Seizure secondary to ETOH abuse

[WolfmanHarris]

Had a call today that I'd like to work through the patho on. First the call, then some questions.

Responded for a 22y/o M, query seizure following a weekend of binge drinking. Arrived to find Pt. lying supine on the floor, conscious, alert and oriented, in moderate distress. Pt. pale/ashen, diaphoretic. Pt.'s brother reports that Pt. became stiff throughout his body and was helped to the floor, non-communicative for approx 5 minutes, though Pt. reports being aware throughout.

Initial assessment found Pt.'s fists clenched, arms drawn inwards towards the body (appearing identical to decorticate posturing), toes/feet pointed. Pt. reports being unable to open fists or straighten arms, though crew able to manipulate limbs to apply NIBP, SPO2 w/o Pt. reporting pain/discomfort. 3 lead showed sinus tach at 170bpm, tachypneic at 32bpm w/ ETCO2 of 29mmHg typical waveform, BGL 6.7mmol/L, SPO2 unobtainable. Pt. denied CP, SOB, abdominal pain.

Pt. and family report that pt. had been binge drinking Friday through Sunday morning with nothing to drink since Sunday morning (approx 24 hrs). Admits to marijauna use, denies other drugs. Pt.'s brother reports two previous episodes of seizure secondary to binge drinking in last two years, both witnessed w/ one described consistent w/ tonic clonic and the other sounding like complex focal.

During assessment Pt. began to state that he felt like another seizure was coming on. Immediately after limbs became even stiffer and inwardly turned, visible facial droop developed w/ slurred speech and Pt. began to deviate to the R. Symptoms lasted approx 45secs before returning to previous baseline. Transported w/o incident and immediately after offloading Pt. had a similar episode to the one above.

Unfortunately we had such a good shift today that I never made it back into the ED to check out his bloodworm so I can't provide any values.

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I'm having some difficulty wading through the underlying pathophysiology here. Certainly I understand that the Pt. was likely profoundly dehydrated and hypovolemic, hyponatremic and hypokalemic. From his end-tidal he was acidotic (ETCO2 remained between 25-30mmHg despite RR>30bpm for 45mins+).

Where I'm having trouble is making sense of how this lead to seizure activity and the hypertonic activity in the limbs. I'd appreciate any thoughts anyone has on this. Don't need you to do my homework for me, but some jumping off points would be great. If I get a chance to look at his bloodwork tomorrow I'll share what I find.

 

[NomadicMedic]

Hypocalcemia?

(Sounds like tetany.)

 

[VentMonkey]

http://www.turner-white.com/pdf/hp_mar00_hypocal.pdf

 

[medicsb]

Top differential: alcohol withdrawal, DTs

Other things to consider: coingestion, beer potomania w hyponatremia causing seizures, head trauma, and then other usual causes of seizures that may be coincident to the EtOH.

I would not hesitate to drown the dude in benzos. I've gone up to 16mg of Ativan over the course of an hour for EtOH withdrawal (not seizures) and have had the pt. wide awake and talking. Though I haven't done it, an attending of mine has put patients on propofol (NOT intubated) for EtOH withdrawal. If the pt. is withdrawing from EtOH, there's no true upper limit of benzos. You give and give until symptoms resolve.

IF he were hyponatremia and seizing, hypertonic sale is indicated, but for EMS, just bolus w normal saline, and you could give benzos but they are not definitive tx and may not work, but it's not like you'll actually know there serum Na.

 

[VentMonkey]

Top differential: alcohol withdrawal, DTs

Other things to consider: coingestion, beer potomania w hyponatremia causing seizures, head trauma, and then other usual causes of seizures that may be coincident to the EtOH.

I would not hesitate to drown the dude in benzos. I've gone up to 16mg of Ativan over the course of an hour for EtOH withdrawal (not seizures) and have had the pt. wide awake and talking. Though I haven't done it, an attending of mine has put patients on propofol (NOT intubated) for EtOH withdrawal. If the pt. is withdrawing from EtOH, there's no true upper limit of benzos. You give and give until symptoms resolve.

