# Dispatch said seizure lasting 20min, Really!?



## MadMedic (Jul 11, 2012)

OK, we have been talking about this call for weeks now, so I thought I would put out to EMTLIFE.

1620, 110 degree dry heat, Call for a 16y/o female seizure.

Caller states that the seizure has been going on for 20min, and that is unlike the PT.

House is mid-class, 2 story, well air-conditioned (house temp at about 76-78 degrees)

O/A PT is prone on second floor carpeted hallway convulsing, Brother and neighbor states this has been going on for approx. 20min now that is why they called.  We move PT to an open area, and start getting vitals, place PT on NRB @ 15, and prepare for a line.  

About a 45 sec into this dance, the PT comes to, surprising us! PT is A&Ox4, pale/diaphoretic, c/o a heavy weight on chest. Recalls feeling weak, and then waking up now.

Vitals:
      1st set                 2nd set
BP -  150/88                143/84
P-     123SR                 116SR
Resp   18NL                   18NL
Skin        Pale/warm/diaphoretic
Pupils        PERRL
Cap Refil     <2
GCS           15     
02       * 99-RA             * 100-RA  
Blood Glucose  76

20g in R-AC with NS, total infused 500cc
EKG - Sinus Tach no ectopy @ 120bpm

Findings were minimal, bruise on forehead from ground level fall, otherwise everything else was negative.

The kicker here is the PT had 3 more episodes lasting about 30 sec. each while we were working on her, she would tell us she was not feeling good and then start to convulse.  She would continue breathing, come to alert to surroundings, no postictal stage, dizzy and a bit more soar.  If your thinking she's faking, We tried to drop her hand onto her face and it hit, sorry.  We got the mother on the phone, she stated the PT had multiple episodes each day, but no longer than 5min, they have been gaining frequency and length lately. PT is on Midodrine, Florinef, Oxycodone, 

I just got off 48 hours, so forgive me if its scattered or incomplete, Ask if you need more info on something.

What are your thoughts on this call, what would you have done different.


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## NomadicMedic (Jul 11, 2012)

Psychogenic non-epileptic seizures... also known as Pseudoseizures.


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## MadMedic (Jul 11, 2012)

n7lxi said:


> Psychogenic non-epileptic seizures... also known as Pseudoseizures.



That is what I thought, but her hand hit her face, we could check pupils with no resistance.  I thought those were the tests for Pseudoseizures?  Is there other ways to tell?

The Mother stated it was POTS - Postural orthostatic tremor syndrome, but that really didn't fit for us either.  And I knew POTS in regards to tachycardia, not tremors. 

Essential Tremor Syndrome (ETS)  Came to mind but that doesn't consist of convulsions only tremors.


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## Anjel (Jul 11, 2012)

Just curious. Why is a 16 yr old on oxy, florinef and midodrine.

Does she have renal problems?


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## medic417 (Jul 11, 2012)

MadMedic said:


> That is what I thought, *but her hand hit her face*, we could check pupils with no resistance.  I thought those were the tests for Pseudoseizures?  Is there other ways to tell?
> 
> The Mother stated it was POTS - Postural orthostatic tremor syndrome, but that really didn't fit for us either.  And I knew POTS in regards to tachycardia, not tremors.
> 
> Essential Tremor Syndrome (ETS)  Came to mind but that doesn't consist of convulsions only tremors.



So you risked physically harmed her because you thought she was faking?<_<


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## Anjel (Jul 11, 2012)

Also besides the med question....

Did you give valium or anything after you saw the seizures repeating themselves? 

Forgive me if this was not indicated, I am just curious.


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## NomadicMedic (Jul 11, 2012)

The "no postictal phase" is kind of a giveaway for me. People do NOT seizure and then just wake right up, 100% with it ...or at least any I've seen. 

