BLS Seizure?
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Does every seizure require a transport? A known epileptic, either in the process of tweaking drug dosages, or with reasonable expectation to rebuild therapeutic dosage, fully A&O, able to take care of self, etc, will you get a refusal? Can a BLS truck get a refusal? Who should they consult?
eveningsky339
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My ambulance service does not operate BLS trucks; it's all ALS with a medic/EMT crew. But, there is a service not too far from us that is certified up to the paramedic level, but usually runs at the intermediate life support level.
Or something.
Anyway, I'm certain it's different with intermediate life support, but if they encounter a seizure patient that requires intervention beyond the intermediate level, they call a medic truck. ALS checks the patient out, and if they are good to go with just a transport, ALS goes home and the patient is transported in the intermediate truck.
Or something.
Anyway, I'm certain it's different with intermediate life support, but if they encounter a seizure patient that requires intervention beyond the intermediate level, they call a medic truck. ALS checks the patient out, and if they are good to go with just a transport, ALS goes home and the patient is transported in the intermediate truck.
WolfmanHarris
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Is the patient still actively seizing?
Ideally a patient who has been seizing would have a ALS available to start a line or saline lock in a post-ictal patient as a route for midazolam if they begin to seize again, but I'm not going to call for ACP intercept or back-up on every reported seizure automatically. This is where the assessment, history and probable cause of the seizure comes into play.
Also look at transport time and expected response time for ALS arrival. If it will be delayed and you have reason to suspect that follow-up seizures are a possibility then get ALS rolling as the longer a pt. is in status the less effective midazolam will be and they may not be able to be brought out.
With this in mind, do not unecessairly delay transport awaiting ALS, as the actively seizing patient is going to need ventilatory support AND is likely going to be extremely difficult to ventilate, meaning your risk for complications is going to increase the longer you're with them. If seizure activity is prolonged (thus making effective midazolam unlikely) and you're service does not have RSI as an option (which Ontario does not for ACP), then rapid transport becomes even more important as your ability to stop the seizure has been lost AND your ability to manage the airway is compromised.
To find where I've parroted most of this, check out:
CEPCP Self-Study Package
This is a recent review package we received as part of our CME requirements. So it's all fresh in my mind. Great little dozen page review on seizures. And if you go exploring you'll find another good package on syncope from last year. (Older packages are unfortunately not posted - Scratch that, just checked and they've added quite a few)
Ideally a patient who has been seizing would have a ALS available to start a line or saline lock in a post-ictal patient as a route for midazolam if they begin to seize again, but I'm not going to call for ACP intercept or back-up on every reported seizure automatically. This is where the assessment, history and probable cause of the seizure comes into play.
Also look at transport time and expected response time for ALS arrival. If it will be delayed and you have reason to suspect that follow-up seizures are a possibility then get ALS rolling as the longer a pt. is in status the less effective midazolam will be and they may not be able to be brought out.
With this in mind, do not unecessairly delay transport awaiting ALS, as the actively seizing patient is going to need ventilatory support AND is likely going to be extremely difficult to ventilate, meaning your risk for complications is going to increase the longer you're with them. If seizure activity is prolonged (thus making effective midazolam unlikely) and you're service does not have RSI as an option (which Ontario does not for ACP), then rapid transport becomes even more important as your ability to stop the seizure has been lost AND your ability to manage the airway is compromised.
To find where I've parroted most of this, check out:
CEPCP Self-Study Package
This is a recent review package we received as part of our CME requirements. So it's all fresh in my mind. Great little dozen page review on seizures. And if you go exploring you'll find another good package on syncope from last year. (Older packages are unfortunately not posted - Scratch that, just checked and they've added quite a few)
LucidResq
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If I'm having a known epileptic that's just had a "typical" seizure for them refuse transport, I want everything you mention plus a responsible, concerned party that will be with them constantly.
I say this as a daughter of an epileptic. My father was allowed to refuse transport once after seizing in a grocery store while I was in school. He went home alone, seized again, and ended up with a gnarly scalp lac & needed sutures. I think he's lucky that's all that happened.
DrParasite
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in my system, a report of a seizure is a bls call and bls dispatch. they are treated with the same acuity as toe pain.
a status ep (continuous seizure) complain, or one of multiple seizures is treated as ALS.
but if someone calls 911 saying their friend is seizing, and if they stop shaking before the 911 call screening is completed, then it's the same as toe pain. of course, if they start seizing again, it gets treated as multiple seizures, and upgraded to ALS
a status ep (continuous seizure) complain, or one of multiple seizures is treated as ALS.
but if someone calls 911 saying their friend is seizing, and if they stop shaking before the 911 call screening is completed, then it's the same as toe pain. of course, if they start seizing again, it gets treated as multiple seizures, and upgraded to ALS
No upgrade for first time seizing or age criteria?
DrParasite
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nope. in fact, my former hospital did a study that said most prehospital pediatric seizures are non-life-threatening, and didn't require an ICU stay.
I would have thought most first time seizures would be ALS, but people with more education and experience than me (Medical Director and other MDs) would think otherwise.
I would have thought most first time seizures would be ALS, but people with more education and experience than me (Medical Director and other MDs) would think otherwise.
But what about a 70 y/o having a first time seizure?
In Peds, seizures are often discharged home with rectal benzo rx. (safe enough to be used by parents)
Truthfully, in my experience the report of a seizure often turns out to be erroneous, but classified with toe pain, might under estimate its potential in the rare cases where it is a sign of serious underlying problem. (like a ruptured aneurysm from congenital A/V malformation or a stroke)
I guess it fails my "how would I like to explain this on the evening news" test.
