Focal Motor Seizure Management Scenario

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Fox800

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Dispatched to a seizure. You arrive to find a 30 year old male complaining of seizure activity in one arm for ~2-3 hours. You observe that one of the patient's arms is indeed moving repetitively as in a focal motor seizure. Not big grand movements but a little twitching. Patient is complaining that his arm feels "tired" but doesn't hurt.

The seizure presentation has been the same since it started, no changes in presentation, no other parts of the body involved, hasn't moved around, yadda yadda.

VS: Textbook stable. Normal BGL. Normal temp. Rule out stroke, rule out anything off the wall. Pt. has no complaints, except for the rather annoying spasming/seizure activity in one arm. No trauma. No curveballs here. You establish IV access. Let's say you're 10-15 minutes from the hospital.
PMH: Seizures, that's it.
Meds: Unknown, let's say dilantin.
NKDA

Do you give a benzodiazepine medication to treat the patient, Or wait to let the EDMD observe the activity? For grins, our seizure management protocol provides for diazepam IV for this patient, with midazolam IV for seizures refractory to diazepam.

I didn't run this call but have heard both arguments. I'd like to see what you guys think.
 
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You know, if the patient isn't in any immediate danger, why not give them a ride up to the hospital and let a doctor check it out, that way it doesn't put me on the wire, why I started a line, and gave a drug, when the patient was stable. I would much rather take them up and let them get checked out, and if the doctor wants me to do something different from then on, he can let me know.
 
For focal seizures? Not a chance. Not here.

Whats the deal with this seizure disorder? I would wanna be clear about the extremity, type and length of the seizure. Has it really been going for 2-3 hours or has it come and gone etc. Does he have a seizure plan? I'd like to try and get in contact with his neurologist if he has one too. If it all checks out he might be considered status focal, but its still not a prehospital issue as far as I can see. Far too easy to wheel a person into ED on a ventilator after misinterpreting a bad case of the jitters.

Young guy...any lifestyle/medical issues that could lead to electrolyte imbalance. Toxicology issues. Metabolic disturbances.
 
Frankly, I'd do very little with this patient. There is a chance that the focal motor seizure activity could become more generalized, but I doubt it. I'd probably start an IV lock and have the local benzo of choice on standby, but... beyond that, I'm basically going to simply provide a nice ride in. Let the lab figure out what's wrong. While he does take dilantin... I don't have a lab to check his dilantin level and while his levels could be low or even in a therapeutic range, something else could be wrong that is causing a break-through seizure.

In other words, his vitals look good, he's mentating fine, and it's been a couple hours since it started, I'm inclined to not worry much about him. Actually, I'd be surprised that he hasn't called his neuro doc already and had someone else drive him to the ED or the office to begin with...
 
Melclin said:
For focal seizures? Not a chance. Not here.

Whats the deal with this seizure disorder? I would wanna be clear about the extremity, type and length of the seizure. Has it really been going for 2-3 hours or has it come and gone etc. Does he have a seizure plan? I'd like to try and get in contact with his neurologist if he has one too. If it all checks out he might be considered status focal, but its still not a prehospital issue as far as I can see. Far too easy to wheel a person into ED on a ventilator after misinterpreting a bad case of the jitters.

Young guy...any lifestyle/medical issues that could lead to electrolyte imbalance. Toxicology issues. Metabolic disturbances.
Click to expand...

I wish I had more info, but I heard this second-hand a while back...so I really don't have any more info about the seizure activity.
 
Fox800 said:
I wish I had more info, but I heard this second-hand a while back...so I really don't have any more info about the seizure activity.
Click to expand...

Yeah, I understand, I was just thinking out loud :)

Benzos do get used for status focal seizures as far as I know, but much less aggressively and, presumably, after some considerably more high level thinking and testing that we can provide.

In any other person, I would bet good money on electrolyte disturbance, maybe break out the BP cuff and try to illicit trousseau's sign. Even with an established seizure disorder, I still think doctors would want to take blood, probably get neuro consults, take a detailed history etc, before they did much. But I don't know. In fact, I know almost nothing about the intricacies of seizure disorders and even less about this person's specific history. Which is exactly why I shouldn't be making decisions about filling this person with midaz.
 
Ehhh, depends...

Going to our local facilities I'd be very inclined to give him a light dose of benzos as a trial. Reason being is that he's not going to see a neuroloigist in the ED for this and most of what's been mentioned as a root cause will receive objective diagnostic testing (labs, CT, ect). If they fail to terminate with a single, low dose of benzos or return when it wears off then I'd leave it alone. I'd also plan on using a short acting benzo for this reason (not diaz). Remember depending on the ED doc he may not glean a whole lot more from the activity than you do, not a slam on EM just not their specialty.

If we're going somewhere with in house neuro, I'd be more inclined to do nothing and let the guy who has all manner of brain-related minnutae memorized see him.

Most important is that if you decide to treat you doccument the acivity very clearly.
 
I wouldnt have a huge problem giving this guy a small dose of midaz. It really depends on the Hx. If after taking a good Hx it appeared these were indeed focal seizures, why not make him more comfortable by stopping it? As said before most of the tests at the hosp will be objective. Hopefully most paramedics will be able to describe the seizure activity to the receiving neuro doc.
 
For me management depends on a couple of things. Overall no, I don't medicate the majority of focal motor seizures. There are a couple of exceptions though;

1. The focal motor seizures that happen in strange spots that are impairing the patients ability to function.

2. In people with kidney problems if the seizure has been prolonged. These patients have a lower tolerance for potassium being released into the system. It does depend on the "size'" of the seizure, 1 finger vs whole leg.

3. Jacksonian March patients who are known to go into generalized seizure. It is easier to stop it now rather than later.
 
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