Seizure

[usalsfyre]

Fairly straightforward, but I'm interested to see how other would have handled it.

Time is about 0400. Dispatched for a seizure along the interstate in a passenger bus on arrival found a male patient in his late 20's curled in roughly the fetal position over two seats. No family or friends on the bus, the patient is traveling alone. We're approximately 2 hours from the originating city and 4+ from the destination. Bystanders stated he had a brief grand mal seizure. Patient will look your direction upon speaking to him, but will not respond verbally.

HEENT: Head is intact, airway open but drool is coming from the corner of his mouth. Eyes are spontaneously open, pupils appear to be about a 3. Pt has good facial symmetey. Attempts at assessing further are met with the patient attempting to bite you.

Chest: Equal rise and fall noted, unable to assess further as the patient attempts to bite/strike you

Abdomen: Ditto from above, no signs of trauma.

Extremities: Intact, don't try to touch them though.

Vitals: Unable to obtain due to the patient's agitation and combativeness.

Patient is in the middle of the bus, other passengers are growing angry the bus isn't continuing on to it's destination/you're in their way to get out and go smoke. You've got a full ALS drug box, another truck happens to be in the area should you need it.

 

[wyoskibum]

Could be anything....

Fairly straightforward, but I'm interested to see how other would have handled it.

First and foremost I would check for Medical Alert and do my best to obtain a BGL. Perhaps see if there is any info in his wallet if you can get it.

Is the pt post ictal from a breakthrough seizure and pt has a Hx of seizures or is there another cause? I've had many a pt who had a "Grand Mal Seizure" but has a BGL of 20. Is there evidence of ETOH or drug abuse? Perhaps this a withdrawl seizure?

I would do my best to get the pt off the bus and into the Ambulance as the pt is altered. Call for additional help if you think you might have restrain pt.
Continue assessment & differential diagnosis, transport when you can.

 

[Veneficus]

Fairly straightforward, but I'm interested to see how other would have handled it.

Time is about 0400. Dispatched for a seizure along the interstate in a passenger bus on arrival found a male patient in his late 20's curled in roughly the fetal position over two seats. No family or friends on the bus, the patient is traveling alone. We're approximately 2 hours from the originating city and 4+ from the destination. Bystanders stated he had a brief grand mal seizure. Patient will look your direction upon speaking to him, but will not respond verbally.

HEENT: Head is intact, airway open but drool is coming from the corner of his mouth. Eyes are spontaneously open, pupils appear to be about a 3. Pt has good facial symmetey. Attempts at assessing further are met with the patient attempting to bite you.

Chest: Equal rise and fall noted, unable to assess further as the patient attempts to bite/strike you

Abdomen: Ditto from above, no signs of trauma.

Extremities: Intact, don't try to touch them though.

Vitals: Unable to obtain due to the patient's agitation and combativeness.

Patient is in the middle of the bus, other passengers are growing angry the bus isn't continuing on to it's destination/you're in their way to get out and go smoke. You've got a full ALS drug box, another truck happens to be in the area should you need it.

As was stated, i would check the BGL, that shouldn't be too bad.

I would also hang out on scene for a few minutes, when people are post ictal, they can become combative for s short time until they are oriented. (I know the op knows, not for his benefit)

If he seizes again, then we can break out the benzos and get him out into the truck etc. But waiting a few minutes to see if the kid comes around so we can have a little chat and see what is going on. At the very least if he becomes a little more oriented, it will make procedures as little easier.

If this is his first seizure, then we're off to the hospital. If it is something with a history, we'll make a call when we know what it is and what is going on.

The passengers should get over it, though I might offer to get out of the way for a minute while they pass the isle. A little good will goes a long way.

 

[usalsfyre]

Ask....

...and ye shall receive

BGL is 130 done of a lancet to the bicep while you wade through the punches/kicks/bites. You notice the patient is diaphoretic during this.

It's been 10 minutes, patient is still combative and you've been unable to remove him from the seat (think of someone laying in an airline seat, with his feet towards you who doesn't want to come out) or get a set of vitals. The pt is talking now, alternating screaming obscenities at you and crying for "mama". The patient is also now occasionally (every couple of minutes) vomiting clear mucous.

 

[EMSrush]

This is a good thread....

I have placed NRB's on biting patients in the past with success, but would be cautious due to the vomiting in this case, would definitely keep suction handy.

What'cha got in your drug box in this case?

 

[18G]

Sounds like maybe a toxicological cause to me.... his behavior and presentation does not seem to fit most typical postictals.

At this point in the scenario I would make sure he continues to maintain his airway and breathing and circulatory status.

For now since he is stable from what info were able to obtain... my goal would be to get him in the back on the ambulance where he can be better managed. The only way to assess him and get him off the bus is to sedate him.

...also diaphoresis... seizure activity... emesis.... drooling... not in a likely setting and maybe a far out consideration but consider some type of poisioning from the organophosphates.

 

[Sam Adams]

his behavior and presentation does not seem to fit most typical postictals.

...also diaphoresis... seizure activity... emesis.... drooling...

I respectfully disagree. I've seen them individually and collectively. The only other physical findings I expected to read from this scenario were oral/ lingual trauma and urinary and fecal incontinence.

 

[18G]

The majority of epileptic postictals I've cared for where lethargic and confused.... no emesis and not diaphoretic... a little moist from the amount of energy expended... but not what I would call diaphoretic.

If the seizure was drug or other tox induced than I would expect a different presentation. Something about this patient isn't ringing out a typical postical seizure patient.

 

[Veneficus]

...and ye shall receive

BGL is 130 done of a lancet to the bicep while you wade through the punches/kicks/bites. You notice the patient is diaphoretic during this.

