Hypoglycemic Seizure — Anticonvulsant before Dextrose?

[CWATT]

I’ve been noodling about this for a while now. It’s an issue I’m pretty amped-up about, but feel like it might create a polarizing response. The issue is this...

I have two seizure protocols that effectively state for any patient experiencing a seizure in presence of hypoglycemia, they are to receive IV Dextrose as first-line treatment rather than anticonvulsants. The second protocol actually requires the paramedic first ‘manage the airway’, establish a full-set of vitals including BGL and temperature, review CBCs, and electrolytes, and establish an IV prior to anticonvulsant therapy. Moreover, these patients are not elligable to receive anticonvulsants until a minimum of 5 minutes has elapsed.

I believe most of us are cognoscent that the protocol-based profession that is Paramedicine is written to the lowest common detonator. The assumption being, if you allow the paramedic to administer anticonvulsants, on cessation of seizure activity the paramedic may assume the underlying cause has been corrected.

My problem is this — is subjecting the patient to a minimum of 5 minutes of apnea, possible self-inflicted trauma, and massive metabolic stress appropriate? The protocols recognize the priority intervention is to ‘manage the airway’ because the patient is not oxygenating or ventilating, however you are not able to do so in a tonic or tonic-clinic seizure. You can insert all the NPAs in the world, if that patient isn’t ventilating because of muscle tone, all you’re about to do with a BVM is pump a bunch of air into their stomach. Moreover, the seizure activity is dramatically increasing their metabolic oxygen demand, possibly exacerbating a primary hypoxic event (think seizure secondary to opiate overdose).

Interestingly, I was evaluated on this very scenario twice. The first time I followed the book and hated myself for it; my theoretical partner was tied-up ‘managing the airway’ while I performed all the assessments and interventions which took much more than 5-minutes (during which time my theoretical patient seized continuously). I discussed it after afterward with the evaluator -a Critical Care Paramedic- who reccomended for purposes of scenario testing I ‘treat concurrently’. When evaluated a second-time (different evaluator) I did as such and subsequently failed. I discussed the failure with a couple people, some supporting my action, others criticizing me for missing ‘basic’ stuff.

I’m curious what the group feels about this. I’m also really curious how seizures are handled in hospital. I struggle to imagine a room full of health-care professionals standing around reviewing a CBC while the patient thrases around on the bed.


- C

 

[Peak]

I think that the best answer isn't going to be particularly straight forward, and how we would assess and treat a patient would depend on individual presentation. Let me give two scenarios to illustrate my point.

You get tones for AMS/Seizures, it's at an address that you respond to frequently with a known resident in his 40s who has relatively well managed IDDM but has been known to get distracted and not monitor his sugars. You arrival to a male with grand mal seizure out front of the residence, his wife reports that he was mowing the lawn, did not eat this morning but did take his morning does of lantus, had started to feel faint so he sat on the grown and a minute or so later started to have a seizure. There is no report or evidence of trauma. While you do note clonic/tonic activity however is is eupnic, has a clear oral airway, mucus membranes are pink/moist/intact, skin is warm/appropriate for ethnicity/mildly clammy, cap refill is brisk.

In this case I have already assessed his airway, breathing, and cardiovascular status. Based on the information so far my assessment is that the patient is most likely hypoglycemic and at this point does not need GABA receptor modifiers from an airway/breathing/cardiovascular status. My management at this point would be to check a blood sugar, establish access, and presuming that his blood sugar is low administer the available IV dextrose solution. I would then continue with the rest of my primary/secondary/ongoing assessments and appropriate management.

Case number two is a early 20s male who is dropped off at the ambulance bay at 0030 by friends who then immediately leave. The patient appears pale, has copious oral secretions/sonorous respirations, capillary refill is approx 3 seconds. Skin is dry and hot. Patient with myoclonic/tonic activity that appears much more severe on the right side over left. You note from a distance that the patient has a much more dilated left pupil. The patient is wearing a camel back, has on copious body glitter, and the obligatory rainbow marijuana leaf fitted flat bill hat, and you recall that since it is december 30 it is now the first night of decadence.