IF he were hyponatremia and seizing, hypertonic sale is indicated, but for EMS, just bolus w normal saline, and you could give benzos but they are not definitive tx and may not work, but it's not like you'll actually know there serum Na.

At what point in the prehospital setting are we going to stop/ max out on Benzo's before realizing if it in fact hyponatremic sz's that Benzo's are useless?...

This is where differential diagnosis comes into play, IMO, if again their seizures are refractory to Benzodiazepines as anticonvulsant therapies. It's also a good way to show the ED folks that us field providers do have "critical thinking" skills.

Just some food for thought to my fellow prehospital folks.

 

[akflightmedic]

Unfortunately we had such a good shift today that I never made it back into the ED to check out his bloodworm so I can't provide any values.

Interesting case and great info from the others....I definitely want to hear more about the bloodworm!

(Sorry, could not resist! I always go for the joke!)

 

[VentMonkey]

Interesting case and great info from the others....I definitely want to hear more about the bloodworm!

(Sorry, could not resist! I always go for the joke!)

Lobbed it...

 

[NomadicMedic]

Interesting case and great info from the others....I definitely want to hear more about the bloodworm!

(Sorry, could not resist! I always go for the joke!)

 

[Carlos Danger]

At what point in the prehospital setting are we going to stop/ max out on Benzo's before realizing if it in fact hyponatremic sz's that Benzo's are useless?...

Seizures due to ETOH withdrawal do respond to benzos, but these guys can require really hefty doses. Most EMS units don't carry enough to worry about having given too much.

My first job as an RN was in a really busy urban ED where we boarded a lot of inpatients in the ED. I took care of lots of alcoholics in acute withdrawal, giving them 10, 20, even up to 30mg of PO valium per hour until they were really calm and resting.

I guess I'd say since you have no way to confirm hyponatremia in the field, and since withdrawal syndrome is probably at least as likely, and since benzos aren't going to hurt anything anyway, I'd just keep giving them until you can't give any more.

 

[WolfmanHarris]

View attachment 3038

I'd really love to know what programming decision had autocorrect decide that bloodworm was more likely than bloodwork. Especially since the rest of autocorrect seems to be learning to stop highlighting my medical words.

Anyways, unfortunately when I made it back into the hospital today, the Pt. was discharged and his bloods weren't available to access anymore.

I appreciate the input and the links, got me heading in the right direction for some reading this morning and lead me to an answer for one thing that was really nagging at me. The tetany symptoms and the seizures made sense with hypocalcemia, I'm just not used to seeing that symptom in any of my alcoholic or even drunken youth patients, but given the 48hrs of drinking it made sense. Most teenage/YA shenanigans are self-limited by acute ETOH poisoning prompting the call, yet this pt. had had 24 hours plus to sober up and had been recovering at home, drinking water and laying around, so why had the symptoms been so delayed?

My theory here is that the pt induced his tetany and seizure activity through his recovery. By his own admission he had only been taking in water in the last 24hrs with no food, gatorade, etc. So while he was replacing his volume, he wasn't replacing his electrolytes. As a result, while his absolute electrolyte levels would not be continuing to decrease, his concentration would as his rehydration with flat water diluted the electrolytes effectively decreasing his levels and triggering the muscle spasms, tachycardia and seizures. Does this make sense or am I still missing a key piece?

 

[VentMonkey]

I'd really love to know what programming decision had autocorrect decide that bloodworm was more likely than bloodwork. Especially since the rest of autocorrect seems to be learning to stop highlighting my medical words.

Anyways, unfortunately when I made it back into the hospital today, the Pt. was discharged and his bloods weren't available to access anymore.

