Status seizure

[zzyzx]

You are called to a psyche facility for a patient who has had multiple seizures. The patient is a 50 y/o female on a 14-day hold and has a history of paranoid schizophrenia. As you walk in, the patient is actively seizing. Staff is available for any questions you may have.

 

[NomadicMedic]

Full history? Current meds? History of recent trauma? Is she detoxing? What have they given her? Blood sugar?

 

[ERDoc]

How many days has she been here? What medications were stopped when she checked-in?

 

[NysEms2117]

@DEmedic just trying to learn here, i have very little idea but could you explain detoxing's link with seizures a bit? thank you.

 

[gotbeerz001]

Seizures are a symptom associated with withdrawals.


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[zzyzx]

No vitals available since she is seizing.

Blood glucose: WNL

A mental health worker tells you that just yesterday she began getting an increased dose of Risperdal. She has been there a week and no meds were stopped. She is a paranoid schizophrenic and has not been eating much because she thinks the staff is trying to poison her, though the tech says that he observed her drinking a lot. She also has recently been given a nicotine patch. He does not believe she could have ingested any other drugs because their patients don't have access to any medications.

No other medical history, and no history of epilepsy.

No recent trauma.

The mental health worker states that she has no history of alcohol abuse.

 

[Akulahawk]

No vitals available since she is seizing.

Blood glucose: WNL

A mental health worker tells you that just yesterday she began getting an increased dose of Risperdal. She has been there a week and no meds were stopped. She is a paranoid schizophrenic and has not been eating much because she thinks the staff is trying to poison her, though the tech says that he observed her drinking a lot. She also has recently been given a nicotine patch. He does not believe she could have ingested any other drugs because their patients don't have access to any medications.

No other medical history, and no history of epilepsy.

No recent trauma.

The mental health worker states that she has no history of alcohol abuse.

How much water?

 

[NomadicMedic]

How much water?

That's a great question. Hyponatremia, leading to seizure?

Risperidone ius known to lower the seizure threshold so we're gonna need to get some benzo on board, othersie we'll just stand here all day and watch seizures. My only option at my current service is Versed. Let's start there and get some vitals.

 

[zzyzx]

The tech says, "Yeah she was always at the drinking fountain. So weird!"

 

[zzyzx]

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."

Now that you can be fairly certain that the patient is hyponatremic due, what would you like to do? she is still seizing.

Interestingly I had once been told by a doc that he thought psychogenic polydipsia induced hyponatremic seizures dont exist considering all the water you would have to drink, but apparently it does because this was my patient the other day! Perhaps her fasting was a contributing factor, or perhaps there were other factors.

 

[NomadicMedic]

She needs the seizures controlled and needs hypertonic fluid. Benzos to start, then supportive care until we get to the ED. Monitor all the way. Manage any acute events as they happen.

 

[VFlutter]

She needs the seizures controlled and needs hypertonic fluid. Benzos to start, then supportive care until we get to the ED. Monitor all the way. Manage any acute events as they happen.

1L 3% Saline bolus STAT, what is the worst that can happen? I have only seen CPM/ODS once in a patient that was overly corrected at an outside hospital. Not something to take lightly.

 

[ERDoc]

It absolutely does exist. Although not from psychogenic polydypsia, does everyone remember the "hold you pee for a wii" contest? Same idea, just lacking the psychiatric diagnosis.

 

[NomadicMedic]

1L 3% Saline bolus STAT, what is the worst that can happen? I have only seen CPM/ODS once in a patient that was overly corrected at an outside hospital. Not something to take lightly.

I don't know any medic units that carry 3% saline.

So, stop seizure, put patient in truck, drive patient to place where there is hypertonic fluid. If patient attempts to due during the driving portion of the program, use paramagic to prevent death if possible.

 

[zzyzx]

You dont have any hypertonic saline on your ambulance. The seizures are refractory to your benzos. You are 45 minutes from an ER. What can you do?

 

[NomadicMedic]

 

[ERDoc]

View attachment 2944

 

[VFlutter]

You dont have any hypertonic saline on your ambulance. The seizures are refractory to your benzos. You are 45 minutes from an ER. What can you do?

Propofol

 

[zzyzx]

ER Doc, what would you do if your nurses told you they needed to wait for the pharmacy to bring down the 3% saline? A lot if ERs dont have it stocked.

 

[Carlos Danger]

You dont have any hypertonic saline on your ambulance. The seizures are refractory to your benzos. You are 45 minutes from an ER. What can you do?

1. Give more benzos. Literally, keep dosing benzos every couple of minutes until you run out.

2. 1 mg/kg of propofol, if you carry it.

3. Rocuronium, if your GABA agonists are not working after a few healthy doses, especially assuming that the seizure has been going on for >30 min by now

4. Phenytoin, fosphenytoin, or levitiracetam, if you have access to either of them.

4. A liter of normal saline fairly rapidly and then at a moderate rate, say, 500/hr while transporting.