Dispatch said seizure lasting 20min, Really!?

[MadMedic]

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.

 

[NomadicMedic]

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

 

[MadMedic]

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.

 

[Anjel]

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

Does she have renal problems?

 

[medic417]

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?<_<

 

[Anjel]

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.

 

[NomadicMedic]

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.

 

[Aidey]

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

 

[mycrofft]

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.

 

[MadMedic]

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.

 

[johnrsemt]

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.

 

[Anjel]

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.

 

[MadMedic]

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.

 

[MadMedic]

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.

 

[Anonymous]

POTS and no postictal.... vasovagal seizures?

 

[mycrofft]

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.

 

[medic417]

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.

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

 

[MonkeySquasher]

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

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. =)

 

[mycrofft]

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.

 

[VFlutter]

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.