Seizures

[tah06090]

When walking into a seizure what are the 2 things you look/wanna know right off, ie blood glucose, hx epilepsy, trauma, pupils just curious we did neurology 2 weeks ago in class and everyone said something different wanted some more opionions thanks

 

[vquintessence]

Personally I believe the two big ones would be ruling in/out trauma and the pts PMHx? On another note however I'd like to contradict my recommendation...

I would avoid trying to limit it to such a narrow criteria to be on the lookout for. Use all the appropriate clinical presentations as a process of inclusion/exclusion for differential and working diagnosi.

You've mentioned many of the significant factors/signs already, and hell, a couple of those will have huge rammifications to your treatment, sense of urgency and preparation. Each scenario is obviously unique; no SZ fits the same exact treatment modality.

Ex 1: Generalized SZ witnessed tonic-clonic activity. (+)hx of SZ, pt is med compliant with 250mg Keppra x3 daily however despite recent med increases, he has been experiencing several "break throughs" in the past two weeks.

Ex 2: Generalized SZ witnessed tonic-clonic activity. No prior hx SZ according to the concerned loved one. Pt was recently "rowdy" in a bar and consequently he was thrown outside head-first to the sidewalk by bouncers doing their job.

Which pt should require a higher index of suspicion regarding differential dx? Which one may require the most intense amount of assessment, preparation and long term treatment? The questions are rhetorical, but you get the point; sorry I'm in a bored & ranting state...

 

[tah06090]

Thanks i know what you mean about doing athourough assesment but one instructor was like doesnt matter what the seizure is from hit them with benzos right off and another was like before govong benzos figure out if its ie diabetic his logic was fix it instead of masking it sort of mentality/ over medicating giving one drug instead of 2

 

[Shishkabob]

How long it's been happening (if active) and medical history.

 

[Lifeguards For Life]

When walking into a seizure what are the 2 things you look/wanna know right off, ie blood glucose, hx epilepsy, trauma, pupils just curious we did neurology 2 weeks ago in class and everyone said something different wanted some more opionions thanks

do they have a history of seizures, and how long have they been seizing for.

 

[Veneficus]

Thanks i know what you mean about doing athourough assesment but one instructor was like doesnt matter what the seizure is from hit them with benzos right off and another was like before govong benzos figure out if its ie diabetic his logic was fix it instead of masking it sort of mentality/ over medicating giving one drug instead of 2

I think the "one drug instead of two" has some failed logic to it.

Benzos and glucose (dextrose) have completely different mechanisms. You are not giving opposing or synergistic medications.

But let's make it a learning experience and consider the logistics of it.

If you have a seizing patient. (a seizure is life threating no matter what the cause.) In many instances the benzo does stop the siezure. (protects the brain, heart, and diaphragm)

If you have hypoglycemia and a seizing patient are you planning to fight with and restrain (with all the stress that can cause) the patient start an IV and then try to push a med that is necrotic if it extravasiates?

Are you planning to just stab the PT. with IM glucagon and let him seize while you wait see if it works?

When you don't know if a patient is Having an MI from a spasm, a thrombus, or an embolus, are you planning to do nothing until you find out if you are giving heparin or not?

My thinking is this:

If i have a seizing pt. That is an obvious life threat. Whether they have a history or not, whether it is caused by something immediately reversible or not, is not important. I will address the known life threat, and work out if I can reverse the primary cause later.

If you give the glucose because of hypoglycemia, it doesn't mean the seizure will stop. Then you are giving both anyway?

If you give the glucose and wait and see if it helps you are allowing a life threatening condition to continue, and even if the pt doesn't die could have longterm disability from the event.

Seems to me the risk of aggresive management is actually less of a risk than conservative in this case.

 

[Aidey]

It can be pretty difficult to do anything to a patient having generalized tonic-clonic activity. Holding them down to get IV access and do other things can hurt them more if their movements are "large".*

Even if the seizure is from another cause you are probably going to have to stop the seizure in order to do any treatment for the underlying cause. IM or IN benzos if no IV access, and treat from there.