In this case I would expect a much more "typical" approach to assessment and management. His airway is at risk and needs to be managed, and his initial presentation does not necessarily present a reassuring cardiovascular status. You were provided no history from the friends, and cannot exclude any of your AMS considerations including trauma or toxicity. I would expect C-Spine management, airway management, IV access/POC labs including BLG/BMP/VBG/Trop, full vitals/monitor, 12 lead, et cetera during his initial management. Due to his tonic/clonic activity, poor respiratory status, and concerning cardiovascular status I would expect the patient to be given a dose of versed. In this scenario the patient's BGL just came back at 34 so you would also treat him with IV dextrose. Due to his lack of history and concerning initial presentation he will still be a full workup and is far from done with his evaluation.

If the patient is hypoglycemic and seizing then we should be addressing the cause of the problem and giving dextrose. I don't necessarily expect for clinicians to immediately have a BGL and wouldn't necessarily fault them for giving a benzo, however their AMS evaluations should always include glucose testing during the initial phases. I also wouldn't want someone to preclude benzos because a blood sugar is mildly low, if a patient was consuming glucose from their myoclonic activity they may have mild hypoglycemia that is neither causative nor will glucose remedy, although that would still need to be managed.

As an aside I have had patients who did maintain their own airway and were eupnic during grand mal seizures, although certainly more in kids than adults.

I would value all of the experience being offered to you in school, but also understand that the real world and the classroom are not the same. Working on the engine and bus were not the same as medic school, and working in the ED was nothing like nursing school. I would recommend against bucking the system as a student, just understand that their is learning in addition to the classroom (and once you have experience then you can try to address the educational system).

Other than a BGL we don't often consider lab work during the primary/secondary assessment and management. Infection can certainly exacerbate seizure disorders (in addition to other maladies that may present changes on their CBC), but that does not preclude the need to provide them appropriate initial management. Our patients rarely come in with a recent CBC, and even the fastest POC CBC machines still take about 5 minutes to result though I have yet to see one in a major ED (they are typically in freestanding or critical access hospitals) and those ran in the lab typically take 10-20 minutes to result after being sent up.

 

[DrParasite]

The second protocol actually requires the paramedic first ‘manage the airway’, establish a full-set of vitals including BGL and temperature, review CBCs, and electrolytes, and establish an IV prior to anticonvulsant therapy.

Do you frequently get the results of CBC and electrolytes in the field? I don't think I have ever seen the results obtained prior to an intervention being provided.

I’m also really curious how seizures are handled in hospital. I struggle to imagine a room full of health-care professionals standing around reviewing a CBC while the patient thrases around on the bed.

That's a question for a neurologist. I have heard (and never verified if it was correct) that in the hospital, practitioners will leave patients actively seizing (typically not grand mal, but other types) for hours before initiating pharmacological intervention to stop the seizure.

BTW, if you give an anticonvulsant to the hypoglycemic seizure, your patient is still in bad shape... cardiac arrest may soon follow. The sign (the seizure) has stopped, but the underlying condition is still very present. If you give dextrose, the patient's BGL rises, their condition improves, and you don't have the side effects of the benzos skewing your followup patient assessment to see what is going on with the patient.

 

[Gurby]

If you got called for a seizure, you get there and they're still seizing, it's been >5 minutes already. I would guess that the protocol is written the way it is so that if you have an IFT and they start to seize, you don't immediately reach for benzos because seizure will probably break on its own?

Would take a real convincing history for me to give glucose before benzos when arriving on scene to find somebody seizing.

LOL at full set of vitals and an IV on your actively seizing patient. I wonder if you are misinterpreting the protocol? Maybe post it here?

 

[medichopeful]

That's a question for a neurologist. I have heard (and never verified if it was correct) that in the hospital, practitioners will leave patients actively seizing (typically not grand mal, but other types) for hours before initiating pharmacological intervention to stop the seizure.

In the ICU, we generally don't allow patients to actively seize for hours. However, it might be different if it's on a different unit (sleep lab, etc), where they may let it last to get a better understanding/evaluation of the seizure.

BTW, if you give an anticonvulsant to the hypoglycemic seizure, your patient is still in bad shape... cardiac arrest may soon follow. The sign (the seizure) has stopped, but the underlying condition is still very present. If you give dextrose, the patient's BGL rises, their condition improves, and you don't have the side effects of the benzos skewing your followup patient assessment to see what is going on with the patient.

Terminate the seizure with benzos, then treat the cause. Preferably with a short-acting agent to allow neuro follow-up, but in status epilepticus use whatever you have.

