# Seizure



## usalsfyre (Nov 22, 2010)

Fairly straightforward, but I'm interested to see how other would have handled it. 

Time is about 0400. Dispatched for a seizure along the interstate in a passenger bus on arrival found a male patient in his late 20's curled in roughly the fetal position over two seats. No family or friends on the bus, the patient is traveling alone. We're approximately 2 hours from the originating city and 4+ from the destination. Bystanders stated he had a brief grand mal seizure. Patient will look your direction upon speaking to him, but will not respond verbally. 

HEENT: Head is intact, airway open but drool is coming from the corner of his mouth. Eyes are spontaneously open, pupils appear to be about a 3. Pt has good facial symmetey. Attempts at assessing further are met with the patient attempting to bite you. 

Chest: Equal rise and fall noted, unable to assess further as the patient attempts to bite/strike you 

Abdomen: Ditto from above, no signs of trauma. 

Extremities: Intact, don't try to touch them though. 

Vitals: Unable to obtain due to the patient's agitation and combativeness. 

Patient is in the middle of the bus, other passengers are growing angry the bus isn't continuing on to it's destination/you're in their way to get out and go smoke. You've got a full ALS drug box, another truck happens to be in the area should you need it.


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## wyoskibum (Nov 22, 2010)

*Could be anything....*



usalsfyre said:


> Fairly straightforward, but I'm interested to see how other would have handled it.



First and foremost I would check for Medical Alert and do my best to obtain a BGL.  Perhaps see if there is any info in his wallet if you can get it.

Is the pt post ictal from a breakthrough seizure and pt has a Hx of seizures or is there another cause?  I've had many a pt who had a "Grand Mal Seizure" but has a BGL of 20.  Is there evidence of ETOH or drug abuse?  Perhaps this a withdrawl seizure?

I would do my best to get the pt off the bus and into the Ambulance as the pt is altered.  Call for additional help if you think you might have restrain pt.
Continue assessment & differential diagnosis, transport when you can.


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## Veneficus (Nov 22, 2010)

usalsfyre said:


> Fairly straightforward, but I'm interested to see how other would have handled it.
> 
> Time is about 0400. Dispatched for a seizure along the interstate in a passenger bus on arrival found a male patient in his late 20's curled in roughly the fetal position over two seats. No family or friends on the bus, the patient is traveling alone. We're approximately 2 hours from the originating city and 4+ from the destination. Bystanders stated he had a brief grand mal seizure. Patient will look your direction upon speaking to him, but will not respond verbally.
> 
> ...



As was stated, i would check the BGL, that shouldn't be too bad.

I would also hang out on scene for a few minutes, when people are post ictal, they can become combative for s short time until they are oriented. (I know the op knows, not for his benefit)

If he seizes again, then we can break out the benzos and get him out into the truck etc.  But waiting a few minutes to see if the kid comes around so we can have a little chat and see what is going on. At the very least if he becomes a little more oriented, it will make procedures as little easier. 

If this is his first seizure, then we're off to the hospital. If it is something with a history, we'll make a call when we know what it is and what is going on. 

The passengers should get over it, though I might offer to get out of the way for a minute while they pass the isle. A little good will goes a long way.


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## usalsfyre (Nov 22, 2010)

*Ask....*

...and ye shall receive

 BGL is 130 done of a lancet to the bicep while you wade through the punches/kicks/bites. You notice the patient is diaphoretic during this. 

It's been 10 minutes, patient is still combative and you've been unable to remove him from the seat (think of someone laying in an airline seat, with his feet towards you who doesn't want to come out) or get a set of vitals. The pt is talking now, alternating screaming obscenities at you and crying for "mama". The patient is also now occasionally (every couple of minutes) vomiting clear mucous.


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## EMSrush (Nov 22, 2010)

This is a good thread....

I have placed NRB's on biting patients in the past with success, but would be cautious due to the vomiting in this case, would definitely keep suction handy.

What'cha got in your drug box in this case?


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## 18G (Nov 22, 2010)

Sounds like maybe a toxicological cause to me.... his behavior and presentation does not seem to fit most typical postictals. 

At this point in the scenario I would make sure he continues to maintain his airway and breathing and circulatory status. 

For now since he is stable from what info were able to obtain... my goal would be to get him in the back on the ambulance where he can be better managed. The only way to assess him and get him off the bus is to sedate him. 

...also diaphoresis... seizure activity... emesis.... drooling... not in a likely setting and maybe a far out consideration but consider some type of poisioning from the organophosphates.