I appreciate the input and the links, got me heading in the right direction for some reading this morning and lead me to an answer for one thing that was really nagging at me. The tetany symptoms and the seizures made sense with hypocalcemia, I'm just not used to seeing that symptom in any of my alcoholic or even drunken youth patients, but given the 48hrs of drinking it made sense. Most teenage/YA shenanigans are self-limited by acute ETOH poisoning prompting the call, yet this pt. had had 24 hours plus to sober up and had been recovering at home, drinking water and laying around, so why had the symptoms been so delayed?

My theory here is that the pt induced his tetany and seizure activity through his recovery. By his own admission he had only been taking in water in the last 24hrs with no food, gatorade, etc. So while he was replacing his volume, he wasn't replacing his electrolytes. As a result, while his absolute electrolyte levels would not be continuing to decrease, his concentration would as his rehydration with flat water diluted the electrolytes effectively decreasing his levels and triggering the muscle spasms, tachycardia and seizures. Does this make sense or am I still missing a key piece?

While I myself don't know either, like the link I posted stated, there may be many causes for hypocalcemia (assuming this is what it was that caused the tetany, and symptoms you described). For all we know said patient had an undiagnosed endocrine disorder.

Definitely a good case presentation. Thanks for sharing, it got everyone thinking.

Ironically enough I once had a patient who presented with carpopedal spasms that presented with what in hindsight was most likely Trosseau's Sign though it was down played as hyperventilation related. I tried my best to get them to agree to go as my "spidey senses" told me so, but the patient refused.

Lo and behold a few calls later we transport another patient to a local ED, and who is there receiving IVF, and electrolytes?..you guessed it.

Lastly, THIS is where I think a course such as AMLS can really help ANY paramedic with differential diagnosis.

 

[medicsb]

At what point in the prehospital setting are we going to stop/ max out on Benzo's before realizing if it in fact hyponatremic sz's that Benzo's are useless?...

This is where differential diagnosis comes into play, IMO, if again their seizures are refractory to Benzodiazepines as anticonvulsant therapies. It's also a good way to show the ED folks that us field providers do have "critical thinking" skills.

Just some food for thought to my fellow prehospital folks.

You won't be able to diagnose hyponatremic seizures in the field. Fortunately, such a thing is rare. I've never seen it, at least not that I know of. As mentioned benzos might not work or may require higher doses (as in they may work). However, there are cases where patients do not respond to benzos adequately, and in the ED we move to other meds such as keppra, phenytoin, or as a last resort: phenobarb. Anyhow, normal saline has 154mEq of sodium, though it is in no means the best Tx, a seizing alcoholic can be given benzos and fluid bolus.

In the prehospital setting you have limited options. You make due with what you have. You need to act with limited information. We do the same in the ED. A seizing patient isn't able to tell us anything, and it's not uncommon for EMS to have limited information. Most of the time the seizing patient has a seizure history and is either been noncompliant with meds or is having a break-through seizure. Then there's head injuries, alcohol withdrawal, new-onset seizures for whatever other reason. You use what info you have. In the face of limited or no information, its benzos and supportive care to start. Certainly, there are certain things we look for which can change treatment - are they on isoniazide and need vitamin B6? Is it a pregnant woman late in pregnancy or recently post-partum and in need of mag for eclampsia? Are they hyponatremic and need hypertonic saline? Are they hyperthermic (e.g. heat stroke) and need cooling? Are they hypoglycemic and need D50?

 

[VentMonkey]

You won't be able to diagnose hyponatremic seizures in the field. Fortunately, such a thing is rare. I've never seen it, at least not that I know of. As mentioned benzos might not work or may require higher doses (as in they may work). However, there are cases where patients do not respond to benzos adequately, and in the ED we move to other meds such as keppra, phenytoin, or as a last resort: phenobarb. Anyhow, normal saline has 154mEq of sodium, though it is in no means the best Tx, a seizing alcoholic can be given benzos and fluid bolus.