I HAVE seen people with pseudoseizures  wake up following the seizure activity. Just because it's a physical reaction to a mental issue doesn't make it any less real. However, I find these people do NOT need valium or versed to "break" seizure activity, instead use benzos as anxiolytics, helping to relieve the stress that may have triggered the event.


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## Aidey (Jul 11, 2012)

Based on the meds the pt has some sort of autonomic dysfuction.


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## mycrofft (Jul 11, 2012)

The hand drop can be done safely, just don't aim for the nose.

THAT's why I like ammonia poppers!

A true postictal state is rare, scant or nonexistent for pseudoseizures especially factitious ones.


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## MadMedic (Jul 12, 2012)

medic417 said:


> So you risked physically harmed her because you thought she was faking?<_<



REALLY!?  How high do you think we put her hand?  I take it you have never had a faking teenager as a PT.  Also, that was the first question the Doc asked me when we got to the hospital, did you try the hand test.

I don't like to give medication to PT that don't need them or treat s/s that aren't real.

Also, Valium or Versed was not indicated.  We were talking about drawing it up when we first arrived, but when she came to so quickly, that went back in the box.

And I believe her Mother stated that the Medication she was on was for hypotension.  At least I never heard of Renal issues.  I believe those meds can be prescribed for both issues.


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## johnrsemt (Jul 12, 2012)

How did you KNOW that she was faking?  Or how do you know that any patient is faking?

   I have had 2 patients in 14 years EMS that would have full blown grand mal seizures and go from 5-10 minutes of seizing to 100% alert in 1-2 seconds.  One we transported 6 times a week, 90 miles each way for Dialysis and pt would seize sometimes 20-30 times a transport  or for 15-20 minutes during transport.  
  It does happen; and to state that you have never seen it so they are faking is wrong.


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## Anjel (Jul 12, 2012)

I still think I would of called and asked for valium after the second seizure you witnessed. Fake or not. She needed to be slowed down.


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## MadMedic (Jul 12, 2012)

We didn't witness status epilepticus, which is a life threatening condition, since the PT has long periods of apnea, which in turn causes hypoxia of vital brain tissue, which result in respiratory arrest, severe metabolic and respiratory acidosis, extreme hypertension, increased ICP, serious elevation in body temp, necrosis of the cardiac muscle and severe dehydration. 

If we had, we would have been a lot more aggressive with our treatment.

This PT was breathing, 02 Sat never got below 98%, CO2 level never got below 40, and BP was only slightly elevated.  We tested to see if she was faking but she was NOT, but the convulsions did not warrant Valuim, these were not seizures but convulsions.

I have had PT that fake seizures to get valium, because they are out of their drugs, and want us to provide them.  This case was odd because she was not faking but not having a seizure either.


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## MadMedic (Jul 12, 2012)

johnrsemt said:


> How did you KNOW that she was faking?  Or how do you know that any patient is faking?  to state that you have never seen it so they are faking is wrong.



I never stated that the PT was faking, I stated that we tested to see if she was.  And found that she WAS NOT.   What I stated is that I have never seen convulsions like this that were not being faked.


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## Anonymous (Jul 12, 2012)

POTS and no postictal.... vasovagal seizures?


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## mycrofft (Jul 12, 2012)

Grand mal seizure and no postictal? None? Really? I'v seen where they become responsive but not 100% oriented, confabulate somewhat, but after a prolonged period of every single muscle in the body at full throttle and no respirations?

Maybe we have a miscommunication about what constitutes a grand mal seizure, or signal of a seizure's cutoff time is not agreed upon, or the pts were not having actual *grand mal* seizures.

BTW, my personal definition of a seizure does not include those of a psychogenic nature. (Psychogenic as opposed to factitious).  A seizure can occur to someone with mental illness, a seizure can occur as a heralding sign of intracranial insult which may result in an alteration of psychiatric condition, but by definition a seizure is the manifestation of electrical hyperactivity of part or all of the brain, not a somatic reaction to psychiatric issues _except in cases where catecholamines (fright, rage) trigger seizures in a seizure disorder patient_. Not being sad or ignored or disappointed or depressed etc.

