# Overdose or Seizure?



## ZombieEMT (Dec 12, 2013)

27 year male patient found unconscious and responsive. Patient's father started CPR prior to arrival (father reports patient did not stop breathing). Upon arrival, patient is found conscious, alert and oriented (confused as to certain events) ambulating in the living room. Patient appeared somewhat lethargic and dazed. Baseline vitals P110 BP128/76 R20 SaO298 lungs clear, pupils equal and reactive (slightly dilated). Patient vital signs remained in similar limits. Patient gradually became more alert and and less dazed as time went by. Family reports possible overdose due to history. Patient admits to taking one Xanax and one Percocet, but denied all other drugs alcohol. Report given to ALS who automatically treat patient has a thug and dont believe anything out of his mouth and treat as overdose.

Patient's only medical history is seizures (no prescribed medication). ALS disregards because they are set on overdose and treat with Narcan. 

1. Would it be wrong to trust what the patient says and treat as possible seizure?
2. Does the presentation of the patient resemble that of a seizure? Noting the gradual improvement in mental state and coming out of unconscious state without treatment.
3. Do you automatically treat as OD just because of history?
4. Whats your opinion on the line of event.


----------



## Wheel (Dec 12, 2013)

No respiratory depression means no narcan from me. This presents like a seizure to me, especially with a history. I'd also be considering syncope.


----------



## VFlutter (Dec 12, 2013)

ZombieEMT said:


> 27 year male patient found unconscious and responsive. Patient's father started CPR prior to arrival (father reports patient did not stop breathing). Upon arrival, patient is found conscious, alert and oriented (confused as to certain events) ambulating in the living room. Patient appeared somewhat lethargic and dazed. Baseline vitals P110 BP128/76 R20 SaO298 lungs clear, pupils equal and reactive (slightly dilated). Patient vital signs remained in similar limits. Patient gradually became more alert and and less dazed as time went by. Family reports possible overdose due to history. Patient admits to taking one Xanax and one Percocet, but denied all other drugs alcohol. Report given to ALS who automatically treat patient has a thug and dont believe anything out of his mouth and treat as overdose.
> 
> Patient's only medical history is seizures (no prescribed medication). ALS disregards because they are set on overdose and treat with Narcan.
> 
> ...



I have a problem with "treat as a thug". But to assume the patient is lying is a fair enough assumption. 

Any shaking, tremors, etc? Incontinence? 

Partial or absence seizure is a strong possibility. 

I am not treating as as seizure until he has another one in my presence. Giving him more benzos empirically is not going to help the situation. Especially if they were not Ton/Clon. 

I wouldn't give Narcan unless he was in respiratory distress. Let the ER get a Tox screen and work from there. And certainly no Romazican if he is awake.


----------



## ZombieEMT (Dec 12, 2013)

There was no shaking or tremors witnessed prior to arrival, just wound unconscious on the floor.

My only point is that if you will not treat it as a seizure unless you witness it, why should you treat it as an overdose without evidence?

No offence meant with "treat as a thug" but there are some providers (both BLS and ALS) that I have worked with that automatically would have said overdose, or treat other overdoses, like complete trash.


----------



## Rano Pano (Dec 12, 2013)

Skins? Last time seen normal? Hours or minutes? Was alcohol involved?

Maybe a dumb question, but does Xanax have anticonvulsant properties as other benzos?


----------



## triemal04 (Dec 12, 2013)

ZombieEMT said:


> 27 year male patient found unconscious and responsive. Patient's father started CPR prior to arrival (father reports patient did not stop breathing). Upon arrival, patient is found conscious, alert and oriented (confused as to certain events) ambulating in the living room. Patient appeared somewhat lethargic and dazed. Baseline vitals P110 BP128/76 R20 SaO298 lungs clear, pupils equal and reactive (slightly dilated). Patient vital signs remained in similar limits. Patient gradually became more alert and and less dazed as time went by. Family reports possible overdose due to history. Patient admits to taking one Xanax and one Percocet, but denied all other drugs alcohol. Report given to ALS who automatically treat patient has a thug and dont believe anything out of his mouth and treat as overdose.
> 
> Patient's only medical history is seizures (no prescribed medication). ALS disregards because they are set on overdose and treat with Narcan.
> 
> ...


1.  Not at all.  It would be good to know more specifics about his seizures, like if he has an actual disorder, why he's not taking meds, and what he is supposed to be taking, if anything.  Regardless of that, there is nothing presented that needs actual TREATMENT.

2.  Yes.  It's called the postical period.  

3.  No.  It less resembles an overdose than something else.  Regardless of that, there is nothing presented that needs actual TREATMENT.  

