Melclin
Forum Deputy Chief
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We have a patient locally who has recently been recognised as a frequent flyer after discussing his most recent presentation, ?continuous seizures.
I realise some of this information is not entirely clear but we’re working on a lot of second hand information at the moment. His most recent presentation was as follows.
32YOM, with an unclear hx per brother, of “quadriplegia”, wheelchair bound, insensate bellow the ribs, but the brother is bizarrely non-specific about his motor function. Per another source, the pt has no ability to use his legs.
He also has a recent hx within the past ~6mths of several presentations for seizures that have been seen and treated in several ways.
• At one centre he had undergone a number of investigations during his admission and his seizures were left untreated during that time. Per the brother, he was told at that stage that he was “faking it” and that it was “in his head”. Advice from the same centre RE his current presentation was “pseudoseizures” and they highly recommend not treating him.
• His seizures have been attributed to medication reactions, particularly tramadol, by ED doctors at a different centre.
• He has been treated with midazolam unsuccessfully we believe both at hospital and by ambulance with at least one previous ambulance attendance leading to the pt being RSI’d.
His current presentation strikes the crew immediately as not being the typical tonic clonic seizure.
His airway is patent and clear, no secretions or vomitus, no snore or grunting, despite the movement his tidal volume appears adequate, nil increased WOB, RR of ~20, mildly hypertensive & tachycardic, no more diaphoretic than any other person in the room due to the ambient heat, warm pink skin. BSL 7.2, Temp 36.6.
I’m not sure how much a description will help but I’ll give it a try anyway for anyone who might be interested. He was found seizing after his brother returned home and was still seizing on ambulance arrival (30mins). He continues to seizure until terminated, total of approx 60 mins). His jerking movements are asymmetrical, reasonably infrequent and at irregular intervals. They are relaxed & controlled motions that appear voluntary. It has none of the violence of the early clonic phase and none of the subtle, unnatural looking clonus of a prolonged seizure. At irregular intervals the activity calms to an occasional shudder and returns 20-30 seconds later. PEARL 4mm. His eyes are gently closed, and when opened, alternate between tracking normally, ++ rapid laterally beating nystagmus and R deviation. He appears to have no threat reflex. Touching his eyelashes elicits no movement of the eyelids. His abdominal muscles are contracting rhythmically. He makes occasional movements that appear coordinated at some level such as grasping the side of the stretcher for a few moments. Concerted efforts at painful stimuli illicit no response.
He is on warfarin and has been complaining of headaches for several days.
In this instance, 20mg IM midazolam terminate the activity after a surprising delay, leaving the pt GCS 3 but with intact airway reflexes and normal resp effort/rate/SpO2. 30 mins later the ‘seizure activity’ begins again, does not respond to 5mg IV midazolam, and the pt is intubated via RSI. After intubation the pt requires heroic amounts of sedation and analgesia to maintain the tube. He remains a mystery to the ED doctors.
The problem: We will see this patient again and question is what we do in the future.
Withholding treatment leaves open the possibility that his unusual presentation of legitimate generalised seizures requiring termination go untreated and his airway goes unprotected.
Treating him subjects him to some reasonably dangerous interventions including RSI. He is not an easy tube and RSI is not without risk anyway. Not to mention the burden on the system of having to deal with an unnecessarily intubated patient.
From the description of this situation, can anyone offer opinions on terminate/not to terminate dilemma, and how this might relate to the different kinds of seizure he might be having?
Might his spinal injuries affect the way his seizures present?
We will be following up on this patient via management in the hopes of developing a management plan for the future.
I realise some of this information is not entirely clear but we’re working on a lot of second hand information at the moment. His most recent presentation was as follows.
32YOM, with an unclear hx per brother, of “quadriplegia”, wheelchair bound, insensate bellow the ribs, but the brother is bizarrely non-specific about his motor function. Per another source, the pt has no ability to use his legs.
He also has a recent hx within the past ~6mths of several presentations for seizures that have been seen and treated in several ways.
• At one centre he had undergone a number of investigations during his admission and his seizures were left untreated during that time. Per the brother, he was told at that stage that he was “faking it” and that it was “in his head”. Advice from the same centre RE his current presentation was “pseudoseizures” and they highly recommend not treating him.
• His seizures have been attributed to medication reactions, particularly tramadol, by ED doctors at a different centre.
• He has been treated with midazolam unsuccessfully we believe both at hospital and by ambulance with at least one previous ambulance attendance leading to the pt being RSI’d.
His current presentation strikes the crew immediately as not being the typical tonic clonic seizure.
His airway is patent and clear, no secretions or vomitus, no snore or grunting, despite the movement his tidal volume appears adequate, nil increased WOB, RR of ~20, mildly hypertensive & tachycardic, no more diaphoretic than any other person in the room due to the ambient heat, warm pink skin. BSL 7.2, Temp 36.6.
I’m not sure how much a description will help but I’ll give it a try anyway for anyone who might be interested. He was found seizing after his brother returned home and was still seizing on ambulance arrival (30mins). He continues to seizure until terminated, total of approx 60 mins). His jerking movements are asymmetrical, reasonably infrequent and at irregular intervals. They are relaxed & controlled motions that appear voluntary. It has none of the violence of the early clonic phase and none of the subtle, unnatural looking clonus of a prolonged seizure. At irregular intervals the activity calms to an occasional shudder and returns 20-30 seconds later. PEARL 4mm. His eyes are gently closed, and when opened, alternate between tracking normally, ++ rapid laterally beating nystagmus and R deviation. He appears to have no threat reflex. Touching his eyelashes elicits no movement of the eyelids. His abdominal muscles are contracting rhythmically. He makes occasional movements that appear coordinated at some level such as grasping the side of the stretcher for a few moments. Concerted efforts at painful stimuli illicit no response.
He is on warfarin and has been complaining of headaches for several days.
In this instance, 20mg IM midazolam terminate the activity after a surprising delay, leaving the pt GCS 3 but with intact airway reflexes and normal resp effort/rate/SpO2. 30 mins later the ‘seizure activity’ begins again, does not respond to 5mg IV midazolam, and the pt is intubated via RSI. After intubation the pt requires heroic amounts of sedation and analgesia to maintain the tube. He remains a mystery to the ED doctors.
The problem: We will see this patient again and question is what we do in the future.
Withholding treatment leaves open the possibility that his unusual presentation of legitimate generalised seizures requiring termination go untreated and his airway goes unprotected.
Treating him subjects him to some reasonably dangerous interventions including RSI. He is not an easy tube and RSI is not without risk anyway. Not to mention the burden on the system of having to deal with an unnecessarily intubated patient.
From the description of this situation, can anyone offer opinions on terminate/not to terminate dilemma, and how this might relate to the different kinds of seizure he might be having?
Might his spinal injuries affect the way his seizures present?
We will be following up on this patient via management in the hopes of developing a management plan for the future.