And, yes, vasovagal "funky chicken" seizures are real and the scourge of immunization drives or blood collection centers.


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## medic417 (Jul 13, 2012)

MadMedic said:


> REALLY!?  How high do you think we put her hand?  I take it you have never had a faking teenager as a PT.  Also, that was the first question the Doc asked me when we got to the hospital, did you try the hand test.
> 
> I don't like to give medication to PT that don't need them or treat s/s that aren't real.
> 
> ...



Wow remind me to avoid Arizona.  There are other more humane ways to test if someone is conscious or not.


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## MonkeySquasher (Jul 13, 2012)

MadMedic said:


> REALLY!?  Also, that was the first question the Doc asked me when we got to the hospital, did you try the hand test






medic417 said:


> Wow remind me to avoid Arizona.  There are other more humane ways to test if someone is conscious or not.




That's why I do one or more of the following...  Corneal reflex, NPA, openly talk about "puting the foley tube where they pee".  Usually one of the three will make them magically become conscious again.  One is a valid test, one is an accepted BLS maneuver, and one is just fun to talk about.  =)


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## mycrofft (Jul 14, 2012)

Using a therapeutic measure (airway, IV, urinary catheter, etc.) for such purposes is an actionable tort. Talking about it will not make things better. If you talk about it then do it, they will know what's coming, or a bystander (concerned friend or family member) can cite that when they file a complaint, a lawsuit, or both. Licensure could be screwed up also.

I've seen people NOT react to sternal rubs no matter what.

Ammonia...use it right, without warning, and it's about 99.3% effective in indicating to you your patient's level of consciousness (not "whether they are faking it"). Time and again, I've broken up a fakery with it, and not just a few times the actor has suddenly sat up and been basically complaining that they covered all the symptoms.






 And, a few times I discovered that yes they really WERE to of it, despite my suspicions.


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## VFlutter (Jul 14, 2012)

Here is some good info on Pseudneuro problems including Pseudoseizures.

http://http://www.aafp.org/afp/1998/0515/p2485.html


They are considered a somatoform disorder, more specifically a conversion disorder, according to the DSM IV. Just because they are psychogenic in nature does not make them any less real or mean that they are "faking".


Also, the vasovagal seizure idea is interesting given her medical history.


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## Dwindlin (Jul 14, 2012)

medic417 said:


> Wow remind me to avoid Arizona.  There are other more humane ways to test if someone is conscious or not.



Give me a break. Ever done a sternal rub?  Orbital pressure?  Nail bed pressure?  These are all accepted ways to check for reaction to pain and way more harmful/painful than letting someone's hand fall.


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## VFlutter (Jul 14, 2012)

Side effects of her medications should also be considered, particularly the Fludrocortisone. The moms comment about progressively getting more frequent and longer could be a sign of toxicity. Would explain the hypertension, convulsions, fatigue, and other s/s.


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## medic417 (Jul 14, 2012)

Dwindlin said:


> Give me a break. Ever done a sternal rub?  Orbital pressure?  Nail bed pressure?  These are all accepted ways to check for reaction to pain and way more harmful/painful than letting someone's hand fall.



Give me a break.  Actually give the patient a break that is a broken nose.  

Wow we have some real brilliant people hanging around this place.:wacko:


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## Melclin (Jul 14, 2012)

ChaseZ33 said:


> conversion disorder,



Ahhhhh beat me too it.

The world of seizures is a big and complex world. I'd be cautious with statements like, there has to be a post-ictal period. There is a lot about obscure neurological conditions that I don't know. So I'd prefer not to use absolutes like that. 

That said I think people who are faking it are pretty obvious. I've never had to use it for fakers in the seizure realm because I've never had one I couldn't talk out of it, but for fakers of unconsciousness I've used the hold their eye open, show them a 14g cannula and tell them that if they're really unconscious, they'll need one of these inserted trick. Interested in what you've said mycrofft. Our laws are obviously different but I'd be interested to know whether or not I could get into legit legal trouble using this trick.


