# 22 y/o male c/c seizure



## rhan101277 (Oct 17, 2011)

Call comes in as 22 y/o male seizure.  You arrive at residence to find the pt in a postictal state.  He has no incontinence that you can tell but has a small tongue laceration.  The patient is slow to respond but alert GCS 14.  

Vitals:

B/P: 128/88
Pulse Ox: 100%
RR: 20
HR: 180
CBG: 122

Family reports patient he has a seizure hx but has never been diagnosed.  The pt takes no meds has no allergies.  After getting patient to the truck he comes around and is more coherent to his surroundings, he vomits x 4, emesis bag was grabbed fast enough.  More hx of what transpired throughout the day is gathered.

2 redbulls with in the last hour + 2 cokes
4 Excedrin migraine in the last 8 hours

Pt continues to show rapid heart rate in the truck but it drops to 160's with some calming techniques, vagal maneuvers are not successful.  Heart rate in between vomiting peaks in the 180's.  Pt feels fine.

How do you treat this patient?


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## Handsome Robb (Oct 17, 2011)

SVT on the monitor I'm assuming? Any ectopy present? Any complaint of chest pain/tightness/palpitations? What does his skin look like? What does his vomit look like? How long has he been having these undiagnosed seizures and how frequent? Has he seen a doctor for it? What type of seizure are we talking about (grand mal, tonic clonic, ect) how did the family describe the seizure activity? Is there any history in his family of seizure disorders besides his own? Does there seem to be a consistent trigger to these seizures or are they random? What was the pt doing before the onset? How long did the seizure last? Why the excessive caffeine intake? Has he been sick recently? Narcotic/drug/ETOH use admitted/suspected?

Reoccurring seizures aren't something to mess around with he needs to be seen. I'd get a line TKO then give him some phenergan or zofran, whatever is your favorite flavor. Phenergan seems to work better to control active vomiting from what I have read. Give him another emesis bag to keep the truck clean. Have some midazolam ready incase he decides to seize again. Depending on my transport time I might call for orders for adenosine but if I'm pretty close to the ER I'd hold off and let them convert his rhythm in the controlled environment of the ED.


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## Aidey (Oct 17, 2011)

It is only SVT in the sense that sinus tachycardia is a supra ventricular rhythm. The kid has had 500ish mg of caffeine in the last several hours. That and the seizure explain his tachycardia. He needs an IV, maybe an anti-emetic and the a little bit of fluids and to be observed. Vomiting post seizure is pretty normal. 

Adenosine won't do crap for him. The caffeine just needs to wear off.


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## Handsome Robb (Oct 17, 2011)

Aidey said:


> Adenosine won't do crap for him. The caffeine just needs to wear off.



I thought that might be the case. :glare: I was good up until that point.


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## Fish (Oct 18, 2011)

I bet this isn't SVT, let that Caffine wear off. Keep this kid calm and tell him to lay off the juju juice next time. 

NVROB, you have to call for an Adenosine Order? What is your protocols for SVT?

And just as an FYI, Sync Cardioversion isn't as dangerous as you might think. The odds of someone arresting during it are something in the 1:1,000

Give this kid an anti-emetic, and some Ativan!!!!!! Take his earlobes in between you index finger and thumb and gently whisper "whoo sah" over and over.


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## Handsome Robb (Oct 18, 2011)

Fish we only have to call if they are asymptomatic and we have a long transport time. If symptoms are present we don't have to call. If they are alert to verbal we go 6/12/12 if not they get cardioverted right off the bat.

There are very few things we have to call for here.


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## Fish (Oct 18, 2011)

NVRob said:


> Fish we only have to call if they are asymptomatic and we have a long transport time. If symptoms are present we don't have to call. If they are alert to verbal we go 6/12/12 if not they get cardioverted right off the bat.
> 
> There are very few things we have to call for here.



Hmmmmm, they make you wait for them to be symptomatic before it becomes a standing order?

I know some systems skip the first 6 since it rarely works, I have never worked in a system like this. But I hear they have good success.


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## Handsome Robb (Oct 18, 2011)

Fish said:


> Hmmmmm, they make you wait for them to be symptomatic before it becomes a standing order?
> 
> I know some systems skip the first 6 since it rarely works, I have never worked in a system like this. But I hear they have good success.



Considering 99% of our transports are <10 minutes is the reason I was told.

Symptomatic is chest pain, ALOC, SBP <90, cap refill >2 seconds, SOB. It isn't hard for us to justify much of what we do and we are allowed to deviate if we can justify why we did it.


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## truetiger (Oct 18, 2011)

In a situation such as this....a diltiazem drip would probably be your best bet. A chemical or electrical cardioversion is not likely going to fix the problem because the underlying cause is still present.


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## Aidey (Oct 18, 2011)

Diltiazem? For unsymptomatic tachycardia very likely caused by ingesting a large amount of caffeine. Why on earth would you do that?


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## rhan101277 (Oct 18, 2011)

I did 18ga TKO with 1,000cc bag NS.

4mg zofran which did subside the vomiting.

Monitored rhythm/rate, upon ER arrival rate was down to 130.  I was thinking this was most likely medication effect and using adenosine would result in the rate just coming back.  Since the sympathetic system is increased the SA node firing.  Normal firing rate is 60-100, but max heart rate is 220-age.  You can still have max heart rate and it just be sinus tach.

We have standing orders for conversion of stable SVT, but this was sinus tach.  If I could not have gotten it to slow down w/ coaching and 5 minutes of time then I would have considered it and even though standing orders I would have contacted med control for a second opinion in this case.


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## truetiger (Oct 18, 2011)

Sorry, I was adding to the adenosine/cardioversion conversation. Wasn't advocating giving it to that patient.


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## Fish (Oct 18, 2011)

truetiger said:


> In a situation such as this....a diltiazem drip would probably be your best bet. A chemical or electrical cardioversion is not likely going to fix the problem because the underlying cause is still present.



I am going to respectfully disagree, this guy needs no Meds in my opinion except for Zofran and a very Mild anti anxiety/sedative like Ativan. Treating his tachycardia Is the wrong treatment path in my opinion, let the caffine wear off. This guy is in no danger.


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## truetiger (Oct 18, 2011)

I guess you missed my last post...


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## Fish (Oct 18, 2011)

truetiger said:


> I guess you missed my last post...



I didn't see it


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## truetiger (Oct 18, 2011)

No worries....it happens


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