The only situation I can think of where I possibly wouldn't immediately treat the seizure with benzos is if the pt has eclampsia. Even so, I would likely give something IM or IN while we worked on getting a line and giving Mag. I know that benzos don't work very well in eclampsia seizures, but it's worth a shot.

Now that I'm thinking about it, does anyone know how long of an onset mag has in eclampsia seizures?


Something to keep in mind too is that seizures can cause hypoglycemia. I've only ever seen it in kids, (and those kids had multiple/extended seizure activity) but I'm sure there is a risk with adults also.


* By large I mean a lot of movement/thrashing vs smaller movements. I hope that makes sense.

 

[MrBrown]

Our guideline for seizure states to check BGL and treat accordingly, it is before the bit about midazolam so I don't know if the thinking of the Clinical Management Group is to give glucose before midaz or not.

My thinking is certinaly to give midazolam before glucose.

I have seen people put IVs in feet and give midaxz, some perfer IM while others use IN. I think IN midaz is great stuff for when you cannot get a line.

Or we could go back to the days of when we used PR stesolid

 

[Veneficus]

Now that I'm thinking about it, does anyone know how long of an onset mag has in eclampsia seizures?

I have seen it given as a 2 Gram bolus and stop the seizure before it was finished by slow IV push.

I have also seen it given as a drip initially and it only took a couple of minutes.

 

[redcrossemt]

The only situation I can think of where I possibly wouldn't immediately treat the seizure with benzos is if the pt has eclampsia. Even so, I would likely give something IM or IN while we worked on getting a line and giving Mag. I know that benzos don't work very well in eclampsia seizures, but it's worth a shot.

Interesting. I once asked a doc about this and they told me to give valium to stop the seizure, and then follow up with mag... Does anyone have protocols or reference material that leans one way or the other?

 

[mycrofft]

1. Pt is suffocating and wearing out various other systems in the body, maybe falling injury. Keep them alive. Get a line going and be prepared to getGiven no history or labs, IV glucose can work amazingly fast. You can suppress nearly any seizureform activity given the right dosage of benzos (Valium being a good one, if not the fastest) with relatively little risk of respiratory depression. If you could get one, a plain red top (not SST, but one of those would be good too as the secod tube) tube of blood wold be good for the receiving hospital to asses gloucose and drugs before you treat them.
2. Your assesment on approach plus quick data collection from any bystanders etc. is all you need other than getting that pt aereated then medicated. Any way to ascertain meds and allergies, then medical conditions, would be good too. Eveything beyond that is good, but don't delay over it.

 

[zzyzx]

"Interesting. I once asked a doc about this and they told me to give valium to stop the seizure, and then follow up with mag... Does anyone have protocols or reference material that leans one way or the other? "

I would disagree. Mag is both a CNS depressant and a smooth muscle dilator, so not only are you fixing the underlying problem of eclampsia--widespread vasoconstriction--but you are also stopping the seizure. So, there's no reason to give Valium first. If mag doesn't stop the seizure, then it would seem reasonable to consider benzos.

 

[redcrossemt]

I would disagree. Mag is both a CNS depressant and a smooth muscle dilator, so not only are you fixing the underlying problem of eclampsia--widespread vasoconstriction--but you are also stopping the seizure. So, there's no reason to give Valium first. If mag doesn't stop the seizure, then it would seem reasonable to consider benzos.

From the research I've read, there's been no direct correlation between magnesium and it's anticonvulsant effect. Otherwise, no one has proven how it stops the seizure. There's some peripheral nerve block, and some vasodilation, but we're not really sure which pathway stops the seizure (the fact that we're not really sure what causes the seizure is probably the more fundamental issue).

I have read more information on the topic and it seems appropriate to first give the magnesium and only follow with a benzodiazepine if the patient doesn't respond to a loading dose of 4-6 g of mag sulfate.

If anyone can add anything else, you have my ears... (or eyes as it may be here).