# Seizure-nario.



## NomadicMedic (Mar 29, 2014)

It's 2030 on a rainy Thursday evening. You respond as a single medic, in a chase car, to a private residence for a reported syncope. The BLS ambulance, with your partner on board, is returning from the hospital and is at least 10 minutes away. A fire department first responder, not an EMT, arrives right behind you and carries your monitor and ALS pack up the stairs for you. Otherwise, you're by yourself for at least the next 10 minutes. 

You arrive at the address and find an old Victorian house, which has been converted into a church on the first floor. The second floor appears to be a boarding house. There are approximately 15 people waiting for you anxiously at the door. All are Haitian, only one speaks broken English.

You are led to the second floor, in a back bedroom. On the floor, you find a Haitian male in his mid-60s. He presents with active focal seizures on his right side, his gaze is deviated up and to the right. His eyes are open, he seems to track you, but cannot speak and has what appear to be effective, rapid respirations and strong radial pulses at about 100. 

Quickly examining the environment, it's surprisingly neat and clean. There is no drug paraphernalia, no alcohol bottles, no prescription drug bottles and nothing that overtly leads you to believe that this was a traumatic injury. 

The one guy who speaks English tells you that the patient was totally normal today. They heard a "thump" and ran upstairs to find him on the floor, in the midst of a seizure. This seizure has not stopped since 911 was called, about 5 minutes ago. He has no significant medical history aside from an infection on his foot. He's being treated by a local podiatrist and his only medications are Tylenol with Codeine and Keflex. No allergies that anyone knows about. 

What would you like?


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## Carlos Danger (Mar 29, 2014)

DEmedic said:


> What would you like?



Monitor / Spo2
IV
Chemistry and a gas if I have an istat 
If no istat, then a BGS 
EKG and capnography when I get to it


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## NomadicMedic (Mar 29, 2014)

Monitor shows sinus tach about 110 with occasional PVCs.

SPO2 is mid 90s, but he's thrashing around pretty good and the probe doesn't really want to stay on. You don't have a good Pleth all the time so you're not sure if that's a real SPO2 or not. 

No ISTAT so no ABG or chem. (remember, you're all by yourself with just the gear you have in an ALS backpack) 

You attempt to get a blood glucose fingerstick three times, but the damn glucometer keeps coming up "E6 error". 

You get a nasal cannula with end tidal capnography on him, and it shows a respiratory rate of 36 and CO2 of 22. The waveform is nonobstructive.

As you place an IV, an 18 gauge in his left AC, he thrashes hard and that IV becomes dislodged. 

You've been there for three or four minutes now… He is still actively seizing


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## Carlos Danger (Mar 29, 2014)

OK then.....

IM Midazolam, or whatever benzo I have, then repeat the assessment and IV once he's no longer thrashing.


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## mycrofft (Mar 29, 2014)

DEmedic said:


> Monitor shows sinus tach about 110 with occasional PVCs.
> 
> _SPO2 is mid 90s, but he's thrashing around pretty good and the probe doesn't really want to stay on_. You _don't have a good Pleth _all the time so you're not sure if that's a real SPO2 or not.
> 
> ...



Throw down the used supplies, stand up and stalk off muttering "How can I be expected to do my best work under these primitive conditions?!".
:angry:​


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## mycrofft (Mar 29, 2014)

PS: sure sounds like a left parieto-temporal intracranial insult of some sort. CVA treatment, while it might not be proven to be specifically correct after the fact, will support life until definitive (non-rolling) care is given after big diagnostics.

I don't see a BP here nor findings of cursory exam of eyes, facial and lingual symmetry. Continence? Bitten buccal lining? 

Benzo protocol, O2 if clinically indicated (resps decrease and or cyanosis), try for a _right side_ IV after splinting the arm from humerus to wrist, maintain airway and scene safety PRN, prepare for transport (have residents clear the way and post someone out front to direct them in).

ZEBRA ALERT: Coming from Haiti, this could even be cystercircosis of the brain. Of no use to the responders, but, hey...


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## VFlutter (Mar 29, 2014)

Gaze preference can be very suggestive however is not definitive. In seizure you usually see a ipsilateral gaze deviation or preference whereas stroke usually produces Contralateral. Ie. left sided weakness with left gaze deviation is suggestive of seizure w/ Todd's paralysis instead of stroke where you would expect to see left weakness and right deviation.


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## Handsome Robb (Mar 29, 2014)

I'm going to give him midazolam IN or IM, whichever you prefer. Repeated PRN. Since they're focal seizures I don't see why we can't get a pressure off the left arm. Ask your partner to bring in their glucometer, off chance does the FD guy have one on his rig that he brought? Might be a possibility...

I would think if this is a bleed with a rightward gaze would't the seizure activity be on the left side of the body if not grand mal? 

Not a lot we can do until we control the seizure activity and get a transport unit. 

Hypocapnea can cause seizures...but I'm thinking that it's secondary to the seizures however it is something to consider. If we can break the seizure activity and he's ok with his airway I'm going to leave it alone but once we get to status seizures if his airway starts to go or he's not ventilating adequately we're going to have to do something. Almost one of those patients  that you might want to withhold post intubation paralysis if it's possible in order to monitor for further seizure activity. 

It's a pediatric study, and they all were epileptic...but here ya go.

http://www.ncbi.nlm.nih.gov/pubmed/8617175

Also, if we have ativan lets use that instead.