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## VFlutter (Jul 14, 2012)

medic417 said:


> Give me a break.  Actually give the patient a break that is a broken nose.
> 
> Wow we have some real brilliant people hanging around this place.:wacko:



Have you ever seen a skin laceration caused by a sternal rub? I'd rather take the broken nose 


I prefer a good trap squeeze or nipple twister. Kind of joking about the second one... But the trap squeeze does work great if you do it right


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## medic417 (Jul 14, 2012)

ChaseZ33 said:


> Have you ever seen a skin laceration caused by a sternal rub? I'd rather take the broken nose
> 
> 
> I prefer a good trap squeeze or nipple twister. Kind of joking about the second one... But the trap squeeze does work great if you do it right



:unsure::unsure::unsure:

I have not said in this topic that I endorse any form of torture being described in this topic.  But given a bruise minor laceration of sternum skin or a broken nose I'll take the bruise/laceration thank you very much.


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## Dwindlin (Jul 14, 2012)

medic417 said:


> :unsure::unsure::unsure:
> 
> I have not said in this topic that I endorse any form of torture being described in this topic.  But given a bruise minor laceration of sternum skin or a broken nose I'll take the bruise/laceration thank you very much.



Where are you seeing these broken noses?  How far do you think people are dropping these hands from?  It's tough to break a nose throwing a punch, much less dropping a limp arm with no force placed behind it.  

If you are dropping their arm from high enough (frankly I question whether its possible) to break a nose you are doing it wrong.  The whole point is to drop it low enough that the only way they can avoid hitting themselves is with a conscious effort.  

So your against those "torture" methods, then tell me how do check responsiveness?  Or are you going to tell me that response to pain isn't an important thing to know?


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## medic417 (Jul 14, 2012)

Dwindlin said:


> Where are you seeing these broken noses?  How far do you think people are dropping these hands from?  It's tough to break a nose throwing a punch, much less dropping a limp arm with no force placed behind it.
> 
> If you are dropping their arm from high enough (frankly I question whether its possible) to break a nose you are doing it wrong.



Seriously?  You think it takes that much force?  I really see no benefit it discussing this point with those that obviously know so little.


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## VFlutter (Jul 14, 2012)

medic417 said:


> Seriously?  You think it takes that much force?  I really see no benefit it discussing this point with those that obviously know so little.




It takes about 30g of force to fracture the nasal bone.  


Force = mass x acceleration. With the average mass of a persons hand and how little it should accelerate (dropping from a foot) I highly doubt you are going to see many fractured as a result of this. 


Also regardless of your personal opinions it is a widely accepted and legitimate test that you will find in most Neuro books (under hand-face drop test) such as Emergency Neurology: Principles and Practice By Sid M. Shah, Kevin M. Kelly


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## JPINFV (Jul 14, 2012)

ChaseZ33 said:


> Here is some good info on Pseudneuro problems including Pseudoseizures.
> 
> http://http://www.aafp.org/afp/1998/0515/p2485.html
> 
> ...



I was hoping I wouldn't be the first to point out that there's a difference between pseudo/psychogenic seizures and a patient faking it.


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## Dwindlin (Jul 14, 2012)

medic417 said:


> Seriously?  You think it takes that much force?  I really see no benefit it discussing this point with those that obviously know so little.



It takes roughly 76 lb. (340N, or 35g) of force to break a nose on average.  So I'll say again, if you can generate that much force by dropping someones hand/arm you are doing it wrong.

That data is from "Essential Tissue Healing of the Face and Neck" pp. 20, table 2-1.  Force is listed in N, conversion from N to lb is .22481 for those interested.

Edit:  Unrelated note, you can disagree with me all you like, but the little personal shots are unnecessary.


