Status seizure

Since the pt is most likely hypervolemic, a loop diuretic could be used, but by the time it kicks in, you could have the hypertonic saline. You could try benzos, but they are not likely to help much. Be careful paralyzing this pt. You may stop the shaking but that doesn't mean they have stopped seizing.
 
Let's talk about this patient with the typical paramedic/ALS load out. I don't have anything other than benzos.
 
Benzodiazipines, more benzodiazipines, and maybe some Ketamine. This patient would end up intubated and sedated, potentially paralyzed as well.

Hyper tonic saline would be nice, but it's 45 minutes away, so let's be driving. Istat would be great.
 
I'm surprised no one got this.
There is something most paramedics carry that would work for hyponatremic seizures. It's also in every crash cart.;)
 
zzyzx said:
I'm surprised no one got this.
There is something most paramedics carry that would work for hyponatremic seizures. It's also in every crash cart.;)
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The problem with sodium bicarb is that you are giving A LOT of sodium quickly, which can cause problems pretty much as serious as refractory seizures. I suppose you could give small boluses of it. I'd still rather try to control the seizures using other means and then treat the hyponatremia in a more measured fashion.
 
Remi said:
The problem with sodium bicarb is that you are giving A LOT of sodium quickly, which can cause problems pretty much as serious as refractory seizures.
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Yes, give it over 5 to 10 minutes like hypertonic saline
 
This thread made me go and check our Pyxis and nope, no hypertonic saline. I would have to agree with DEmedic, without knowing the sodium level, no one is likely to give/order it. Now, if the ambulance had an istat;)
 
Why not just give it based on the history alone? Say there's a marathon going on and you had a healthy young runner with no history of seizures come into the ER actively seizing. If he is refractory to all the treatments done on the ambulance and in the ER, are you going to watch him seize for 30 to 45 minutes waiting for the BMP to come back with a sodium level?

What is the fear in just giving hypertonic saline (or the sodium bicarb)? Even if turns out that the patient had a normal sodium level, I don't see the downside.
 
zzyzx said:
Why not just give it based on the history alone? Say there's a marathon going on and you had a healthy young runner with no history of seizures come into the ER actively seizing. If he is refractory to all the treatments done on the ambulance and in the ER, are you going to watch him seize for 30 to 45 minutes waiting for the BMP to come back with a sodium level?

What is the fear in just giving hypertonic saline (or the sodium bicarb)? Even if turns out that the patient had a normal sodium level, I don't see the downside.
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Messing with the sodium levels is not something to do without lab values. Push the sodium level too high it can kill a patient.
 
zzyzx said:
A supervisor comes in and tells you that she was supposed to be on fluid restrictions. He states that the patient on a previous stay had to be taken to the ER and was hyponatremic."
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Maybe after this, but still... this is probally outside the sphere of understanding of most paramedics. And trying to explain to the doc (or nurse) that Bicarb has the same osmolarity of 6% saline would probally be lost over the med radio. I'd gather that most, if not all, of the ground paramedics in the US would hear, "just get here as quick as you can..."
 
luke_31 said:
Messing with the sodium levels is not something to do without lab values. Push the sodium level too high it can kill a patient.
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Brain swelling and herniation will kill the patient without treatment.
I understand what you are saying, but with one or two 100 ml boluses of hypertonic saline, or the equivalent in sodium bicarb, is not going to cause osmotic demyelination, especially not in an acute hyponatremia. You are only bumping the sodium levels 2-4 mEq. Likewise, if the patient had a normal sodium level and you were treating a hyponatremia that didn't exist, I don't think you would cause harm.
 
I can assure you that if you were to make a habit of treating serious electrolyte derangements without labs, you would get burned badly before long.
 
ERDoc said:
This thread made me go and check our Pyxis and nope, no hypertonic saline. I would have to agree with DEmedic, without knowing the sodium level, no one is likely to give/order it. Now, if the ambulance had an istat;)
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My ER also doesn't have hypertonic saline immediately available, though it is in the hospital (somewhere). Occasionally it would be nice to have an iStat available for some patients.
 
Remi said:
I can assure you that if you were to make a habit of treating serious electrolyte derangements without labs, you would get burned badly before long.
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LOL. You mean like hyperkalemia?
 
zzyzx said:
LOL. You mean like hyperkalemia?
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It's not just Na and K to worry about with labs. The labs as a total also speak for what is wrong with the patient. Na and K are just the two that in EMS we are most aware of. Other combinations of abnormal labs can cause similar symptoms that Na shows too.
 
zzyzx said:
LOL. You mean like hyperkalemia?
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I was talking about administering electrolytes based on the assumption that they are low and that you are able to increase serum levels in a controlled fashion with no labs, no IV pump, and probably very little experience with the drugs.
 
So since the cat is sorta already outta the bag here, I would like to add my two cents if I may.

The only thing that would stop a hyponatremic seizure is, well, sodium. Kudos to DEMedic btw for the salt tabs pic (didn't even think of it). I don't know that it would even matter how much, or many different Benzo's we could dump in this patient to stop the seizure, most likely it won't.

I do agree with Rocketmedic's treatment in terms of RSI to further control the airway, and manage at least the over utilization of this patient's skeletal muscles assuming there is continued tonic clonic activity associated with their hyponatremic seizure.

Hypertonic saline seems to be the definitive treatment assuming we were to prove this in fact was related to sever hyponatremia via an iSTAT, and possibly ECG changes to augment our iSTAT findings, nonetheless, a smooth diesel bolus with proper airway management, and supportive care seems the best course of action for us prehospital providers.
 
One thing to remember when you RSI a seizure pt is that just because the shaking has stopped, doesn't mean the seizure has. While the pt looks calm, their brain is still cooking in an electrical storm.
 
ERDoc said:
One thing to remember when you RSI a seizure pt is that just because the shaking has stopped, doesn't mean the seizure has. While the pt looks calm, their brain is still cooking in an electrical storm.
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Excellent reminder, ERDoc. Apologies for not being more specific, but would it stil be a good idea given the fact that I would prefer to stop the over utilization of said patients skeletal muscle activity to prevent further complications?

Again, remembering to continuously reassess their seizure (pupillary?) activity should it present after administering a paralytic agent.

Another question, some of the docs in my area don't seem very keen on long-acting agents for reasons such as what you've mentioned, which does make sense to me, what are your thoughts?
 
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