Seizures in General

[wchawkins]

Ok, today in EMT-B, we went over the chapter on seizures, the works. I wanted to see what actually happened, so I did some searching on the net. Only thing I really have to say is, in my opinion, it is going to be really tough seeing younger ones, especially ones having grand mal seizures... Is this pretty much true, or is it not as bad as I am thinking?

 

[Ridryder911]

Actually seizures are usually very short or brief (usually < 30 seconds). It is unusual to actually see seizure activity in many of the seizure calls dispatched to. Usually, if one does so happen to see a seizure it is r/t non-compliance to medication or therapuetic level if medicine is off.

In regards to children, I much rather see seizures in children than adults. Reason, many are febrile that are benign and can be treated and prevented, unlike adults of that can be r/t tumors, electrolyte imbalance, serious cardiac problems and of course epliepsy.

R/r 911

 

[mycrofft]

Talk to a seizure patient. It helped me.

In fact, there is a statistical likelihood one of your friends or acquaintances has seizure disorder.
On the majority of the true seizure cases I've been on, the seizure was over by the time we got there. The majority of the pseudoseizure cases, the pt was still apparently seizing.

Don't be afraid, just remember the basics and that the patient is very vulnerable in every way, including socially and psychologically.

Oh, and take away their car keys! (Just kidding except that it's a good idea and at least in California the DMV is supposed to receive reports if drivers have seizures).

PS:Ridryder, how about toxic/pharmaceutical?

 

[LucidResq]

I've lived with my dad and my dad only for over 9 years. When I was 10 he randomly had a grand mal seizure. Now that was terrifying as I had no idea what the hell was going on and I was alone with him at home.

He continued to have a few sporadic seizures for a couple of years afterwards, and each time it got easier for me to deal with. In fact, I felt pretty calm during his 3rd seizure.

I'm sure the same thing happens in EMS, especially when it's not your emergency. The more you see it the less anxiety it causes.

BTW - the cause of the seizures was ruled idiopathic, but he has them under control with medication and hasn't had one for about 2 years.

 

[Ridryder911]

PS:Ridryder, how about toxic/pharmaceutical?

True, there are definite induced seizures from ingestion or withdraw of toxic and pharmaceutical as well as alcohol and hypoglycemic induced. There are as many causes as different types of seizures.

 

[mikie]

Another aspect of the seizure is the posticale (sp?) state*. It can be 'interesting' -disoriented, unaware of their surroundings, etc.

Some with epilepsy may not have the standard big convulsing seizures, rather (correct when I'm wrong) petite-mal and it can appear ALOC, some convulsing, (one of my pts. turned most of his body all the way (at the torso) around, kinda creepy)

*And ya, often, when dispatched for a seizure, they aren't activity convulsing

 

[KEVD18]

"seizures are fun to watch, boring to diagnose"

 

[Ridryder911]

Another aspect of the seizure is the posticale (sp?) state*. It can be 'interesting' -disoriented, unaware of their surroundings, etc.

Some with epilepsy may not have the standard big convulsing seizures, rather (correct when I'm wrong) petite-mal and it can appear ALOC, some convulsing, (one of my pts. turned most of his body all the way (at the torso) around, kinda creepy)

*And ya, often, when dispatched for a seizure, they aren't activity convulsing

Postictal and petit-mal... The big one (generally considered) is grand-mal or sometimes the Jacksonian seizures or Jacksonian march.

Remember, the general seizure has three phases :

Tonic- pre seizure, < LOC, moaning, head turns muscles becomes somewhat rigid

Clonic- the spastic movements, convulsive movements (we DON't call them fits also)

Postictal- the relaxation of the seizure.

If the patient has one continous seizure (usually > 30 minutes) without an increase or change in LOC for more than 5 minutes then it is considered to be Status epilepticus a life threatning problem.

 

[BossyCow]

I had a child who presented with what the doc called 'salaam seizures' apparently common in young children. Where the child bends forward at the waist like they are bowing. Very odd, a slow gentle movement unlike the more common grand mal.

 

[gillysaurus]

One of my first calls ever as an EMT was a little girl (about 2 y/o) in status seizure. She seized for 27 minutes total before they were able to bring her out of it even for just a little bit, and that was long after we'd handed her off at the ED. She didn't respond to what seemed like half her body weight in anti-seizure drugs, she just looked totally helpless as her body writhed around the whole time.

In fact, now that I'm thinking back to it, the poor thing went into cardiac arrest after several failed intubation attempts by a flight medic at the ED. They got her back, but they suspected brain damage as a result. Later on in the night we got word that she had finally stopped seizing and started showing purposeful movement.

We ruled out febrile seizure in the field and, surprisingly, they ruled out trauma at the ED. I still don't know what was causing her to seize like that.