 

[medichopeful]

I’m curious what the group feels about this. I’m also really curious how seizures are handled in hospital. I struggle to imagine a room full of health-care professionals standing around reviewing a CBC while the patient thrases around on the bed.
- C

With benzos (or propofol at times). That being said, not all seizures are treated, some are just observed.

Keep in mind that treatment and evaluation doesn't end after the seizure is terminated. It's not like we give a benzo, then just move on. The benzo is the "emergent" treatment, then follow-up treatment follows (keppra, lytes, etc.).

 

[CWATT]

@Peak — thank you for the response. I’ve read it twice already and will look at it again in the morning once I’ve digested it some more.

@DrParasite — if we’re doing an IFT, we can get a CBC en-route or available upon request at the sending. That’s interesting angle on the follow-up neuro exam. The protocols for one area I’m registered to work list head-trauma as a contraindication for analgesia for this exact reason. I disagree with this, but protocols be protocols.

@Gurby — So I’m actually dealing with two protocols. I’m reluctant to post a photo, but the algorithm for one requires a BGL check, and if ‘yes’ to hypoglycemic, it states to proceed with Hypoglycemic protocol. Thus, you can only proceed to anticonvulsants if ‘no’ to hypoglycemia, meaning IV Dextrose is first line, and benzos are only indicated once measurable, corrected blood Glucose levels. It also directly states ‘hypoglycemia’ as a contraindication to anticonvulsants.

The second begins with “seizure onset” followed by the following list (bold indicates an intervention):

- Support ABCs and provide oxygen
- Monitor closely for loss of airway reflexes, respiratory depression, hypotension (BP), or cardiac arrhythmias
- Assess LOC
- Attach Cardiac, SpO2 monitors
- Establish IV/IO access if not already obtained
- Consider possible causes for seizures
- Blood Glucose check
- Check temperature and continue to monitor
- Evaluate CBC, electrolytes (Na+, Ca+, Mg+)

Once 5 Minutes has elapsed, administer Midazolam

A note on this algorhythm — ‘hypoglycemia’ is listed as the contraindication to Midazolam, but also states to treat concurrently if seizing present. Thus, if you have to go through the list first, once you’ve identified hypoglycemia, prior to 5-minutes of elapsed time, IV Dextrose is first-line treatment. It’s for this reason why I had to state in my original post IV Dextrose is ‘effectively’ first-line when speaking about both protocols.

@medichopeful — I very much agree treatment doesn’t end with benzos; it’s actually my theory why the standing orders (protocols) are written in such a way that it forces medics to investigate possible underlying causes before treatment with anticonvulsants.

 

[Carlos Danger]

Keep in mind that the vast majority of seizures self-terminate within 5 minutes, which is probably why these protocols advise to wait that long before giving benzos. However it is also true that the longer a seizure goes on, the more resistant it is likely to be to benzos. Also, I think we all know that hypoglycemia is the most common correctable cause of seizures. Lastly, people do usually breath some during a generalized seizure and brief seizures aren't considered all that harmful.

What this means in practice, is that if you respond to a call and find a person seizing and know nothing about their history, benzos are the best bet, followed by an attempt to identify the cause of the seizure, which of course means getting a BGL (and any other assessments you have the ability to obtain) as soon as possible and treating further based on those. If on the other hand, the seizure initiates in your presence, it is probably a good practice to support ABC's (NC, maybe an NPA) to whatever extent you can and get a BGL and wait a few minutes to see if the seizure stops on it's own, which they usually do.

At least that's how I approach these scenarios, whether I'm in the hospital or out on the truck.

 

[ParamagicFF]

In general, if I'm called for a seizure and arrive to find the patient still seizing, they are probably getting versed after an ABC check. The less desirable effects of giving versed to a seizure secondary to hypoglycemia seem less significant to the problems caused by allowing a person to continue seizing when they already have been for at least 5-10 minutes already.

I've had this discussion with a few OMDs I've worked for, and they've all agreed to stop attempt to stop the seizure. Conversely, if while I'm assessing a hypoglycemic patient they begin to seize, I'm going to ensure I get the dextrose on board before dropping everything and grabbing the versed. If the seizure activity prevents me from getting a line quickly, maybe I'll deviate.

In protocol situations like this, I find a good narrative will explain everything. It's really hard to write a protocol with the treatment considerations we're discussing in a way that protects the OMD from the "lowest common denominator". Document why you did what you did, and you should be fine. If that's not the case, I would look for a different system ASAP.