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## VFlutter (Jul 14, 2012)

Dwindlin said:


> Edit:  Unrelated note, you can disagree with me all you like, but the little personal shots are unnecessary.



*cough* Ad Hominem *cough*

In regards to the "brilliant people around here" and "not knowing anything about the topic" comments......:rofl::rofl::rofl: seriously? I would like to think we all have provided good information and feedback in this thread. What have you brought to the table?

Serioulsy what is up with people lately. If you want to state an opinion then that is totally fine but have some decent logic and evidence to back it up as well as be able to disagree with people without assuming they are dumb for having an opposing opinion. What ever happened to good old civilized discussion :glare:


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## medic417 (Jul 14, 2012)

Bravo.  Finally some science rather than this is how we always do it or this is how the doc said do it.  Happy to see some people rather than getting mad and making stupid remarks try and back their choices with real proof.  
Keep up the good work.


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## Anonymous (Jul 14, 2012)

On a side note, what about protecting the patients face with your other hand when performing the hand drop test?


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## Tigger (Jul 14, 2012)

How about not dropping the hand on their nose? And from six inches it's not going to make a single bit of difference anyway. It's not torture, it is a legitimate test as provided by other posters. I also read of it an athletic training practice "bible" the name of which escapes me.


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## mycrofft (Jul 15, 2012)

Is the ammonia inhalant disregarded because it is prone to abuse (put in nose, squeeze nares to pop..) or misuse, or is it something else? 
JPINV, I was away, thanks for pointing out a conversion disorder seizure form episode is not the same as a factitious psueodseizure. 
Encepholographically, neither will exhibit the waves seen in a real seizure.

Pinching, poking in the eyes, twisting areolae, grubbing on the sternum....





I bet water boarding would work, too. These are not only going to possibly "leave a mark" when used, but will look GREAT on Youtube via someone's cellphone camera.


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## JPINFV (Jul 15, 2012)

mycrofft said:


> Is the ammonia inhalant disregarded because it is prone to abuse (put in nose, squeeze nares to pop..) or misuse, or is it something else?
> JPINV, I was away, thanks for pointing out a conversion disorder seizure form episode is not the same as a factitious psueodseizure.
> Encepholographically, neither will exhibit the waves seen in a real seizure.


Actually it was Chase that pointed it out in this thread.


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## mycrofft (Jul 15, 2012)

OK, thanks to her/him also.


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## Dwindlin (Jul 15, 2012)

mycrofft said:


> Is the ammonia inhalant disregarded because it is prone to abuse (put in nose, squeeze nares to pop..) or misuse, or is it something else?
> JPINV, I was away, thanks for pointing out a conversion disorder seizure form episode is not the same as a factitious psueodseizure.
> Encepholographically, neither will exhibit the waves seen in a real seizure.
> 
> ...



I just don't have ammonia.  Never have in this region.  Not sure why, have never asked.


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## mycrofft (Jul 15, 2012)

Ammonia inhalants are prone to abuse or ignorant use . Proper technique from my experience: before pt is clearly in sight, don gloves and put capsule in your hand. In one motion crush the capsule and just swing it under their nose, about an inch away, don't hold it there for more than a second. Keep it handy, don't toss it, you might want to do it once more.

Do not do the following:  use more than one at a time, contact the pt with it, hold it under their nose for more than a second, use it without gloves, use it to punish a patient.

In fact, before you do it to a patient, do it to yourself.

Practical tip: store them in a rigid container, I carry two in a serum aliquot tube with their corners bent to allow them to be shaken out. Otherwise they tend to get crushed prematurely, and most will then have a reddish stain to indicate they are used up. ANd your kit will smell like ammonia.

Note the pt reaction, can include the following or more: opens mouth to breathe, eyes open, turns head away, suddenly awakes (I mean at once, no obtunded state), tries to strike you (note degree of accuracy), or occasionally comes up obtunded and sometimes aggressive like when wakening a passed out drunk on the street.


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