# Siezure patient assessment ?



## rhan101277 (Aug 17, 2010)

Your patient is a 22 y/o female who just finished having a grand mal seizure.  She has not had any other seizures during the day, but does take dilantin to control seizures.

You have good breath sounds and normal vitals.  What is the purpose for checking for a gag reflex at this point, besides to let you know your chances on intubating this patient if more seizures happen.  A gag reflex doesn't prevent aspiration of vomit.

I just wanted to get some feedback on other paramedics approach to seizure assessment and treatment, besides the basic stuff like IV, drugs, O2 and cardiac monitor.


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## JPINFV (Aug 17, 2010)

rhan101277 said:


> You have good breath sounds and normal vitals.  What is the purpose for checking for a gag reflex at this point, besides to let you know your chances on intubating this patient if more seizures happen.  A gag reflex doesn't prevent aspiration of vomit.



Off the top of my head, a neuro patient (including seizures) should have cranial nerves checked and gag reflex checks CN IX (afferent limb) and CN X (efferent limb).


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## Aidey (Aug 17, 2010)

If I'm going to check the gag reflex, it isn't going to be something I'm going to do while the pt is still out. The pt needs to be alert enough to know what is going on.

Also, current gag reflex doesn't really affect my chances of intubating if there are additional seizures. Because 1. They are going to get benzos way before we get to intubation and 2. If they need intubation it is likely because they are in status seizure, and thus they will need RSI.


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## rhan101277 (Aug 17, 2010)

Yeah we can't RSI here at all.  You can use DAI with benzo's, which includes a 2-4mg Versed IVP, then continued drug administration for sedation.

Never tried it, some say it works ok, others say it doesn't do enough to suppress gag reflex or help with trismus.

I forgot to put in the above scenario that she is current left lateral recumbent and postictal and you are in route to ER.


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## Melclin (Aug 17, 2010)

rhan101277 said:


> Yeah we can't RSI here at all.  You can use DAI with benzo's, which includes a 2-4mg Versed IVP, then continued drug administration for sedation.
> 
> Never tried it, some say it works ok, others say it doesn't do enough to suppress gag reflex or help with trismus.
> 
> I forgot to put in the above scenario that she is current left lateral recumbent and postictal and you are in route to ER.



2-4mg is very conservative. Not empowering paramedics with adequate drugs/dosages actually causes more harm than good.


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## abckidsmom (Aug 18, 2010)

Assessment-wise, I would document the movements of her seizure (rhythmic jerking of primarily left side, or upper extremities, or whatever), any facial abnormalities during or after the seizure, and her behavior while post-ictal.

Document her meds, her dose and her compliance, if that information is available.  Any alcohol/drugs?  Any recent trauma?  Any trauma with this seizure?  

I would carefully watch her airway and consider an NPA.

I would pad the siderails of the cot, and make sure that all seatbelts of the stretcher were in use.  I'd probably put her in a semi-fowler's position instead of lateral recumbant because it's just more stable of a ride.  People in lateral recumbant positions can scootch off one side or another more easily than those laying flat with the head elevated.


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## Aidey (Aug 18, 2010)

^^^ I have a problem with RL recumbent in my amb because we don't have a CPR seat...if the pt is facing R, I can't see their face.


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## MSDeltaFlt (Aug 18, 2010)

rhan101277 said:


> Your patient is a 22 y/o female who just finished having a grand mal seizure. She has not had any other seizures during the day, but does take dilantin to control seizures.
> 
> You have good breath sounds and normal vitals. What is the purpose for checking for a gag reflex at this point, besides to let you know your chances on intubating this patient if more seizures happen. A gag reflex doesn't prevent aspiration of vomit.
> 
> I just wanted to get some feedback on other paramedics approach to seizure assessment and treatment, besides the basic stuff like IV, drugs, O2 and cardiac monitor.


 
How long did the seizure last?  How violent was it?  Anti-sizure medications won't stop all seizures all the time.  They're primarily designed to stop status epilepticus.  

Get the line on them.  If they have another seizure, give them benzos and titrate to effect with VS.  Outside of that, monitor them closely when they go postictle.  THAT's when their resp and airway will compromise.  

Also be aware that, as they're coming out of the seizure in their postictle state, they may be just alert enough to be scared sh*tless as they shake the cobb webbs out of their heads.  Some can be scare, confused, and borderline violent.  So watch yourself.  A calm voice and demeaner can go a long way.


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## terrible one (Aug 18, 2010)

Melclin said:


> 2-4mg is very conservative. Not empowering paramedics with adequate drugs/dosages actually causes more harm than good.




Would you mind ellaborating on that at all. I've heard this before but not the reason why. Thanks.


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## Sam Adams (Aug 18, 2010)

I'm not going to be checking the gag reflex of a patient who is postictal and who has good vital signs. Vomiting patients is something I try to avoid, especially when they're altered or postictal. What happens if/ when you're patient decides to start seizing again. Now you have an airway filled with gastric contents. With that said, all bets are off when there are signs of hypoxia...


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## socalmedic (Aug 18, 2010)

for Drug Assisted Intubation i was taught 5mg versed and 10mg morphine. we dont have a protocol, but other medics tell me if you have a good reason for wanting to intubate the MD will usually give you the order. man I wish we had RSI in the field instead of waiting for the airship. 

anyway for the Sz, i would monitor, semi fowlers, IV enroute, O2 as needed.


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## FLEMTP (Aug 18, 2010)

Im a little confused... how are you people checking a gag reflex on patients? You can check a gag without ever going near the mouth....a little bit of education goes a LONG LONG way...


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## Smash (Aug 18, 2010)

terrible one said:


> Would you mind ellaborating on that at all. I've heard this before but not the reason why. Thanks.



Well, in terms of drug assisted intubations, 2-4mg of versed is unlikely to obtund the patient enough to remove airway reflexes or trismus.  If you do give enough versed to ovecome airway reflexes, it is almost guaranteed that you will eliminate their respiratory drive and their blood pressure.  Or, it is quite possible that you eliminate BP and resps _without_ depressing airway reflexes enough to intubate.

Therefore, the paramedic is left with some undesirable options:  Either 1) not intubate a patient that needs intubated.  2) Give an inadequate amount of a drug to achieve intubation and then be forced to either try to force a tube down, or again, not intubate. Or 3) give a large amount of an inappropriate drug to eliminate airway reflexes and cause lots of undesireable side effects like profound hypotension, respiratory depression or arrest, and then potentially exacerbate whatever problems the patient had in the first place.

Whereas, if a medical director trusts is medics (because he has ensured high quality patient care, good QA/QI and ongoing continuing education and reaccreditation for example), he/she gives them proper RSI and allows them to manage airways appropriately.  Or, I suppose, he doesn't trust them and gets rid of intuation entirely.  By giving them a half and half option like 2-4mg of versed he does no good to anyone, least of all the patients.

In my opinion drug assisted intubations shouldn't be happening, especially in conditions like head injury.


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