# BLS Seizure?



## Hastings (Mar 31, 2010)

Is it ever possible to have a BLS Seizure?

Does every seizure patient require an IV?


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## medicdan (Mar 31, 2010)

Does every seizure require a transport? A known epileptic, either in the process of tweaking drug dosages, or with reasonable expectation to rebuild therapeutic dosage, fully A&O, able to take care of self, etc, will you get a refusal? Can a BLS truck get a refusal? Who should they consult?


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## Veneficus (Mar 31, 2010)

Hastings said:


> Is it ever possible to have a BLS Seizure?




Sure, bagging a respiratory arrest is BLS.



Hastings said:


> Does every seizure patient require an IV?



no


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## eveningsky339 (Mar 31, 2010)

My ambulance service does not operate BLS trucks; it's all ALS with a medic/EMT crew.  But, there is a service not too far from us that is certified *up to* the paramedic level, but usually runs at the intermediate life support level.

Or something.

Anyway, I'm certain it's different with intermediate life support, but if they encounter a seizure patient that requires intervention beyond the intermediate level, they call a medic truck.  ALS checks the patient out, and if they are good to go with just a transport, ALS goes home and the patient is transported in the intermediate truck.


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## WolfmanHarris (Mar 31, 2010)

Is the patient still actively seizing?
Ideally a patient who has been seizing would have a ALS available to start a line or saline lock in a post-ictal patient as a route for midazolam if they begin to seize again, but I'm not going to call for ACP intercept or back-up on every reported seizure automatically. This is where the assessment, history and probable cause of the seizure comes into play.

Also look at transport time and expected response time for ALS arrival. If it will be delayed and you have reason to suspect that follow-up seizures are a possibility then get ALS rolling as the longer a pt. is in status the less effective midazolam will be and they may not be able to be brought out.
With this in mind, do not unecessairly delay transport awaiting ALS, as the actively seizing patient is going to need ventilatory support AND is likely going to be extremely difficult to ventilate, meaning your risk for complications is going to increase the longer you're with them. If seizure activity is prolonged (thus making effective midazolam unlikely) and you're service does not have RSI as an option (which Ontario does not for ACP), then rapid transport becomes even more important as your ability to stop the seizure has been lost AND your ability to manage the airway is compromised.

To find where I've parroted most of this, check out:
 CEPCP Self-Study Package 

This is a recent review package we received as part of our CME requirements. So it's all fresh in my mind. Great little dozen page review on seizures. And if you go exploring you'll find another good package on syncope from last year. (Older packages are unfortunately not posted - Scratch that, just checked and they've added quite a few)


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## LucidResq (Mar 31, 2010)

emt.dan said:


> Does every seizure require a transport? A known epileptic, either in the process of tweaking drug dosages, or with reasonable expectation to rebuild therapeutic dosage, fully A&O, able to take care of self, etc, will you get a refusal? Can a BLS truck get a refusal? Who should they consult?



If I'm having a known epileptic that's just had a "typical" seizure for them refuse transport, I want everything you mention plus a responsible, concerned party that will be with them constantly. 

I say this as a daughter of an epileptic. My father was allowed to refuse transport once after seizing in a grocery store while I was in school. He went home alone, seized again, and ended up with a gnarly scalp lac & needed sutures. I think he's lucky that's all that happened.


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## DrParasite (Mar 31, 2010)

in my system, a report of a seizure is a bls call and bls dispatch.  they are treated with the same acuity as toe pain.

a status ep (continuous seizure) complain, or one of multiple seizures is treated as ALS.

but if someone calls 911 saying their friend is seizing, and if they stop shaking before the 911 call screening is completed, then it's the same as toe pain.  of course, if they start seizing again, it gets treated as multiple seizures, and upgraded to ALS


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## Veneficus (Mar 31, 2010)

DrParasite said:


> in my system, a report of a seizure is a bls call and bls dispatch.  they are treated with the same acuity as toe pain.
> 
> a status ep (continuous seizure) complain, or one of multiple seizures is treated as ALS.
> 
> but if someone calls 911 saying their friend is seizing, and if they stop shaking before the 911 call screening is completed, then it's the same as toe pain.  of course, if they start seizing again, it gets treated as multiple seizures, and upgraded to ALS



No upgrade for first time seizing or age criteria?