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## Sam Adams (Nov 22, 2010)

18G said:


> his behavior and presentation does not seem to fit most typical postictals.
> 
> ...also diaphoresis... seizure activity... emesis.... drooling...



I respectfully disagree. I've seen them individually and collectively. The only other physical findings I expected to read from this scenario were oral/ lingual trauma and urinary and fecal incontinence.


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## 18G (Nov 22, 2010)

The majority of epileptic postictals I've cared for where lethargic and confused.... no emesis and not diaphoretic... a little moist from the amount of energy expended... but not what I would call diaphoretic. 

If the seizure was drug or other tox induced than I would expect a different presentation. Something about this patient isn't ringing out a typical postical seizure patient.


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## Veneficus (Nov 22, 2010)

usalsfyre said:


> ...and ye shall receive
> 
> BGL is 130 done of a lancet to the bicep while you wade through the punches/kicks/bites. You notice the patient is diaphoretic during this.
> 
> It's been 10 minutes, patient is still combative and you've been unable to remove him from the seat (think of someone laying in an airline seat, with his feet towards you who doesn't want to come out) or get a set of vitals. The pt is talking now, alternating screaming obscenities at you and crying for "mama". The patient is also now occasionally (every couple of minutes) vomiting clear mucous.



Then I call the other crew and the cops and he gets moved to the truck for his $1 million workup and ride to the hospital.


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## usalsfyre (Nov 22, 2010)

EMSrush said:


> What'cha got in your drug box in this case?



Benzodiazapine of your choice.


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## Veneficus (Nov 22, 2010)

usalsfyre said:


> Benzodiazapine of your choice.



Versed is my favorite flavor. (for patients of course, never had any myself, but if I were to choose something for me, I will have some ketamine please. Never had that either, but I really like what I have seen it do)


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## usalsfyre (Nov 22, 2010)

Veneficus said:


> Then I call the other crew and the cops and he gets moved to the truck for his $1 million workup and ride to the hospital.



Pretty much what we did. Two of Ativan IN, have no idea how much was actually absorbed, but he did mellow considerably. The difficulty with this case was access while he was in the bus seat, every time anyone latched onto him to remove him he got away due to the diaphoresis or attempted to assault. We were able to talk him out post loraz. Went to the truck, still agitated when we messed with him, but didn't fight us when we left him alone. We were able to get the cardiac monitor on him, but he fought everything else considerably. 

Enroute, he seized again, seizure terminated with more lorazepam IN and full vital signs, ect obtained. Ativan seemed to have a VERY short action in this guy, 5 to 7 minutes and it was like we gave him nothing. As long as we left him alone, he slept. We touched or spoke to him, he came unglued. On arrival at ED he was snoozing comfortably. Awoke long enough at the ED to tell him his name, that he had a hx of seizures and took Dilantin. Then he became combative again. Unable to follow up further than that so far. 

Bonus point for anyone (besides Vene and JPINFV) that can tell me why he burned through the Ativan so fast. 

(Hint:look at the little history you have)


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## EMSrush (Nov 22, 2010)

usalsfyre said:


> Pretty much what we did. Two of Ativan IN, have no idea how much was actually absorbed, but he did mellow considerably. The difficulty with this case was access while he was in the bus seat, every time anyone latched onto him to remove him he got away due to the diaphoresis or attempted to assault. We were able to talk him out post loraz. Went to the truck, still agitated when we messed with him, but didn't fight us when we left him alone. We were able to get the cardiac monitor on him, but he fought everything else considerably.
> 
> Enroute, he seized again, seizure terminated with more lorazepam IN and full vital signs, ect obtained. Ativan seemed to have a VERY short action in this guy, 5 to 7 minutes and it was like we gave him nothing. As long as we left him alone, he slept. We touched or spoke to him, he came unglued. On arrival at ED he was snoozing comfortably. Awoke long enough at the ED to tell him his name, that he had a hx of seizures and took Dilantin. Then he became combative again. Unable to follow up further than that so far.
> 
> ...



Because he was already taking Dilantin. The Dilantin altered the rate at which the Ativan was metabolized.


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## Sandog (Nov 22, 2010)

> Bonus point for anyone (besides Vene and JPINFV) that can tell me why he burned through the Ativan so fast.



Phenytoin can speed up the removal of many other drugs from your body by affecting certain liver enzymes. This can affect how well these other drugs work. 

???

Oops Rush beat me to it...


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## usalsfyre (Nov 22, 2010)

Rush/Sandog, very astute. Now go see how many of your coworkers know that.


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## EMSrush (Nov 22, 2010)

usalsfyre said:


> Rush/Sandog, very astute. Now go see how many of your coworkers know that.