In the prehospital setting you have limited options. You make due with what you have. You need to act with limited information. We do the same in the ED. A seizing patient isn't able to tell us anything, and it's not uncommon for EMS to have limited information. Most of the time the seizing patient has a seizure history and is either been noncompliant with meds or is having a break-through seizure. Then there's head injuries, alcohol withdrawal, new-onset seizures for whatever other reason. You use what info you have. In the face of limited or no information, its benzos and supportive care to start. Certainly, there are certain things we look for which can change treatment - are they on isoniazide and need vitamin B6? Is it a pregnant woman late in pregnancy or recently post-partum and in need of mag for eclampsia? Are they hyponatremic and need hypertonic saline? Are they hyperthermic (e.g. heat stroke) and need cooling? Are they hypoglycemic and need D50?

Yes, it was a somewhat rhetorical question, however intended to illicit a response such as this in hopes that other prehospital providers reading this thread could get their "critical thinking wheels" turning.

 

[Handsome Robb]

What are people's max doses of benzos for seizures? We have no max and carry 50mg of versed. 10 mg IM or 5 mg IV q10.


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[VentMonkey]

What are people's max doses of benzos for seizures? We have no max and carry 50mg of versed. 10 mg IM or 5 mg IV q10.


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That is A LOT of Versed, lol. We carry 16 of Versed, and 20 of Valium. We used to carry Ativan as well, but it was retracted from our protocols. The beauty of having an RN most of the time however, is push dose boluses til the cows come home, assuming normotension.

As far as on the other/ ground side without an RN, yes, if my patient was a stat ep, and assuming I am reasonably close to the ED, best believe, IMO, I have free range with the Benzo's as I see fit in attempts to stop the seizures. If I am in BFE, then I call for the helicopter to at least stop the muscle fatigue that will most like be brought on by their stat ep state.

 

[Handsome Robb]

That is A LOT of Versed, lol. We carry 16 of Versed, and 20 of Valium. We used to carry Ativan as well, but it was retracted from our protocols. The beauty of having an RN most of the time however, is push dose boluses til the cows come home, assuming normotension.

As far as on the other/ ground side without an RN, yes, if my patient was a stat ep, and assuming I am reasonably close to the ED, best believe, IMO, I have free range with the Benzo's as I see fit in attempts to stop the seizures. If I am in BFE, then I call for the helicopter to at least stop the muscle fatigue that will most like be brought on by their stat ep state.

Our narc box is rather large. 50 of versed, 1000 of fent and 2000 of ketamine.

While I know RSI/DSI doesn't stop the seizure activity if I'm getting close to using all my versed that means they've been having ongoing seizures for 30-40 minutes. At that point we're going to do a DSI more than likely. There's been arguments made that the ketamine may be beneficial for these patients either way however I haven't seen any studies about it. Only ones I've found were pediatrics and it being used for S.E. refractory to benzos and anticonvulsants in the PICU setting.


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[Carlos Danger]

Our narc box is rather large. 50 of versed, 1000 of fent and 2000 of ketamine.

That is a lot.....I can do a busy day's worth of cases in the OR and not come close to using that much.

 

[Handsome Robb]

That is a lot.....I can do a busy day's worth of cases in the OR and not come close to using that much.

It mostly has to do with how we do our restock. We don't have narcotic restock at all our stations only regional stations so carrying a lot keeps us from having to constantly go restock at another station.

We generally won't restock until we get to 500 of fent, 30 of versed, 500-1000 of ketamine or any combination of the above.

It's not uncommon for my truck to use ~500 a fentanyl in a day, sometimes more.



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[MonkeyArrow]

It's not uncommon for my truck to use ~500 a fentanyl in a day, sometimes more.

How many calls are you running to use 500 of fent in one day?

 

[Handsome Robb]

How many calls are you running to use 500 of fent in one day?

8-12 in 24 hours. There's days we don't give any as well but if we get 2-3 patients that require pain management it's not difficult to give that much...my partner gave 400 to a single patient the other day over the course of a 30 minute transport.


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