# Status seizure



## zzyzx (Aug 16, 2016)

You are called to a psyche facility for a patient who has had multiple seizures. The patient is a 50 y/o female on a 14-day hold and has a history of paranoid schizophrenia. As you walk in, the patient is actively seizing. Staff is available for any questions you may have.


----------



## NomadicMedic (Aug 16, 2016)

Full history? Current meds? History of recent trauma? Is she detoxing? What have they given her? Blood sugar?


----------



## ERDoc (Aug 16, 2016)

How many days has she been here?  What medications were stopped when she checked-in?


----------



## NysEms2117 (Aug 16, 2016)

@DEmedic just trying to learn here, i have very little idea but could you explain detoxing's link with seizures a bit?  thank you.


----------



## gotbeerz001 (Aug 16, 2016)

Seizures are a symptom associated with withdrawals. 


Sent from my iPhone using Tapatalk


----------



## zzyzx (Aug 17, 2016)

No vitals available since she is seizing.

Blood glucose: WNL

 A mental health worker tells you that just yesterday she began getting an increased dose of Risperdal. She has been there a week and no meds were stopped. She is a paranoid schizophrenic and has not been eating much because she thinks the staff is trying to poison her, though the tech says that he observed her drinking a lot. She also has recently been given a nicotine patch. He does not believe she could have ingested any other drugs because their patients don't have access to any medications.

No other medical history, and no history of epilepsy.

No recent trauma.

The mental health worker states that she has no history of alcohol abuse.


----------



## Akulahawk (Aug 17, 2016)

zzyzx said:


> No vitals available since she is seizing.
> 
> Blood glucose: WNL
> 
> ...


How much water?


----------



## NomadicMedic (Aug 17, 2016)

Akulahawk said:


> How much water?



That's a great question. Hyponatremia, leading to seizure?

Risperidone ius known to lower the seizure threshold so we're gonna need to get some benzo on board, othersie we'll just stand here all day and watch seizures. My only option at my current service is Versed. Let's start there and get some vitals.


----------



## zzyzx (Aug 18, 2016)

The tech says, "Yeah she was always at the drinking fountain. So weird!"


----------



## zzyzx (Aug 18, 2016)

A supervisor comes in and tells you that she was supposed to be on fluid restrictions. He states that the patient on a previous stay had to be taken to the ER and was hyponatremic."

Now that you can be fairly certain that the patient is hyponatremic due, what would you like to do? she is still seizing. 

Interestingly I had once been told by a doc that he thought psychogenic polydipsia induced hyponatremic seizures dont exist considering all the water you would have to drink, but apparently it does because this was my patient the other day! Perhaps her fasting was a contributing factor, or perhaps there were other factors.


----------



## NomadicMedic (Aug 18, 2016)

She needs the seizures controlled and needs hypertonic fluid. Benzos to start, then supportive care until we get to the ED. Monitor all the way. Manage any acute events as they happen.


----------



## VFlutter (Aug 18, 2016)

DEmedic said:


> She needs the seizures controlled and needs hypertonic fluid. Benzos to start, then supportive care until we get to the ED. Monitor all the way. Manage any acute events as they happen.



1L 3% Saline bolus STAT, what is the worst that can happen? I have only seen CPM/ODS once in a patient that was overly corrected at an outside hospital. Not something to take lightly.


----------



## ERDoc (Aug 18, 2016)

It absolutely does exist.  Although not from psychogenic polydypsia, does everyone remember the "hold you pee for a wii" contest?  Same idea, just lacking the psychiatric diagnosis.


----------



## NomadicMedic (Aug 18, 2016)

Chase said:


> 1L 3% Saline bolus STAT, what is the worst that can happen? I have only seen CPM/ODS once in a patient that was overly corrected at an outside hospital. Not something to take lightly.



I don't know any medic units that carry 3% saline. 

So, stop seizure, put patient in truck, drive patient to place where there is hypertonic fluid. If patient attempts to due during the driving portion of the program, use paramagic to prevent death if possible.


----------



## zzyzx (Aug 19, 2016)

You dont have any hypertonic saline on your ambulance. The seizures are refractory to your benzos. You are 45 minutes from an ER. What can you do?


----------



## NomadicMedic (Aug 19, 2016)




----------



## ERDoc (Aug 19, 2016)

DEmedic said:


> View attachment 2944


----------



## VFlutter (Aug 19, 2016)

zzyzx said:


> You dont have any hypertonic saline on your ambulance. The seizures are refractory to your benzos. You are 45 minutes from an ER. What can you do?



Propofol


----------



## zzyzx (Aug 20, 2016)

ER Doc, what would you do if your nurses told you they needed to wait for the pharmacy to bring down the 3% saline? A lot if ERs dont have it stocked.


----------



## Carlos Danger (Aug 20, 2016)

zzyzx said:


> You dont have any hypertonic saline on your ambulance. The seizures are refractory to your benzos. You are 45 minutes from an ER. What can you do?



1. Give more benzos. Literally, keep dosing benzos every couple of minutes until you run out.

2. 1 mg/kg of propofol, if you carry it. 

