A very strange "seizure"

[MrBrown]

Hi all

This is not a "scenario" as such but more something I am wanting your two cents on.

I had a patient who said they at home watching telly, stood up to stretch and woke up on the floor having some sort of posturing and/or seizure.

The funny thing was they said there were able to feel themselves making these weird postural/seizure type movements, unable to see during the event or remember where they were while it was happening or for a few moments afterwards.

GCS when we got there was probably 5 (E1/V1/M3) but the patient stated during thier "aware" period they knew who they where and what (grossly) was happening but not where they were and could not see.

Anybody have any idea? No medical history or meds or head trauma or recent XBOX convention related postural hypotension to speak of.

RR12
BP 190/70
PR 100
ECG NSR
GCS was 5 then 15 within about a minute
PERL

This is one of the most bizzare things I have ever heard of, Brown is stumped.

 

[Veneficus]

Focal seizure?

Be interesting to know if there was an A/V malformation that was found.

 

[MrBrown]

Focal seizure?

Be interesting to know if there was an A/V malformation that was found.

Could be, I don't know, you see this here in big green letters, it doesn't say "DOCTOR" oh wait ... it does, bugger, I had best change that before I get in trouble with the Medical Council.

Any atrioventricular malformation.

My guess was he stood up too quick which lead to hypoxaemia which caused a brief seizure.

Is such a wide pulse pressure significant in some way?

 

[Melclin]

This is more of a question than than an answer...I realise it would be rare if even possible but is there some way a TIA could present like this?

How old were they?

Undiagnosed conversion disorder?

Drugs but wouldn't say or they didn't think it was relevant? Seem like the type to be shrooming?

 

[LondonMedic]

Any atrioventricular malformation.

Arteriovenous malformation

Cranial AVMs are relatively common, they're prone to small bleeds and often present with a seizure, thunderclap headache or, less frequently, focal neurology.

http://en.wikipedia.org/wiki/Arteriovenous_malformation#Signs_and_symptoms



I'd bet pseudoseizure.

 

[MrBrown]

I'd bet pseudoseizure.

... thats why you get the orange jumpsuit

Cheers guys, this one was a stumper thats for sure!

 

[Aidey]

I would go with partial complex seizure. Seizures are one of those odd things that can present 8000 different ways, and I've noticed we (EMS in general) tend to blow them off if they aren't the stereotypical tonic-clonic with a obvious posictal period type.

 

[abckidsmom]

Can I go with a syncopal episode? Stand up, stretch, fall down, black vision, aware of bizarre movements (not completely unconscious) but having muscle spasms because of hypoperfusion.

Rapid return to normal when supine.

Sounds syncopal to me.

 

[Veneficus]

I think I will go with Londonmedic's opinion. I forgot all about pseudoseizures.

Actually I am not really sure I remembered them to begin with. But after looking them up I like it.

 

[mycrofft]

Syncopal episode means you passed out, not an etiology.

Sorta like "gastritis".

With that pulse rate and BP (I assume pulse was unremarkable), maybe vasovagal episode. I've seen a few similar episodes when folks with needle aversion had to go through a shot line in USAF; as they recover, they "do the funky chicken", but there is no postictal period.

Had a hypertensive pt cough so hard with bronchitis he remembered feeling like he was being hung head down, then quickly fading out, recovered within a monute (more like a greyout like pilots eperience?). Maybe that prolonged valsalva plus completely emptying his lungs triggered a barometric response from his aorta to his brain.

Just thoughts.

 

[Cawolf86]

Not a great medical answer here, but I did listen to a recent episode of "This American Life" where a man described something similar. If you are interested you can get it in podcast form - it is episode #409 - "Held Hostage". This segment is about 11 minutes long and begins at 48:20.

He is diagnosed with Narcolepsy with Cataplexy and his symptoms sound similar. Just a random thought!

 

[firetender]

Out of the Box!

You didn't mention him having any sort of history directly or indirectly related to the so-called seizure.

(Please do some follow up and let us know what a Power Greater Than Yourself figured out, Okay, Brown?)

This is my take, as bizarre as it may sound. Upon standing and stretching a vertebrae (probably C-spine) either snapped into place or out of place, a nerve got Twanngged! Just like hammar/knee reflex test) muscle spasms occurred and, without losing consciousness, down to the floor. My guess is rather than being blinded, he closed his eyes. Disorientation occurred on the sudden way down, thus loss of sense of place.

It could also have been a minor, very localized, transient CVA. My money is on that, but I doubt that would be a conclusion they'd be able to come to.

 

[Melclin]

I'd bet pseudoseizure.

I think I will go with Londonmedic's opinion. I forgot all about pseudoseizures.

I'm not fond of the term pseudoseizures. It tends to be used in a derogatory sense by doctors nurses and paramedics alike, here at least.

Maybe its just political correctness, but here the preferred term used by those who don't wish to make a value judgment about the origins of seizures (very few people) in patients with somataform disorders is psychogenic seizure.

I'm sticking with psychogenic seizure due to one of the conversion disorders (Probably just because I have a hard on for unusual psychiatry ). If I keep picking zebras, one day I'll be right and look awesome h34r:

 

[mycrofft]

Psychogenic...good.

The more correct name for the common variety we disparage is "factitious seizureform activity".

THEORETICALLY, any part of the brain can have an uncontrolled electrical episode, and if it is not very wiodespread or involve motor areas, a typical postictal state would not be seen. However, these apparently are very rare if they exist at all.

Had a pt once who genuinely had grand mal seizure disorder controlld with phenobarb and phenytoin, used "psychomotor seizure" as a legal defense to explain why over three days he scouted a roobery site, got the materials, stole a car, shot the clerk, disposed of the weapon, and drove away to hide with an associate.
The standing-up bit and cardiovascular signs makes me stick with orthostatic related hypotension.
Was he on nitro, Viagra, or antiarrythmics?

 

[rescue99]

I would go with partial complex seizure. Seizures are one of those odd things that can present 8000 different ways, and I've noticed we (EMS in general) tend to blow them off if they aren't the stereotypical tonic-clonic with a obvious posictal period type.

Yep, if a seizure at all, this would be my best guess.

 

[MrBrown]

I'm sticking with psychogenic seizure due to one of the conversion disorders (Probably just because I have a hard on for unusual psychiatry ). If I keep picking zebras, one day I'll be right and look awesome h34r:

Sorry mate you can't look awesome, they don't make an orange jumpsuit with "SHRINK" written on it.

"Oz you lazy bugger, get up, its a go"
"What is it Brown?"
"Buggered if I know, Ambulance Control said something a bit nuts"
"I see"
"At least, thats up your alley isint it, best we be off then!"

 

[Aidey]

I'm not fond of the term pseudoseizures. It tends to be used in a derogatory sense by doctors nurses and paramedics alike, here at least.

Maybe its just political correctness, but here the preferred term used by those who don't wish to make a value judgment about the origins of seizures (very few people) in patients with somataform disorders is psychogenic seizure.

I'm sticking with psychogenic seizure due to one of the conversion disorders (Probably just because I have a hard on for unusual psychiatry ). If I keep picking zebras, one day I'll be right and look awesome h34r:

This is a really good point. When I use "pseudoseizure" its because it was an obvious fake seizure and thinking about it, when ever I've heard that term used in EMS (ED staff included) that is what they have been referring to. Psychogenic seizure sounds like a much better description for those grey area seizures.