4.  Pt has a seizure (maybe), is postical, returns to baseline, and is mistreated by the paramedics.  

Could this have been a seizure?  Sure.  Could the patient be high and has enough stimulation so that he's staying awake and lucid?  Sure.  More needs to be done to make that determination.  

Regardless of that, there is nothing presented that needs actual TREATMENT.  Doesn't matter what you think happened, aside from a better assessment and monitoring, nobody needed to DO anything.


----------



## Household6 (Dec 12, 2013)

If he's not presenting as an overdose, then I wouldn't treat an overdose.

HPI can suggest everything from a vasovagal syncope from taking a big BM, to a brain tumor to DTs..

It seems to me that there's not much to treat. He needs transport.


----------



## Rialaigh (Dec 12, 2013)

To make a different point. I am guessing most of you guys would treat this the same way whether you used the overdose or seizure protocol or even the syncope protocol. It really doesn't make a difference. This is an example of treating a "condition" instead of treating the patient. Treatment for an overdose includes 12 lead, monitor, iv. Treatment for a seizure includes 12 lead, monitor, iv. Treatment for syncope includes 12 lead, monitor, iv...


Don't think about it as "which condition you would treat". Never think about it that way. Think about what the possibilities are for underlying causes of the symptoms, think about which of those are life threatening or condition changing in the near future, and think about which of those you can begin to investigate or reverse in the field, that is it...


----------



## Carlos Danger (Dec 12, 2013)

Rialaigh said:


> To make a different point. I am guessing most of you guys would treat this the same way whether you used the overdose or seizure protocol or even the syncope protocol. It really doesn't make a difference. This is an example of treating a "condition" instead of treating the patient. Treatment for an overdose includes 12 lead, monitor, iv. Treatment for a seizure includes 12 lead, monitor, iv. Treatment for syncope includes 12 lead, monitor, iv...



Exactly.

For all practical clinical purposes, someone who is walking around and talking is not an "OD".


----------



## NomadicMedic (Dec 12, 2013)

I always look at these as "I'll fix what NEEDS fixing", in order of importance. In this guys case, there's nothing to fix... You're simply there to fix what MIGHT happen on the way to the hospital.


----------



## Tigger (Dec 12, 2013)

DEmedic said:


> I always look at these as "I'll fix what NEEDS fixing", in order of importance. In this guys case, there's nothing to fix... You're simply there to fix what MIGHT happen on the way to the hospital.



My sentiments exactly. Absolutely no reason to give narcan here, or to any conscious patient really.


----------



## Handsome Robb (Dec 12, 2013)

This screams seizure.

Seizure history, progressive improvement of LOC. Was he incontinent? Seizures can also be a symptom of overdoses.

Narcan is not indicated here and is a medication error if administered.


----------



## Handsome Robb (Dec 12, 2013)

What are you guys saying by "treat as a seizure/OD"? What are you treating?

All this kid is getting as a work up including the monitor and possibly a 12 lead then transport if he wants it. 99% of what we do in EMS is observation...if he has a seizure that persists (some might yell but I'm not giving versed to a seizure that only lasts 15 seconds...) give him some versed. If he becomes hypoxic and respiratory depressed or total respiratory arrest give him some Narcan...other than that just evaluate him and give him a ride.


----------



## mycrofft (Dec 12, 2013)

Seizure without meds?


----------



## EMT856 (Dec 13, 2013)

Some medics are biased. If the pt. denies overdose, and you have nothing else to support the theory of OD, then you treat what has the highest level of suspicion/what is presenting to you. Typically ETOH/Opioid OD would present with marked AMS, and usually resp depression, so absent that, I would move towards Seizure. Who knows though, it could be neither. That is the beauty of EMS, we dont diagnose as a whole, we treat what we see and haul ***.


----------



## ZombieEMT (Dec 13, 2013)

Just to clarify, I am aware that many patient regardless of get certain things like monitor and IV in transport. However, Narcan is given frequently in suspected overdoses. I have never seen Narcan given to treat a suspected seizure. Where other processes might be the same, there are some things that are different.

The ALS provided DID administer Narcan to this patient. My problem is how some providers, both BLS and ALS act towards some patients they suspect ( or even know) overdosed. There are some providers that are rude, pushy, and lazy when it comes to a suspected overdose. Either way, they are still patients.


----------



## EMT856 (Dec 13, 2013)

Sad thing is most EMTs and medics are seasoned way too fast. My main squad that I volunteer with is mainly all paid, and the other EMTs there are almost all seasoned. One just has to try their hardest to treat all patients like they would want their family treated in the same situation, and to do everything you can for every patient. 