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## DrParasite (Mar 31, 2010)

nope.  in fact, my former hospital did a study that said most prehospital pediatric seizures are non-life-threatening, and didn't require an ICU stay.

I would have thought most first time seizures would be ALS, but people with more education and experience than me  (Medical Director and other MDs) would think otherwise.


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## Veneficus (Mar 31, 2010)

DrParasite said:


> nope.  in fact, my former hospital did a study that said most prehospital pediatric seizures are non-life-threatening, and didn't require an ICU stay.
> 
> I would have thought most first time seizures would be ALS, but people with more education and experience than me  (Medical Director and other MDs) would think otherwise.



But what about a 70 y/o having a first time seizure?

In Peds, seizures are often discharged home with rectal benzo rx. (safe enough to be used by parents) 

Truthfully, in my experience the report of a seizure often turns out to be erroneous, but classified with toe pain, might under estimate its potential in the rare cases where it is a sign of serious underlying problem. (like a ruptured aneurysm from congenital A/V malformation or a stroke)

I guess it fails my "how would I like to explain this on the evening news" test.

I didn't see the Med director for Pittsburg defending their system on TV.


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## NJmedic3250 (Mar 31, 2010)

DrParasite said:


> nope.  in fact, my former hospital did a study that said most prehospital pediatric seizures are non-life-threatening, and didn't require an ICU stay.
> 
> I would have thought most first time seizures would be ALS, but people with more education and experience than me  (Medical Director and other MDs) would think otherwise.



In the state of New Jersey stat ep and FIRST TIME SEIZURES are worked up by ALS (O2, IV, cardiac monitor, BGL, and lorazepam if seizures are reoccurring). Also I would say your statement about pediatric seizures is partially correct. Febrile seizures, for example, are associated with a significantly low mortality rate. However, that is not saying a child that is seizing from another etiology cannot die. Unaddressed hypoglycemia and chemical toxicity can kill a child. What a seizure patient does need, is a thorough physical exam and accurate history taking. Both can be performed by BLS. If the patient has been actively seizing for greater than 5 min non stop or has had back to back seizures with no lucid period, he or she requires ALS intervention.


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## Hastings (Mar 31, 2010)

Long story short, to my shock, I discovered yesterday that our protocols say that every patient requires an IV. Can't say I agree.

Thanks for the responses.


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## DrParasite (Mar 31, 2010)

Veneficus said:


> Truthfully, in my experience the report of a seizure often turns out to be erroneous, but classified with toe pain, might under estimate its potential in the rare cases where it is a sign of serious underlying problem. (like a ruptured aneurysm from congenital A/V malformation or a stroke)


you misunderstand.  it doesn't get classified as toe pain, but seizures are treated as a low priority call.  I don't necessarily agree with it, but it is how my medical director has directed us to prioritize calls.


NJmedic3250 said:


> In the state of New Jersey stat ep and FIRST TIME SEIZURES are worked up by ALS (O2, IV, cardiac monitor, BGL, and lorazepam if seizures are reoccurring).


not everywhere in NJ for first time seizures.  and not only that, but first time seizures aren't a criteria for an ALS dispatch in all parts of the state.  If you want to get further info, PM me which system work for, and I will tell you mine, and we can compare notes.  But remember, I just follow the rules, I don't make them.


NJmedic3250 said:


> Also I would say your statement about pediatric seizures is partially correct. Febrile seizures, for example, are associated with a significantly low mortality rate. However, that is not saying a child that is seizing from another etiology cannot die. Unaddressed hypoglycemia and chemical toxicity can kill a child.


not disagreeing with you at all.  however, in YOUR experience, how many pediatric seizures were life threatening?  I can think of only one, and that was after the kid when head first into a tree.  the majority of time (which we deal with when it comes to dispatching), it's a non-life threatening emergency.