I didn't see the Med director for Pittsburg defending their system on TV.
NJmedic3250
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In the state of New Jersey stat ep and FIRST TIME SEIZURES are worked up by ALS (O2, IV, cardiac monitor, BGL, and lorazepam if seizures are reoccurring). Also I would say your statement about pediatric seizures is partially correct. Febrile seizures, for example, are associated with a significantly low mortality rate. However, that is not saying a child that is seizing from another etiology cannot die. Unaddressed hypoglycemia and chemical toxicity can kill a child. What a seizure patient does need, is a thorough physical exam and accurate history taking. Both can be performed by BLS. If the patient has been actively seizing for greater than 5 min non stop or has had back to back seizures with no lucid period, he or she requires ALS intervention.
DrParasite
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you misunderstand. it doesn't get classified as toe pain, but seizures are treated as a low priority call. I don't necessarily agree with it, but it is how my medical director has directed us to prioritize calls.
not everywhere in NJ for first time seizures. and not only that, but first time seizures aren't a criteria for an ALS dispatch in all parts of the state. If you want to get further info, PM me which system work for, and I will tell you mine, and we can compare notes. But remember, I just follow the rules, I don't make them.
not disagreeing with you at all. however, in YOUR experience, how many pediatric seizures were life threatening? I can think of only one, and that was after the kid when head first into a tree. the majority of time (which we deal with when it comes to dispatching), it's a non-life threatening emergency.
which is why I said multiple seizures or status ep (which is exactly what you stated) are ALS dispatches
NJmedic3250
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Nor do I agree...
Yea I got it, a low priority call. (similar to toe pain
) Has the medical director actually directed calls to be prioritized that way, or has he simply signed off on a commercial dispatch system?
@Njmedic,
I do not think that a Basic in any state, without some kind of education outside the EMT-B curriculum is capable of a proper PE and HX.
Anatomy, physiology, pathophysiology, and exam techniques are just not covered in a way to allow/promote proper identification of emergent or life threatening conditions outside of something grossly apparent.
While I admit that many conditions cannot be managed even by ALS level EMS, I have noticed, especially in forum, many basics do not even realize when they are in over their head. Not for their lack of personal capability but for the failure of the "skills based" instructional methods.
Looking through the recent Brady text, the only endocrine disorder I can find is diabetes Mellitus. It is not even the only form of diabetes that can be life threatening. How can a basic provider possibly notice something more insideous to transport or call for help prior to the condition progressing to something grossly apparent?
OMG there is no such #*T%*#(%(ING thing as a "BLS" seizure or an "ALS" seizure or any other kind of "_LS" seizure!
You people are your obsession with BLS vs ALS OMG it makes me so angry it's so painful to keep hearing it, my bleeding ears!
Would a seizure here get an Intensive Care Paramedic? Depends, if it's a known seizure history or one simple seizure that is uncomplicated then no it wouldn't but should it be multiple or unceasing seizures then yes.
In the year or two one of the skills we will probably bring down to Paramedic level (sub-ALS) is midazolam IM and IN for seizures. Australia already has it in some states.
A patient with a known seizure history who has recovered can be left at home here.
You people are your obsession with BLS vs ALS OMG it makes me so angry it's so painful to keep hearing it, my bleeding ears!
Would a seizure here get an Intensive Care Paramedic? Depends, if it's a known seizure history or one simple seizure that is uncomplicated then no it wouldn't but should it be multiple or unceasing seizures then yes.
In the year or two one of the skills we will probably bring down to Paramedic level (sub-ALS) is midazolam IM and IN for seizures. Australia already has it in some states.
A patient with a known seizure history who has recovered can be left at home here.
NJmedic3250
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Yea I got it, a low priority call. (similar to toe pain
Has the medical director actually directed calls to be prioritized that way, or has he simply signed off on a commercial dispatch system?
@Njmedic,
I do not think that a Basic in any state, without some kind of education outside the EMT-B curriculum is capable of a proper PE and HX.
Anatomy, physiology, pathophysiology, and exam techniques are just not covered in a way to allow/promote proper identification of emergent or life threatening conditions outside of something grossly apparent.
While I admit that many conditions cannot be managed even by ALS level EMS, I have noticed, especially in forum, many basics do not even realize when they are in over their head. Not for their lack of personal capability but for the failure of the "skills based" instructional methods.
Looking through the recent Brady text, the only endocrine disorder I can find is diabetes Mellitus. It is not even the only form of diabetes that can be life threatening. How can a basic provider possibly notice something more insideous to transport or call for help prior to the condition progressing to something grossly apparent?
Do I think that a prehospital care provider of any level should be able to complete a complete PE and accurate HX? Absolutely! Is it a reality? Absolutely not. I should clarify that I do not expect basics to diagnose. But identifying a febrile seizure vs etiology "x" can be done without diagnostic equipment. Also, if BLS is even questioning to transport or call for help, you can never be faulted for just going ahead and transporting to an appropriate facility. The ED is ALS also...
NJmedic3250
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Haha.. very effective way to put an end to this thread.
DrParasite
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directed calls to be that way. commercial dispatch says one thing, but there are two areas (seizures being one of them) where the MD changed to what he felt to be more appropriate. Again, it's above my training and pay grade, but that was what he decided.
You seem a bit passive aggressive. That overreaction was remarkable.
I'll rephrase in order to avoid another outburst. Does every seizure patient require an IV?