sign of dried blood is noted on the lower lip.  Pt alert but confused and is grabbing at things, just wondering what things are.  Checking a quick radial pulse you find her skin to be hot and make a mental note of this.  Her radial pulse is very fast.  Pt has nystagmus.  Family denies drug use, denies pt has had any n/v/d, mucus membranes moist.
> 
> ...



Welcome back rhan... Been awhile. 

I would treat the HR. I would just start an IV monitor and transport. I would have my drug box out just in case of another seizure, but we would just take a nice ride to the ER. 

Sounds like its pretty normal for her.


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## DesertMedic66 (Sep 12, 2013)

Anjel said:


> Welcome back rhan... Been awhile.
> 
> I would treat the HR. I would just start an IV monitor and transport. I would have my drug box out just in case of another seizure, but we would just take a nice ride to the ER.
> 
> Sounds like its pretty normal for her.



Would treat the HR or wouldn't?


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## Anjel (Sep 12, 2013)

DesertEMT66 said:


> Would treat the HR or wouldn't?



Sorry I meant would NOT.


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## DesertMedic66 (Sep 12, 2013)

Anjel said:


> Sorry I meant would NOT.



That clears it up. Thanks lol


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## Pavehawk (Sep 12, 2013)

I'd concur with line O2 etc, but I'd keep a close watch on that HR. 175 is at the top end of the max for her age and I'd be suspicious of that. Sinus tach is not unusual after a seizure BUT 175 is pretty fast. Id want to see the LOC coming up and the HR going down. She would not be a BLS patient with those vitals.

Do we know any more about PMH, meds, etc... do we have a BGL?


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## Anjel (Sep 12, 2013)

I agree it's an ALS patient. And I would watch her. But It's not something I would consider treating at 175.


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## Handsome Robb (Sep 12, 2013)

rhan101277 said:


> Call comes in as a possible seizure for a patient with seizure hx.  Patient currently is not seizing is alert and breathing.
> 
> Upon arriving at the residence you find the patient lying on the couch.  She seems postictal, a small sign of dried blood is noted on the lower lip.  Pt alert but confused and is grabbing at things, just wondering what things are.  Checking a quick radial pulse you find her skin to be hot and make a mental note of this.  Her radial pulse is very fast.  Pt has nystagmus.  Family denies drug use, denies pt has had any n/v/d, mucus membranes moist.
> 
> ...



rhan, good to have you back! It's been a long time, how've you been buddy??



Pavehawk said:


> I'd concur with line O2 etc, but I'd keep a close watch on that HR. 175 is at the top end of the max for her age and I'd be suspicious of that. Sinus tach is not unusual after a seizure BUT 175 is pretty fast. Id want to see the LOC coming up and the HR going down. She would not be a BLS patient with those vitals.
> 
> Do we know any more about PMH, meds, etc... do we have a BGL?



I agree with this. This seems pretty normal but 175 is definitely fast. This is an ALS patient. Personally, even if my protocol says I can BLS a patient with a Hx of seizures and a "normal" postictal state I don't like being the guy that has to pull over and change places with my partner then dart the patient if it doesn't break on its own or try to get a line. How long does her postictal state usually last? How long did this seizure last? Did she seize more than once? Are her seizures well controlled? Any recent medication changes? Is she compliant with her medications? When was the last time she saw her Neurologist or had bloodwork done? Has she been seizing more often? Also, you say she's "alert and breathing" but acting postictal and confused. Is she A&O? I know it's a crappy way to determine mental status and competency but it is a good way to trend changes. Definitely can get annoying to the patient though  

The end of the OP said "assuming the fluid bolus has no effect on reducing HR?" How long was the transport? If you're a quick 5 minute ride to the ER I wouldn't really expect to see any dramatic changes but if you're with her for 15-30 minutes and she's not improving I'd be looking for something else going on. BGL has been asked for but hasn't been mentioned, I'm going to assume it's not alarming otherwise it probably would've been posted originally. I don't think you'd be wrong for a little versed or preferably ativan if her HR doesn't change in a longer transport time. We have a couple patients around here that can be really violent when they're postictal and they stay that way for a while. I've ended up sedating one of them a couple times because of it. 

One question I do have is you weren't able to get a blood pressure at all throughout the transport? Just moving around too much?


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## mycrofft (Sep 12, 2013)

Auscultate apical pulse. Is it regular, irregular? Does pulse strength vary? Is skin dry, moist, tenting? (Good one on the mucosa).

Where's this nystagmus coming from? (Is it bilateral?). Pupils? Thats CNS. Not that you can address it, but it indicates something's happening in the brainbox, so let the pros with the imaging equipment take a swing at it. R/o  CVA, intracranial TIA, cysticercosis (? h34r: ?), blunt trauma (check for wounds).




I hate relying on layperson/bystander histories of "seizure", especially strangers who characterize anything as "a seizure". Such have turned out to be seizures, assault, coughing jag=> passing out, vasovagal episode after receiving an immunization (pt always passes out), and malingering. Etc.

Personal impression: grasping at things and wondering what they are seems bogus, or there's something really wrong going on here. What is usually lost is recent memory.


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## rhan101277 (Sep 17, 2013)

Checked back on patient and she had sepsis.  The pt also had DT's from alcohol withdraw and it was causing some involuntary shaking which may have also led to increased her body temp.


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## EMT B (Sep 17, 2013)

What was the source of the sepsis


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## rhan101277 (Sep 22, 2013)

EMT B said:


> What was the source of the sepsis



I am not sure, I was not able to get that information.


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## NBFFD2433 (Oct 12, 2013)

DesertEMT66 said:


> A little bit if O2 and pop a line in just incase the patient seizes again. Vitals, Oxygen, Monitor, IV, Transport.
> 
> I'm trained to the EMT level so Medics may do some different things.



I agree.


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