NJmedic3250 said:


> What a seizure patient does need, is a thorough physical exam and accurate history taking. Both can be performed by BLS. If the patient has been actively seizing for greater than 5 min non stop or has had back to back seizures with no lucid period, he or she requires ALS intervention.


which is why I said multiple seizures or status ep (which is exactly what you stated) are ALS dispatches


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## NJmedic3250 (Mar 31, 2010)

Hastings said:


> Long story short, to my shock, I discovered yesterday that our protocols say that every patient requires an IV. Can't say I agree.
> 
> Thanks for the responses.



Nor do I agree...


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## Veneficus (Mar 31, 2010)

DrParasite said:


> you misunderstand.  it doesn't get classified as toe pain, but seizures are treated as a low priority call.  I don't necessarily agree with it, but it is how my medical director has directed us to prioritize calls.



Yea I got it, a low priority call. (similar to toe pain  ) 

Has the medical director actually directed calls to be prioritized that way, or has he simply signed off on a commercial dispatch system?

@Njmedic,

I do not think that a Basic in any state, without some kind of education outside the EMT-B curriculum is capable of a proper PE and HX. 

Anatomy, physiology, pathophysiology, and exam techniques are just not covered in a way to allow/promote proper identification of emergent or life threatening conditions outside of something grossly apparent.

While I admit that many conditions cannot be managed even by ALS level EMS, I have noticed, especially in forum, many basics do not even realize when they are in over their head. Not for their lack of personal capability but for the failure of the "skills based" instructional methods.

Looking through the recent Brady text, *the only endocrine disorder* I can find is diabetes Mellitus. It is not even the only form of diabetes that can be life threatening. How can a basic provider possibly notice something more insideous to transport or call for help prior to the condition progressing to something grossly apparent?


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## MrBrown (Mar 31, 2010)

OMG there is no such #*T%*#(%(ING thing as a "BLS" seizure or an "ALS" seizure or any other kind of "_LS" seizure!

You people are your obsession with BLS vs ALS OMG it makes me so angry it's so painful to keep hearing it, my bleeding ears!

Would a seizure here get an Intensive Care Paramedic? Depends, if it's a known seizure history or one simple seizure that is uncomplicated then no it wouldn't but should it be multiple or unceasing seizures then yes.

In the year or two one of the skills we will probably bring down to Paramedic level (sub-ALS) is midazolam IM and IN for seizures.  Australia already has it in some states.

A patient with a known seizure history who has recovered can be left at home here.


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## NJmedic3250 (Mar 31, 2010)

Veneficus said:


> Yea I got it, a low priority call. (similar to toe pain  )
> 
> Has the medical director actually directed calls to be prioritized that way, or has he simply signed off on a commercial dispatch system?
> 
> ...



Do I think that a prehospital care provider of any level should be able to complete a complete PE and accurate HX? Absolutely! Is it a reality? Absolutely not. I should clarify that I do not expect basics to diagnose. But identifying a febrile seizure vs etiology "x" can be done without diagnostic equipment. Also, if BLS is even questioning to transport or call for help, you can never be faulted for just going ahead and transporting to an appropriate facility. The ED is ALS also...


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## NJmedic3250 (Mar 31, 2010)

MrBrown said:


> OMG there is no such #*T%*#(%(ING thing as a "BLS" seizure or an "ALS" seizure or any other kind of "_LS" seizure!
> 
> You people are your obsession with BLS vs ALS OMG it makes me so angry it's so painful to keep hearing it, my bleeding ears!
> 
> ...



Haha.. very effective way to put an end to this thread.


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## DrParasite (Mar 31, 2010)

Veneficus said:


> Has the medical director actually directed calls to be prioritized that way, or has he simply signed off on a commercial dispatch system?


directed calls to be that way.  commercial dispatch says one thing, but there are two areas (seizures being one of them) where the MD changed to what he felt to be more appropriate.  Again, it's above my training and pay grade, but that was what he decided.