Zombie, its good that you see that it was wrong of them to treat the patient differently on a personal level because of their suspicions. 

As far as the patient, I  personally would go with seizure unless new signs/symptoms arise or other, stronger evidence points me in another direction.


----------



## Tigger (Dec 13, 2013)

EMT856 said:


> Some medics are biased. If the pt. denies overdose, and you have nothing else to support the theory of OD, then you treat what has the highest level of suspicion/what is presenting to you. Typically ETOH/Opioid OD would present with marked AMS, and usually resp depression, so absent that, I would move towards Seizure. Who knows though, it could be neither. That is the beauty of EMS, we dont diagnose as a whole, we treat what we see and haul ***.



No, that is not the beauty, that attitude is one of the many that hold EMS back from ever progressing into a legitimate entity within healthcare. That phrase "EMS doesn't diagnose" needs to be taken out back, shot several times, and buried in a deep grave so it can never be heard again.

Also, there are very, very few reasons to ever "haul ***" to the hospital.



ZombieEMT said:


> Just to clarify, I am aware that many patient regardless of get certain things like monitor and IV in transport. However, Narcan is given frequently in suspected overdoses. I have never seen Narcan given to treat a suspected seizure. Where other processes might be the same, there are some things that are different.
> 
> The ALS provided DID administer Narcan to this patient. My problem is how some providers, both BLS and ALS act towards some patients they suspect ( or even know) overdosed. There are some providers that are rude, pushy, and lazy when it comes to a suspected overdose. Either way, they are still patients.



Well here's the thing, there was no reason for ALS to administer Narcan. It's not at all indicated for a patient that is walking around. If I were to speculate, the medics may have been trying to "take away the patient's high," as I can't come up with any other reason to give that medication there, correct or not. 

Naloxone is indicated for opioid overdoses with_ respiratory depression._


----------



## mycrofft (Dec 13, 2013)

Tigger said:


> No, that is not the beauty, that attitude is one of the many that hold EMS back from ever progressing into a legitimate entity within healthcare. That phrase "EMS doesn't diagnose" needs to be taken out back, shot several times, and buried in a deep grave so it can never be heard again.
> 
> Also, there are very, very few reasons to ever "haul ***" to the hospital.
> 
> ...



*Agree* with all above except the diagnosis thing. ALTHOUGH…although many prehospital EMS folks _*are*_ diagnosing and doing it well, they are out of bounds and better be able to show how their actions fit assessment to treatment protocol. 

In true diagnosis, there is no strict "If you see ABC, then do D". Ask a doctor.

As a RN I did sick call to up to _*fifty*_ people a day, operated with a standardized procedure binder two inches thick, started meds including scheduled ones, but I did not diagnose. I was wedding Subjective and Objective into an Assessment and followed the Protocol…the real meaning of SOAP notes for techs on protocols and nurses on SP's.
I think after reading your post that one of the true _*arts*_ in PHEMS is deciding how much to try to do on scene before transport.

PS: How dare you (tongue in cheek), sir, imply that treatment has to be based upon assessment and protocol, when there are just so many cool things people have learned in class or from their friends and are fairly  itching to do!!


----------



## Handsome Robb (Dec 13, 2013)

Mycrofft, you're wrong.

EMS providers are not "out of bounds" by forming a differential diagnosis(es). How are we deciding which protocol or treatment pathway we are going to use without doing it? 

Sure if you don't form a DDX and just treat a chest pain patient with MONA because they have chest pain you'll be protected by your protocol but what if you just blasted the dissecting aortic aneurysm with aspirin and nitro? Is that what's best for the patient? That's the exact reason we don't have a "Chest Pain" protocol where I work, we have an "Acute Coronary Syndrome" protocol for when the medic decides from their assessment that this is a potential ACS patient then treats per the ACS protocol.

How about an allergic reaction? You're recognizing the signs, symptoms and appropriate HPI then treating by the severity. That alone is a diagnosis. Is this a mild to moderate allergic reaction requiring diphenhydramine and some albuterol or is this anaphylaxis requiring epinepherine as well.

If all you do for patients is pick then up, ask questions then give them a ride there's no need to form a differential *diagnosis* but if you plan on performing interventions and providing treatment you better have a DDx to support your selection of treatments and interventions.


----------



## mycrofft (Dec 13, 2013)

OK I'm wrong.
:lol:


----------



## Handsome Robb (Dec 13, 2013)

Redacted


----------

