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Old 12-13-2008, 11:28 PM   #1
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seizure vs. stroke

So....the other day we ran a call that I'm not quite sure what was going on.

We got toned out for a 74 y/o male actively seizing. When we got there-pt was slumped to the left in a recliner-responsive only to deep sternal rub. All vitals checked out pretty much ok-his pulse was 100 and BP was around 140/100. Pt's granddaughter on scene who witnessed seizure said it was full body tonic clonic type activity. Pt WAS NOT incontinent of bowel or bladder. Pt's granddaughter also states that due to car accident several years ago that pt doesn't talk right. We went to move pt to the cot-he was completely flaccid. Once we got him out to the ambulance he started coming around a little. Now when we said his name he would open his eyes and look around. He sort of resisted the nasal cannula for 02-but had no response when my partner started the IV. I noticed at this time that the pt's right arm was completed flaccid. I couldn't tell or not if his face was a little droopy-but my partner said the pt was squeezing my partners hand on the left side. I went to take another BP in the right arm and asked him to hold it up since he was coming around and he couldn't even rest his arm on my leg. He didn't get any better or worse on the way to the ER-they ended up transferring him to a bigger hospital for new onset seizures for specialized care. Now-my question is-could this have been some sort of TIA or something going on? The only thing that is puzzling me is that I've never EVER seen a seizure pt completely flaccid on one side. Oh yeah-pt's lung sounds were wet/crackly and he had a slight cough.

So, what do ya'll think?

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Old 12-14-2008, 12:01 AM   #2
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it very well could have been a seizure, although you would expect to see incontinence with a grand mal.

tia/cva is also a distinct possibility.

this call goes back to a discussion we've had a few times lately. textbook cases v. real world cases. the book teaches us to look for certain things to formulate our d/dx but really only covers the most common examples and rarely shows you atypical presentations.

regardless, your tx would be the same. abc's, o2 as necessary(evidence based, not text book based please). line labs ekg for the als providers. transport to the building with the big H on it.

the "eyewitness" testimony of the event can be taken into account, but i wouldnt engrave it in marble. people tend to exagerate when their excited, especially when its family.
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Old 12-14-2008, 09:52 AM   #3
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What meds was he on? I have had 4 patients in the last year now with with either new onset seizure activity or Stroke presentations (one everyone was so certain it was a stroke the tPA was coming from the pharmacy when the CT came back clear) that have have been attributed to Ultram/Tramadol use. Once the Ultram is out of their systems, the s/s resolve.
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Old 12-14-2008, 11:10 AM   #4
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Define "seizure"

How about "seizureform activity"? Or as we called it behind the scenes , "funky chicken".

Lots of things will cause you to exhibit clonic/tonic appearing activity which are not epileptic, such as vasovagal syncope, AC electrical shock, fever, GSW to the head, blunt trauma to the head, choking...anything which overries or relaxes the brain's control over the body's motor pathways. Cut to the chase, what are the circumstances? Some folks call any alteration of consciousness with lowered LOC a "seizure", including MI, CVA, or epilepsy.

(We hid an airman once who had a lttle "funky chicken" after having labs drawn and passing out in the chair. Navy who owned the clinic we used wantd to send him out for a MRI, but he was fine and escaped their tender mercies to avoid a day or two at Oak Knoll.
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Old 12-14-2008, 12:43 PM   #5
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Going soley on what you've just said, here's what I believe might be going on.

Until proven otherwise, we are to treat the worst case scenario. That being said, until proven otherwise, your pt was having a stroke and the seizures are a secondary manifestation.
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Old 12-14-2008, 01:53 PM   #6
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Could also be Todd's paralysis. This is one reason that patients presenting with CVA sx's post seizure are not lysed.
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Old 12-14-2008, 02:07 PM   #7
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What kind of medical history did the patient have? Medications?
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Old 12-14-2008, 02:26 PM   #8
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There are many things including numerous tumors and lesions that can alter the impulses of electrical activity in the brain for a few minutes or even hours. Thus, you can have a seizure for any number of reasons and CVA symptoms also for many reasons. Some can also be brought about by medications, poisons or trauma as mycroft pointed out.

It is not uncommon for a patient having either a seizure and/or CVA to aspirate.

Anybody read about the recent health events of a well known politician named Ted Kennedy?

Last edited by VentMedic; 12-14-2008 at 02:32 PM.
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Old 12-15-2008, 12:56 AM   #9
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Mary Jo came back and "tetched" him. Or "seized" him.

Seizures are a sign/symptom as well as a condition requiring treatment. EMS role is to gather info while supporting ABC's and preparing to make tracks.

Oh, man, I forgot a common cause...diabetics with hypoglycemia.
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