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## Hastings (Apr 1, 2010)

MrBrown said:


> OMG there is no such #*T%*#(%(ING thing as a "BLS" seizure or an "ALS" seizure or any other kind of "_LS" seizure!
> 
> You people are your obsession with BLS vs ALS OMG it makes me so angry it's so painful to keep hearing it, my bleeding ears!
> 
> ...



You seem a bit passive aggressive. That overreaction was remarkable.

I'll rephrase in order to avoid another outburst. Does every seizure patient require an IV?


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## MrBrown (Apr 1, 2010)

Hastings said:


> You seem a bit passive aggressive. That overreaction was remarkable.
> 
> I'll rephrase in order to avoid another outburst. Does every seizure patient require an IV?



Remarkable, no.  IV on every seizure, no.


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## boingo (Apr 1, 2010)

MrBrown said:


> OMG there is no such #*T%*#(%(ING thing as a "BLS" seizure or an "ALS" seizure or any other kind of "_LS" seizure!
> 
> You people are your obsession with BLS vs ALS OMG it makes me so angry it's so painful to keep hearing it, my bleeding ears!
> 
> ...



FWIW, your angst regarding BLS v.s. ALS is a bit misplaced, it seems you have a varying level of prehospital providers as well, no?  Your choice of words differs, but essentially its the same, BLS level providers operate at a lower level and skillset than ALS, you can call it Intensive Care Paramedic, Basic Care Paramedic, Critical Care Paramedic, or whatever you like.


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## MrBrown (Apr 1, 2010)

boingo said:


> FWIW, your angst regarding BLS v.s. ALS is a bit misplaced, it seems you have a varying level of prehospital providers as well, no?
> 
> 
> 
> ...


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## Hastings (Apr 2, 2010)

I am so depressed with what people STILL continue to do with the most basic of threads. It's why I got completely turned off and left in the first place. Most of the time, when someone brings up the terms "BLS" or "ALS" they aren't trying to start some philosophical discussion. It's simply a division in what procedures are required. An IV in many locations is considered an ALS procedure. Thus, starting an IV would make that call an ALS call. If you're just transporting with vitals, that would be considered a BLS call.

P.S. The man who posted this thread is from America. Don't go on a tirade about some New Zealand way of doing things (in the context of how any other way is ridiculous).


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## Hastings (Apr 2, 2010)

On a serious note, this place hasn't changed much. I return after a lengthy time away only to come back and have someone start an unprovoked argument about BLS/ALS in a thread that asked a question as simple as "do all seizure patients require an IV?"

I hope you're drawing in a ton of new members, because I imagine the turnover must be as devastating now as it was back when I was a new medic attempting to learn how to become better (and watching everyone with similar intent getting derailed and degraded in the same manner as above).


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## MMiz (Apr 2, 2010)

Hastings said:


> On a serious note, this place hasn't changed much. I return after a lengthy time away only to come back and have someone start an unprovoked argument about BLS/ALS in a thread that asked a question as simple as "do all seizure patients require an IV?"
> 
> I hope you're drawing in a ton of new members, because I imagine the turnover must be as devastating now as it was back when I was a new medic attempting to learn how to become better (and watching everyone with similar intent getting derailed and degraded in the same manner as above).


Your post has been moved back where it belongs.  If you find MrBrown's posts condescending, I'd have to agree.  I have to admit that these days I rarely read his posts because of it.

This is an online discussion forum, where every member is an expert, and every post is sure to offend half of the community's membership.  Welcome back to EMTLife!


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## usafmedic45 (Apr 2, 2010)

> This is an online discussion forum, where every member is an expert, and every post is sure to offend half of the community's membership. Welcome back to EMTLife!



Well said Matt.


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## Aidey (Apr 2, 2010)

Do I start an IV on every single seizure patient? No, I do not. It completely depends on the situation. Do I transport every single seizure patient? Again, no, it depends on the situation. 

Generally first time seizures and seizures in patients with suspected drug/medication ingestion always get an IV.  Also seizures in the presence of another medical condition, like sepsis, hypoxia, hypoglycemia or trauma (Hopefully that didn't need to be specified). 

With patients who have a history of seizures I will usually start an IV if the following circumstances apply. 