I was wondering if you suspected this phenomenon when he burned through your Ativan so quickly...?


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## usalsfyre (Nov 22, 2010)

EMSrush said:


> I was wondering if you suspected this phenomenon when he burned through your Ativan so quickly...?



Yeah, inital presentation struck me as a seizure, and after my first vitamin A dose wore off in 5 minutes I had a strong suspicion phenotyin was probably a factor in this little goat rope. He went from "I'm chilled out enough to let me talk me out if the bus" to agitated and combative between exiting the bus and getting in the ambulance.


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## 18G (Nov 22, 2010)

I was not aware of the interaction of phenytoin and benzo's... so thanks for sharing the scenario. 

I wanted to know more about this interaction and from what I have been able to find online, the interaction between the two usually increases the effect of the phenytoin which can make the patient prone to phenytoin toxicity. The benzo's inhibit the metabolism phenytoin.

I wasn't able to find much that relates to the phenytoin decreasing the benzodiazopine effect. If anyone has some links to resources on this interaction I would appreciate reading em.


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## Aidey (Nov 22, 2010)

18G said:


> Sounds like maybe a toxicological cause to me.... his behavior and presentation does not seem to fit most typical postictals.
> 
> ...also diaphoresis... seizure activity... emesis.... drooling... not in a likely setting and maybe a far out consideration but consider some type of poisioning from the organophosphates.



I think I've been puked on by more postictal patients than any other type, except maybe drunks. If there is one thing I have learned about people's postictal periods it is that pretty much anything can happen. 



usalsfyre said:


> Pretty much what we did. Two of* Ativan IN*, have no idea how much was actually absorbed, but he did mellow considerably..... seizure terminated with more *lorazepam IN* and full vital signs, ect obtained.



Say what? What kind of Ativan and IN devices are you using? I know for a fact that we can not push Ativan though our IN devices, because of the Ativan not being water based. When we tested it out (with expired Ativan) it eventually shot out in a straight stream through the very tip once enough pressure was applied.


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## 18G (Nov 22, 2010)

In 15 years of active volley and career service I can't recall any that puked in my care. Foaming, heavy secretions yes.... but none that I can remember that actually vomited... strange.


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## Veneficus (Nov 22, 2010)

Aidey said:


> I think I've been puked on by more postictal patients than any other type, except maybe drunks.


 
If you stand behind your basic and direct them to get the vital signs, that won't happen to you. :unsure:


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## usalsfyre (Nov 22, 2010)

Aidey said:


> Say what? What kind of Ativan and IN devices are you using? I know for a fact that we can not push Ativan though our IN devices, because of the Ativan not being water based. When we tested it out (with expired Ativan) it eventually shot out in a straight stream through the very tip once enough pressure was applied.



We use the standard MAD. As far as who makes the lorazepam, I haven't the foggiest, it comes from the pharmacy and we were told it could be used nasally with no issues. Squirts easily from the device. I'm on shift tommorow I'll look closer at it and get some more info.


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## Aidey (Nov 22, 2010)

Interesting, I wonder if you guys have a specially formulated version or something.


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## RNL (Nov 23, 2010)

18G said:


> In 15 years of active volley and career service I can't recall any that puked in my care. Foaming, heavy secretions yes.... but none that I can remember that actually vomited... strange.



Brain oedema, bleeding to CNS- patient may be combative, disoriented, and may vomit

Do you know the final diagnosis usalsfyre?


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## MrBrown (Nov 23, 2010)

He should be thankful he only had a siezure on Greyhound and didn't get murdered, seriously.

Stair chair and drive to the hospital.


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## 18G (Nov 23, 2010)

RNL said:


> Brain oedema, bleeding to CNS- patient may be combative, disoriented, and may vomit



I'm not talking about seizures as a secondary manifestation from head trauma, head bleed, or the like. I am referring to the typical epileptic having seizures.


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## RNL (Nov 23, 2010)

18G said:


> I'm not talking about seizures as a secondary manifestation from head trauma, head bleed, or the like. I am referring to the typical epileptic having seizures.



I agree, but in this particular case, bleeding to CNS due to a ruptured aneurysma (congenital vessel malformation, let's say, taking in to consideration patient's age) may be the reason (ofcourse epilepsia or drug intoxication is much more common). That's why I would take such patient to hospital ASAP. 
What were the eye pupils? Narrow? Wide? Asymmetric?


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## Melclin (Nov 23, 2010)

I wasn't aware of the relationship between loraz and phenytoin, thanks.

I was ganna guess that he was a benzo addict and was having a nasty withdrawal.


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