For some reason, for me, it wasn't difficult to see her in that state. She was so little and everyone cared so much for her well-being that it wasn't scary or sad. Granted, I don't have children or young siblings, but it wasn't nearly as bad as I thought it would be. Later that night we had a boy with febrile seizures (he was post-ictal when we arrived) and that was a much sadder call because the boy was clearly neglected.

You'll likely not come across something as severe as the little girl. But even if you do, you'll be okay. We all get through the stuff that we think is going to scare the poo out of us!

 

[mikie]

If the patient has one continous seizure (usually > 30 minutes) without an increase or change in LOC for more than 5 minutes then it is considered to be Status epilepticus a life threatning problem.

I thought (or believed to had read in my text) it was 10 minutes to be considered status elipticus?

 

[housert]

I work with student's with special needs for my "real" job and have seen just about any tupe of seizure you can think of. From Grand Mal to them stripping their clothes off and running into things. If you have never seen someone having a seizure it can be a little scary, but after you know what to do, you just respond and don't think of it especially if you have someone who uses a Diastat or has the magnet bracelet that you have to use.

 

[Ridryder911]

I thought (or believed to had read in my text) it was 10 minutes to be considered status elipticus?

This standard was from the American College of Emergency Physicians.

 

[mikie]

This standard was from the American College of Emergency Physicians.

so are you saying it is 30 minutes? cause that's a darn long time!

 

[mycrofft]

We use five minutes. The big issue is this:

While the CNS is out to play, who's taking care of the respirations?

Let's see, also: psycohomtor seizures, which enable you to plead innocent to crimes because you had a four day one (that sorta blows the five minute limit; is jail time then the postictal state?); and the short seizureform activity after a vasovagal episode (say, after an immunization and you're shot-phobic) or heavy valsalva maneuver (cough til you pass out).

Many of the so-called diagnostic signs of a grand mal seizure can be absent from a real seizure, but the tried and true S/S of a pseudo seizure are rarely present in a true grand mal seizure. I love to snap that ammonia behind my back, walk up quietly and put it immediately under the nose..."Uh, where am I? I had a seizure". (The patient rarely rememebrs the seizure; as in LOC, often the question "Do you remember waking up?" is better).
Again, I'm impressed by my co-posters! This is time well spent.

 

[So. IL Medic]

There are many types of seizures. A brief overview can be found at Washington U Med School http://neuro.wustl.edu/patientcare/...enter/patientfamilyphysician/seizuretypes.htm

However, I have never liked the way pseudoseizure is bandied about by EMS and ER personnel. Too often it is assumed that the pt is "faking it." Pseudoseizure generally refers to anti-epileptic medication resistant seizures that are very real but do not have an organic cause. Instead, they are psychogenic. Not fake but caused by genuine psychological disoders.
http://www.emedicine.com/NEURO/topic403.htm

As to status epilepticus, Rid is correct is stating the traditional definition is 30 minutes of continual or a series of seizures without return to normal LOC.

For the last ten years, this definition has been narrowing due to concerns over neural damage of seizures lasting over five minures. Many now use the five minute definition.

http://www.emedicine.com/emerg/topic554.htm

 

[mikie]

While the CNS is out to play, who's taking care of the respirations?

From what I recall, if the patient is seizing for an extended period of time and does not seem to be profusing well & shallow resp. to attempt to bag similar to 'blow-by' where you're bagging, just not a tight mask seal b/c of the convulsions. is this correct to some extent?

 

[AlaskaEMT]

In the hospital today I assessed a post-seizure pt and discovered Todd's Postictal Paralysis. The nurses and doc missed it.

 

[mycrofft]

Way to go, Alaska. Mikie...

If a patient is respiring too shallowly, ventilation is indeed needed, but when the chest is rigored...not easy.

 

[BruceD]

** Beaten to it! ** mods you can delete this ...

There is ongoing debate about the definition of status as determined by length of seizure.

The local neurologists (your mileage may vary) use 20 mins of continuous seizures or multiple seizures where the patient does not regain full consciousness between seizure episodes as their definition of status epilepticus.

At least one study has demonstrated that seizures lasting longer than 5 mins in adults and 7 mins in children are unlikely to spontaneously resolve.
(ref: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=321036#b14 )

(from the above reference)... In the PHTSE study, 79% (55 of 71) of patients given placebo were still seizing at the time of arrival at the emergency department. These observations suggest that, in adult patients, seizures lasting more than five minutes are unlikely to end spontaneously.

Prospective studies in children also suggest that if a seizure continues for more than seven minutes, it is unlikely to end soon spontaneously. Shinnar and colleagues 13 studied the duration of first unprovoked, afebrile seizures in 407 children. ...