1. They have not had a seizure for an extended period of time.
2. They have had a recent medication change, and take one of the meds where levels can be checked, like Depakote or Dilantin. In that case the IV is more for the labs than actual IV access. 
3. The pt has a history of status seizures, or a history of cluster seizures (ie, they never only seize once). 


Legally, anyone who can answer the questions and isn't a threat to themselves or someone else can refuse, so yes, not all seizure pts get transported. If the patient has a known history of seizures I am more likely to spend a little extra time on scene waiting for their postictal period to lapse so I can speak with them and find out what they want. If their postictal period is sustained we will transport.  Also, if someone who knows the pt is on scene and telling us something is different we'll go ahead and transport without waiting for the pt to come to. 

I have occasionally gotten permission to not transport known seizure patients who are still postictal but are in the care of their parent/spouse/caregiver/whatever. However, I have only ever done that when the parent/spouse/caregiver is requesting no transport.


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## Hastings (Apr 3, 2010)

I'll give you the basic scenario. Get called Priority 1 for a 25 y/o male, had a seizure in the shower, door to bathroom locked. Downgraded to priority 3 by FD on scene. Arrive on scene to find the patient sitting on the couch. Awake, alert, oriented. Pt states he has had idiopathic seizures for 10 years, states they last no more than 5-10 seconds, used to be controlled by medications but he can no longer afford them. So the patient has a seizure while having this shower, came out of it, finished the shower, got dressed, opened the locked door, and was going about his chores when FD arrived. Pt isn't injured and has no complaints. Pt didn't necessarily believe he needed to go to the hospital, but we told him we'd be happy to take him in to talk to someone about getting the medication that he needs. He agrees, is ambulatory to ambulance and into the ER. I did not start an IV. The nurse was furious.


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## Melclin (Apr 3, 2010)

IM midaz works pretty much just as well as a first line invention as I understand it. If he had a seizure without an IV in, terminate it with IM midaz. Problem solved. 

IN is another option.


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## MrBrown (Apr 3, 2010)

Hastings said:


> ... I did not start an IV. The nurse was furious.



Did she say why at all?


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## Stew (Apr 3, 2010)

Hastings, I wouldn't have gained IV access if it were me. What is the point? Fully conscious and alert, nil reversible causes found on examination which would require an IV treatment, transporting for more of a 'social' reason (info regarding medication availability).
From my current protocols I'd only be permitted to administer IM midazolam if he started again anyway.

edit- answer to the original question, no. Not all of my seizure patients get an IV.


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## reaper (Apr 3, 2010)

Remember one thing. You don't work for the Nurse. Let her be furious all day long. You make your own decisions on scene. I cannot stand any medic that starts a line on a pt, just because they are afraid the nurses will yell, if they don't.

I start Iv's because I need them. I do not start courtesy Iv's for the Nurses.


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## Aidey (Apr 4, 2010)

reaper said:


> I start Iv's because I need them. I do not start courtesy Iv's for the Nurses.



I agree. We don't carry IV locks, which is primarily what the hospitals like to have. When I start an IV it is because either I anticipate needing it, or I anticipate that the pt will receive IV meds very soon after arriving at the hospital. For example, and asthma pt who is probably going to get IV steroids. 

I've actually not done IVs on some patients who I know will get one at the hospital on purpose. Namely, patients who I have a very very strong suspicion they will be doing blood cultures on. If I start an IV they have to poke the patient a second time since they can't draw cultures off an existing IV. Why subject the pt to multiple IV sticks when I won't be using the IV myself?


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## MDewell (Apr 5, 2010)

reaper said:


> ...I do not start courtesy Iv's for the Nurses.



I was going to say something to this affect after reading the thread, but I was beaten to it. 

That reminds me..I can tell you from horror stories around here that nursing home nurses will tend to call for an ambulance for patient who's not responsive, and when the crew arrives, finds the patient had to have been gone for awhile. Turns out, nurses around here do this so they don't have to do the paperwork...they leave it to someone else. I wonder how often that happens around the world.

Didn't mean to hijack the thread for a second...I'll scurry back off to my world.

Great thread BTW.


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