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## MonkeyArrow (Mar 29, 2014)

As stated above, go with your anti-convulsant of choice. Secure the airway with an adjunct. As to the cause, I don't know if the background info is something of merit but judging by the fact that we are in the future (why is this relevant?) and that we are in an older victorian house, I am instantly thinking a rundown type house. Also, the fact that they are all of another ethnicity and all board in a second floor convert might indicate a human smuggling/drug smuggling where the pt. is malnourished or has taken some tainted drugs. 

The only reason why I even thought of and mentioned this is because of the detailed paragraph with the first floor being a church, 15 haitians, etc. (why else would all that matter. Heck, it probably doesn't but......)


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## mycrofft (Mar 29, 2014)

An early_ bleed_ or old scars in the brain will act as a focus for hyperactivity, while an embolic _infarct_ will cause an absence of activity there, no? Or is that too picky? (Or antique).

Hypocapnea to an irritated or circulatory challenged brain is like revving an engine at redline to see which cylinders aren't running a hot as the others…or a cardiac treadmill until you cause angina and EKG changes. If it's prone to fail, it will tend to.

When I think a house full of refugees living in the loft or renovated upper floor (read that tear out the walls and put up partitions) I see old lead paint being stirred up, along with rodents and their droppings and dried urine, old insulation, exposed utility conduits.


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## NomadicMedic (Mar 29, 2014)

2mg of Versed in his nose. (We carry 5/5 which sucks for IN) Didn't stop his seizure. I walked in at about this point, with my glucometer. 86 was the sugar. (It's been 13 minutes since my partner made patient contact)

Got a line and the remaining 3mg of versed. Seizure stopped. 

Now, respirations of 6, trismus and blood coming out of his mouth. Not pouring out, but not just a trickle either. 

....yeah. This really happened last week.


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## Handsome Robb (Mar 30, 2014)

Suction, NPA if it's not already in place and bag him if you've got the hands, if not NRB and setup for an RSI. We need to control his airway. 


4-lead, 12-lead when I get the chance and/or more hands. 

I'm going to be kicking myself right about now for not looking in his mouth right off the bat. Blood from oral trauma possibly or more than that? 

Toxicological, infectious disease or neurological are my thoughts. 

I'm going to admit I feel rather lost...crap it's not going to be pretty whenever I make it back to the truck. 

Oh btw once we get his airway settled and get him packaged up I'd like to start moving. 

Also...What do his lungs sound like?


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## mycrofft (Mar 30, 2014)

*AFTER airway...*

Don't feel bad for not talking time to gaze into the mouth. 
Oral blood despite trismus:
First, decide if it is gastric blood ( coffee grounds or tobacco leaves). Second, is it really mixed with saliva (behind the teeth) or not (buccal)? Buccal would also tend to be predominant on one side. Tongue actually isn't commonly bitten in my experience, not compared to buccal lining. Third, look up the nose to assist (not definitely) rule out nasal bleed. Fourth, look at teeth to help r/o dental or Laforte fx.


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## NomadicMedic (Mar 31, 2014)

So, once we got his seizure stopped, he got wrapped up in a Reeves stretcher and moved to the ambulance. We proceeded to RSI him, which proved to be difficult as his airway was swollen, bleeding and full of chunks of Fritos and broken dentures. He also had history of some past airway insult, as his anatomy was "not where it should be". It appeared as though he had had some tumor surgery, there was a lot of scar tissue and cords were very difficult to visualize.

He quickly started to come out of the induction and paralytic agents, was given another 5mg versed and 10mg vecuronium along with 100 µg of fentanyl. 

Both my partner and I felt that he is suffered a cranial insult of some type, so he was pretreated with lidocaine. (I know, but it's still in the protocol…)

Is placed on a transport event, ventilated effectively and remained stable throughout the transport.

It turned out that he had a large, previously undiagnosed tumor in the left temporal region. 

He was flown to the large level one, and I haven't received any follow-up.


Some of the other information was thrown in as confounders, simply because a large tumor in the guys head was the last thing I expected. Nice job picking it out, obviously it was a neurological issue… But could have just as easily been some sort of toxin or other ingested substance.


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## mycrofft (Mar 31, 2014)

Not common for toxins to cause a unilateral affect, unless you are _right_ on the threshold stimulus for an insulted area, so it causes affect from there and not other healthier areas.

And I can't think of such a toxin or drug right off hand. Organophasphates?

THEN the issue is scene safety. I bet civilians don't have protocols for acetocholinase inhibitor intoxication?


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## Psych (Apr 5, 2014)

This one was cool. I was shocked at the tumor. Agreed with all the interventions but kind of wanted more info on the foot infection. First I thought it was going to be a neurotoxic penicillin allergy causing seizures because of the keflex. Then I saw the no allergies and I was dead set on viral encephalitis from like hemmorhagic hantavirus or something similarly environmentally related (perhaps rabies...I don't know how that foot got infected!) or maybe meningoencephalitis. The sudden onset from him acting "totally normal" Either way I would have given midazolam to stop the SE, hit him with a bolus of 10mg dexamethasone for the ICP or cerebral edema I would have suspected, succs and ketamine  then intubated and keep up with the versed and ketamine to keep him as sedated as protocol would allow to protect his brain from himself. Sweet scenario!


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