3. Rocuronium, if your GABA agonists are not working after a few healthy doses, especially assuming that the seizure has been going on for >30 min by now

4. Phenytoin, fosphenytoin, or levitiracetam, if you have access to either of them.

4. A liter of normal saline fairly rapidly and then at a moderate rate, say, 500/hr while transporting.


----------



## ERDoc (Aug 20, 2016)

Since the pt is most likely hypervolemic, a loop diuretic could be used, but by the time it kicks in, you could have the hypertonic saline.  You could try benzos, but they are not likely to help much.  Be careful paralyzing this pt.  You may stop the shaking but that doesn't mean they have stopped seizing.


----------



## NomadicMedic (Aug 20, 2016)

Let's talk about this patient with the typical paramedic/ALS load out. I don't have anything other than benzos.


----------



## RocketMedic (Aug 20, 2016)

Benzodiazipines, more benzodiazipines, and maybe some Ketamine. This patient would end up intubated and sedated, potentially paralyzed as well.

Hyper tonic saline would be nice, but it's 45 minutes away, so let's be driving. Istat would be great.


----------



## zzyzx (Aug 22, 2016)

I'm surprised no one got this. 
There is something most paramedics carry that would work for hyponatremic seizures. It's also in every crash cart.


----------



## Carlos Danger (Aug 22, 2016)

zzyzx said:


> I'm surprised no one got this.
> There is something most paramedics carry that would work for hyponatremic seizures. It's also in every crash cart.



The problem with sodium bicarb is that you are giving A LOT of sodium quickly, which can cause problems pretty much as serious as refractory seizures. I suppose you could give small boluses of it. I'd still rather try to control the seizures using other means and then treat the hyponatremia in a more measured fashion.


----------



## zzyzx (Aug 22, 2016)

Remi said:


> The problem with sodium bicarb is that you are giving A LOT of sodium quickly, which can cause problems pretty much as serious as refractory seizures.


Yes, give it over 5 to 10 minutes like hypertonic saline


----------



## NomadicMedic (Aug 22, 2016)

Well, here's the EMcrit post. Basically, an amp of Sodium Bicarb is equal to 6% sodium, so a bolus dose of 50meq would be the same as a 100ml bolus of 3% saline. 

Interesting. I'd honestly never thought of it, and doubt that I'd ever get orders for it without labs. 

http://emcrit.org/pulmcrit/emergent-treatment-of-hyponatremia-or-elevated-icp-with-bicarb-ampules/


----------



## ERDoc (Aug 23, 2016)

This thread made me go and check our Pyxis and nope, no hypertonic saline.  I would have to agree with DEmedic, without knowing the sodium level, no one is likely to give/order it.  Now, if the ambulance had an istat


----------



## zzyzx (Aug 23, 2016)

Why not just give it based on the history alone? Say there's a marathon going on and you had a healthy young runner with no history of seizures come into the ER actively seizing. If he is refractory to all the treatments done on the ambulance and in the ER, are you going to watch him seize for 30 to 45 minutes waiting for the BMP to come back with a sodium level? 

What is the fear in just giving hypertonic saline (or the sodium bicarb)? Even if turns out that the patient had a normal sodium level, I don't see the downside.


----------



## luke_31 (Aug 23, 2016)

zzyzx said:


> Why not just give it based on the history alone? Say there's a marathon going on and you had a healthy young runner with no history of seizures come into the ER actively seizing. If he is refractory to all the treatments done on the ambulance and in the ER, are you going to watch him seize for 30 to 45 minutes waiting for the BMP to come back with a sodium level?
> 
> What is the fear in just giving hypertonic saline (or the sodium bicarb)? Even if turns out that the patient had a normal sodium level, I don't see the downside.


Messing with the sodium levels is not something to do without lab values. Push the sodium level too high it can kill a patient.


----------



## NomadicMedic (Aug 23, 2016)

zzyzx said:


> A supervisor comes in and tells you that she was supposed to be on fluid restrictions. He states that the patient on a previous stay had to be taken to the ER and was hyponatremic."



Maybe after this, but still... this is probally outside the sphere of understanding of most paramedics. And trying to explain to the doc (or nurse) that Bicarb has the same osmolarity of 6% saline would probally be lost over the med radio. I'd gather that most, if not all, of the ground paramedics in the US would hear, "just get here as quick as you can..."


----------



## zzyzx (Aug 23, 2016)

luke_31 said:


> Messing with the sodium levels is not something to do without lab values. Push the sodium level too high it can kill a patient.



Brain swelling and herniation will kill the patient without treatment.
I understand what you are saying, but with one or two 100 ml boluses of hypertonic saline, or the equivalent in sodium bicarb, is not going to cause osmotic demyelination, especially not in an acute hyponatremia. You are only bumping the sodium levels 2-4 mEq. Likewise, if the patient had a normal sodium level and you were treating a hyponatremia that didn't exist, I don't think you would cause harm.


