Unresponsive/Seizure

[BirdtheEMTB]

Here is a scenario that I would like to have everyone evaluate:
You arrive at a Extended care facility, you find the staff with the Pt. in a wheelchair. Now remind you the Pt. is severely mentally handicapped. Unresponsive to painful stimuli, and currently seizing........what do you do.

 

[MMiz]

An an EMT-Basic I'd:
1. Notify dispatch or call 911 (if I was private) to request ALS. Ask NH how long he has been seizing and for a SAMPLE history.
2. Ensure the patient doesn't fall out of the wheelchair. It may just be easier to put him on the ground in the recovery position.
3. Ensure pt airway. If he's been at it for 10-15 minutes, then I might put in a nasal airway and start bagging if I don't see strong respirations. Really depends on a number of conditions (skin color, cap refill, etc.). I'd also have a suction ready just in case.
4. O2 via NRB at 15 LPM or bag patient with BVM (see above)
5. If he stops, put in recovery position. If protocols allow, perform glucose test (or ask NH to do one).
6. I'd either wait for ALS to come and do a 12 lead, start an IV, etc.

 

[BirdtheEMTB]

ALS is onscene, IV access is attempted but not successfull. The bus is rolling, 12 lead is placed, airway is patent but resps are very shallow, Clear equal bilaterally, Still no IV access. Pt. has no distal pulses, but faint CA pulse .....ask questions and you will get more.

 

[Epi-do]

Is the patient still seizing? What are baseline vitals? Medical history? Meds?
Does he have a hx or seizures, and if so when was his last one? Any recent labs that the ECF has given you copies of? Was the patient at his normal baseline prior to the seizure? If it has stopped, how long did it last?

 

[BirdtheEMTB]

BP: ?
Pulse:38
Spo2:68
Resp:6-8
Gluc:48

Pt on the monitor.....Asystole
Staff from facility in the front of the bus, saying that Pt. has had seizures in the past, last noted seizure was 10 min. before EMS arrived. Again no IV access. Enroute called for ALS backup. 8 min out to facility. Pt. has 6-8 seizures on the way.

 

[mycrofft]

Asystolic and seizing...watch out for creature erupting from chest.

Not much to do in your timeframe except support the "in and out / round and round" and ask Scottie for more power to the warp engines. Um, top of my head...everything above plus check for DNR order and take a temp, specifically look for signs of dehydration. Make sure whether or not the pt has urinary catheter in (I had a pt as a nursing student where the convo aids had forgotten pt used a leg bag, left it on for three days).
I hate these.

 

[Epi-do]

How can the pt be in asystole, have a pulse, and still be seizing? Something doesn't add up.

If the patient is not in asystole and is still having seizures, I am able to give Versed intranasally. Get the seizing under control, control the airway and ventilate the patient. Look for causes of the bradycardia and seizures and address those issues that can begin to be addressed in the field, including drug OD, electrolyte imbalances, hypovolemia, or septic shock. This patient is also hypoglycemic, which needs to be addressed, preferably with D-50. If IV access still cannot be obtained, consider glucagon, knowing that it will take longer to work - and that is if the patient has the stores in their liver to begin with.

If the patient is truly in asystole, then CPR, secure an airway and bag patient, epi and atropine. Two rounds of drugs, and then call the hospital for orders to stop resussitative efforts. If IV access is impossible to get, consider an IO. Look for reversible causes, but not much else you can do. Asystole is not a shockable rhythm, and the ER is going to call the patient shortly after you get there. No reason to transport a dead body, putting everyone at unnecesary risk during an emergent transport.

 

[Sasha]

Confirm the monitor. You can't have a pulse and be in asystole.

 

[Sasha]

Also if you're unable to get IV access, you can give valium rectally, and in the area I do my ride times at, start an IO.

 

[firecoins]

give patient Versed IM.

If a patient has a pulse, I doubt the pt is in asystole. Not going to get a good 12 lead on seizing patient so i wouldn't waste my time until later. Than I can waste my time.

 

[Ridryder911]

give patient Versed IM.

You do realize it would take about 1/2 an hour to take affect. Why not give it nasally? It works in about 30 seconds.

First, you can't have an aystole with a pulse. Second the one of the highest causes of seizures is hypoglycemia. Treat the cause, one may not have an to treat the seizure.

If you are going to present scenarios be sure they are logical and concurrent with true physiological findings.

R/r 911

 

[KEVD18]

If you are going to present scenarios be sure they are logical and concurrent with true physiological findings.

R/r 911

i agree.

you're going to shoot a XII lead during an active seizure?

 

[firecoins]

You do realize it would take about 1/2 an hour to take affect. Why not give it nasally? It works in about 30 seconds.

R/r 911

don't have it nasally.

 

[Sasha]

i agree.

you're going to shoot a XII lead during an active seizure?

And how the heck do you get asystole on an actively seizing patient? I think it would look more like vfib!

 

[KEVD18]

And how the heck do you get asystole on an actively seizing patient? I think it would look more like vfib!

well theres that too. but the bottom line is that if you have a mechanical pulse and the idiot box is showing asystole(or any other pulseless rythm for that matter), theres a problem with the box and you shouldnt trust it.

 

[Sasha]

:lol:

well theres that too. but the bottom line is that if you have a mechanical pulse and the idiot box is showing asystole(or any other pulseless rythm for that matter), theres a problem with the box and you shouldnt trust it.

Of course. That is why you ALWAYS confirm the monitor before proceeding with any pulseless rhythm protocols, or for that matter, post resusciation pulse positive protocols. Treat the patient, not the monitor, after all. I learned that on one ride where I look at the monitor, showing vfib, so I freak out and start OMG WE NEED IVS AND AND AND I GOT THE PADDLES!!!!! h34r:

My preceptor was like... Dear. Thats because hes moving a LOT... Notice he is pink, warm, and dry? Does he appear to be SOB, or with chest pain? :blush:

:lol:

 

[Jon]

Have the BLS crew insert an oral or nasal airway and start assisting ventilations.

Keep looking for an IV. If no immediate success, IM glucagon, and go from there - but that will take a few minutes, so we then work through the monitor quickly to check it is functioning. Double check that the leads are attached correctly, then ensure the cable is intact and attached to the monitor, and replace at least 1 of the monitor batteries if possible.

If the monitor is still dead... add another medic. This call is becoming a train wreck. After the hypoglycemia is corrected, we still have the bradycardia to worry about, unless that gets corrected with the hypoglycemia.


So... do we get an IV and get to give D50? Does IM Glucagon work successfully?

Afterwards, do the seizures stop? Vitals?

 

[BossyCow]

And how the heck do you get asystole on an actively seizing patient? I think it would look more like vfib!

Right the lack of artifact from the seizure should have been the first clue.