It's been 10 minutes, patient is still combative and you've been unable to remove him from the seat (think of someone laying in an airline seat, with his feet towards you who doesn't want to come out) or get a set of vitals. The pt is talking now, alternating screaming obscenities at you and crying for "mama". The patient is also now occasionally (every couple of minutes) vomiting clear mucous.

Then I call the other crew and the cops and he gets moved to the truck for his $1 million workup and ride to the hospital.

 

[usalsfyre]

What'cha got in your drug box in this case?

Benzodiazapine of your choice.

 

[Veneficus]

Benzodiazapine of your choice.

Versed is my favorite flavor. (for patients of course, never had any myself, but if I were to choose something for me, I will have some ketamine please. Never had that either, but I really like what I have seen it do)

 

[usalsfyre]

Then I call the other crew and the cops and he gets moved to the truck for his $1 million workup and ride to the hospital.

Pretty much what we did. Two of Ativan IN, have no idea how much was actually absorbed, but he did mellow considerably. The difficulty with this case was access while he was in the bus seat, every time anyone latched onto him to remove him he got away due to the diaphoresis or attempted to assault. We were able to talk him out post loraz. Went to the truck, still agitated when we messed with him, but didn't fight us when we left him alone. We were able to get the cardiac monitor on him, but he fought everything else considerably.

Enroute, he seized again, seizure terminated with more lorazepam IN and full vital signs, ect obtained. Ativan seemed to have a VERY short action in this guy, 5 to 7 minutes and it was like we gave him nothing. As long as we left him alone, he slept. We touched or spoke to him, he came unglued. On arrival at ED he was snoozing comfortably. Awoke long enough at the ED to tell him his name, that he had a hx of seizures and took Dilantin. Then he became combative again. Unable to follow up further than that so far.

Bonus point for anyone (besides Vene and JPINFV) that can tell me why he burned through the Ativan so fast.

(Hint:look at the little history you have)

 

[EMSrush]

Pretty much what we did. Two of Ativan IN, have no idea how much was actually absorbed, but he did mellow considerably. The difficulty with this case was access while he was in the bus seat, every time anyone latched onto him to remove him he got away due to the diaphoresis or attempted to assault. We were able to talk him out post loraz. Went to the truck, still agitated when we messed with him, but didn't fight us when we left him alone. We were able to get the cardiac monitor on him, but he fought everything else considerably.

Enroute, he seized again, seizure terminated with more lorazepam IN and full vital signs, ect obtained. Ativan seemed to have a VERY short action in this guy, 5 to 7 minutes and it was like we gave him nothing. As long as we left him alone, he slept. We touched or spoke to him, he came unglued. On arrival at ED he was snoozing comfortably. Awoke long enough at the ED to tell him his name, that he had a hx of seizures and took Dilantin. Then he became combative again. Unable to follow up further than that so far.

Bonus point for anyone (besides Vene and JPINFV) that can tell me why he burned through the Ativan so fast.

(Hint:look at the little history you have)

Because he was already taking Dilantin. The Dilantin altered the rate at which the Ativan was metabolized.

 

[Sandog]

Bonus point for anyone (besides Vene and JPINFV) that can tell me why he burned through the Ativan so fast.

Phenytoin can speed up the removal of many other drugs from your body by affecting certain liver enzymes. This can affect how well these other drugs work.

???

Oops Rush beat me to it...

 

[usalsfyre]

Rush/Sandog, very astute. Now go see how many of your coworkers know that.

 

[EMSrush]

Rush/Sandog, very astute. Now go see how many of your coworkers know that.

I was wondering if you suspected this phenomenon when he burned through your Ativan so quickly...?

 

[usalsfyre]

I was wondering if you suspected this phenomenon when he burned through your Ativan so quickly...?

Yeah, inital presentation struck me as a seizure, and after my first vitamin A dose wore off in 5 minutes I had a strong suspicion phenotyin was probably a factor in this little goat rope. He went from "I'm chilled out enough to let me talk me out if the bus" to agitated and combative between exiting the bus and getting in the ambulance.

 

[18G]

I was not aware of the interaction of phenytoin and benzo's... so thanks for sharing the scenario.

I wanted to know more about this interaction and from what I have been able to find online, the interaction between the two usually increases the effect of the phenytoin which can make the patient prone to phenytoin toxicity. The benzo's inhibit the metabolism phenytoin.

I wasn't able to find much that relates to the phenytoin decreasing the benzodiazopine effect. If anyone has some links to resources on this interaction I would appreciate reading em.

 

[Aidey]

Sounds like maybe a toxicological cause to me.... his behavior and presentation does not seem to fit most typical postictals.

...also diaphoresis... seizure activity... emesis.... drooling... not in a likely setting and maybe a far out consideration but consider some type of poisioning from the organophosphates.

I think I've been puked on by more postictal patients than any other type, except maybe drunks. If there is one thing I have learned about people's postictal periods it is that pretty much anything can happen.

Pretty much what we did. Two of Ativan IN, have no idea how much was actually absorbed, but he did mellow considerably..... seizure terminated with more lorazepam IN and full vital signs, ect obtained.

Say what? What kind of Ativan and IN devices are you using? I know for a fact that we can not push Ativan though our IN devices, because of the Ativan not being water based. When we tested it out (with expired Ativan) it eventually shot out in a straight stream through the very tip once enough pressure was applied.

 

[18G]

In 15 years of active volley and career service I can't recall any that puked in my care. Foaming, heavy secretions yes.... but none that I can remember that actually vomited... strange.