----------



## Carlos Danger (Aug 23, 2016)

I can assure you that if you were to make a habit of treating serious electrolyte derangements without labs, you would get burned badly before long.


----------



## Akulahawk (Aug 23, 2016)

ERDoc said:


> This thread made me go and check our Pyxis and nope, no hypertonic saline.  I would have to agree with DEmedic, without knowing the sodium level, no one is likely to give/order it.  Now, if the ambulance had an istat


My ER also doesn't have hypertonic saline immediately available, though it is in the hospital (somewhere). Occasionally it would be nice to have an iStat available for some patients.


----------



## zzyzx (Aug 23, 2016)

Remi said:


> I can assure you that if you were to make a habit of treating serious electrolyte derangements without labs, you would get burned badly before long.



LOL. You mean like hyperkalemia?


----------



## luke_31 (Aug 23, 2016)

zzyzx said:


> LOL. You mean like hyperkalemia?


It's not just Na and K to worry about with labs. The labs as a total also speak for what is wrong with the patient. Na and K are just the two that in EMS we are most aware of. Other combinations of abnormal labs can cause similar symptoms that Na shows too.


----------



## Carlos Danger (Aug 24, 2016)

zzyzx said:


> LOL. You mean like hyperkalemia?


I was talking about administering electrolytes based on the assumption that they are low and that you are able to increase serum levels in a controlled fashion with no labs, no IV pump, and probably very little experience with the drugs.


----------



## VentMonkey (Aug 28, 2016)

So since the cat is sorta already outta the bag here, I would like to add my two cents if I may.

The only thing that would stop a hyponatremic seizure is, well, sodium. Kudos to DEMedic btw for the salt tabs pic (didn't even think of it). I don't know that it would even matter how much, or many different Benzo's we could dump in this patient to stop the seizure, most likely it won't. 

I do agree with Rocketmedic's treatment in terms of RSI to further control the airway, and manage at least the over utilization of this patient's skeletal muscles assuming there is continued tonic clonic activity associated with their hyponatremic seizure. 

Hypertonic saline seems to be the definitive treatment assuming we were to prove this in fact was related to sever hyponatremia via an iSTAT, and possibly ECG changes to augment our iSTAT findings, nonetheless, a smooth diesel bolus with proper airway management, and supportive care seems the best course of action for us prehospital providers.


----------



## ERDoc (Aug 29, 2016)

One thing to remember when you RSI a seizure pt is that just because the shaking has stopped, doesn't mean the seizure has.  While the pt looks calm, their brain is still cooking in an electrical storm.


----------



## VentMonkey (Aug 29, 2016)

ERDoc said:


> One thing to remember when you RSI a seizure pt is that just because the shaking has stopped, doesn't mean the seizure has.  While the pt looks calm, their brain is still cooking in an electrical storm.


Excellent reminder, ERDoc. Apologies for not being more specific, but would it stil be a good idea given the fact that I would prefer to stop the over utilization of said patients skeletal muscle activity to prevent further complications? 

Again, remembering to continuously reassess their seizure (pupillary?) activity should it present after administering a paralytic agent.

Another question, some of the docs in my area don't seem very keen on long-acting agents for reasons such as what you've mentioned, which does make sense to me, what are your thoughts?


----------



## Carlos Danger (Aug 29, 2016)

Neuromuscular blockade is an important maneuver if standard measures aren't working. It doesn't stop the seizure of course, but it reduces oxygen consumption, hypercarbia, temperature, and the possibility of complications such as rhabdomyolysis.

If you do intubate a seizure, they need to go to a capable facility with a real ICU and neurology service, and it is critically important that the receiving ED physician understands that you tubed them BECAUSE of seizures refractory to your benzos. Don't let anything get lost in translation.


----------



## ERDoc (Aug 29, 2016)

One you have paralyzed them the only way to know if they are still seizing is to put on an EEG.  For the reasons Remi gave, RSI is not a bad idea just understand you are not truly stopping the seizure activity.  I would use short acting meds.  In a case of hyponatremia it is nice to know if your hypertonic saline is working and from a practical standpoint the only way to do that is to see if they are shaking.  Getting an EEG takes a while, if the hospital even has one.


----------



## VFlutter (Aug 29, 2016)

On a side note, we just got a group of Epileptologists at our hospital and we now do continuous EEGs in the Unit. Pretty cool stuff. It is awesome when you can see the effect of your interventions.


----------



## Akulahawk (Aug 29, 2016)

When I was in nursing school, I did my preceptorship time on a neurocare floor. It's not an ICU by any means but it does very much specialize in seizures. Four of those beds have the capability of having continuous EEG along with either tele-med or an in-house neurologist (just depends where the doc is at the time). We could see the real-time EEG, which was recorded along with in-room AV recording and we actually attempted to drive patients to seize. We've caught many pseudo-seizures that way... In any event, one of the takeaways from that experience is that it's possible to make basically everyone have seizures. One other "benefit" of that experience is that seizures aren't that scary to me when/if my patient seizes. 

Yeah, it is very cool to see the effect of your interventions!


----------

