Seizures

[EMT B]

Dispatched via 911 to a local clinic for a male in his 30s having seizures.

Arrives on scene to find a male in his 30s laying on his side in one of the rooms. Nurse states (and wife confirms) tht for the past year the pt has about 8 or 9 tonc clinic seizures per day. He does not have an aura, but he does have a period of unresponsiveness prior to seizures. Patient went to the clinic today because during one of his seizures he had an episode of apnea and his lips became cyanotic. At the clinic they did an IV with TKO NS and a 12 lead that showed NSR w/o ectopy. CT scan came back negative. BGL of 93. Pt was afebrile. His last seizure was 2hrs prior to our arrival. He received 2 Ativan from the clinic physician, as well as 2LPM O2 via NC. Vitals were unremarkable. During transport patient became unresponsive for about 2 min before having a tonic clonic seizure that lasted about 20 seconds. Respiratory rate never dropped below 8 during this episode, and no cyanosis was noted.

Can't remember if I forgot anything or not..feel free to ask any clarifying questions. I was not the primary caregiver, I was a third on the rescue so I may take some time to clarify things I'm unsure about.

Any idea what could be going on?

 

[JPINFV]

Multiple seizures per year over the past year would, in my mind, point to a tumor, but the CT was negative. Does the patient use drugs? Ever used drugs? The vast majority of things that I can think of off the top of my head that hasn't been tested for aren't things compatible with a year of life (electrolytes, Naegleria fowleri/brain amoeba, etc). An MRI would be nice.

 

[Wheel]

Multiple seizures per year over the past year would, in my mind, point to a tumor, but the CT was negative. Does the patient use drugs? Ever used drugs? The vast majority of things that I can think of off the top of my head that hasn't been tested for aren't things compatible with a year of life (electrolytes, Naegleria fowleri/brain amoeba, etc). An MRI would be nice.

Pseudo seizures, perhaps?

 

[EMT B]

Pt denied recreational drug use. That does remind me that the patient stopped his controlling meds because all of the ones he tried either didn't help or made things worse. I can't recall the meds..there was too many of them.

I could very well be mistaken, but don't pseudo seizures typically last longer than epileptic seizures? He has a hx of epilepsy and the seizures average about 30 sec each (per wife)

 

[Mariemt]

Did the patient urinate?

Sometimes a conversion disorder can cause idiopathic seizures. A psychogenic seizure patient will not urinate
Interesting huh?

 

[Mariemt]

Pt denied recreational drug use. That does remind me that the patient stopped his controlling meds because all of the ones he tried either didn't help or made things worse. I can't recall the meds..there was too many of them.

I could very well be mistaken, but don't pseudo seizures typically last longer than epileptic seizures? He has a hx of epilepsy and the seizures average about 30 sec each (per wife)

No longer called pseudo seizures. And can last as long as the pt needs

 

[JPINFV]

No longer called pseudo seizures. And can last as long as the pt needs

I've never met a patient with psychogenic seizures who could control the length of their seizure. Malingering or factitious disorders, on the other hand...

 

[Mariemt]

I've never met a patient with psychogenic seizures who could control the length of their seizure. Malingering or factitious disorders, on the other hand...

I didnt say they were controlling them.

Psychogenic seizures are a release of the build up of stress, emotion and their outlet. It is not controlled and to them they are very real. They don't believe they are psychogenic and will go all out to find answers
The length of the episode can be directly related to the amount of stress or emotion going on in their life or in their head.

 

[EMT B]

Did the patient urinate?

Sometimes a conversion disorder can cause idiopathic seizures. A psychogenic seizure patient will not urinate
Interesting huh?

That is interesting! And no the patient did not urinate.

Here's an interesting article though about the diagnosis of psychogenic seizures based primarily on the post-ictal breathing patern. The capnography waveform we got in his post-ictal state correlates to this article's description of the breathing patern after generalized tonic-clonic seizures

 

[mycrofft]

Pseudo seizures, perhaps?

Not with cyanosis. Almost all grand mal seizures result in apnea because of respiratory muscles being in full opposition. Ammonia inhaler (judiciously used) will reveal if they are breathing during the seizure, or not in a true grand-mal (for whatever cause).

Let's see, where in the brain might we find tissue controlling breathing and consciousness close together....

And the pseudo thing? Sophistry, at the basic level. The conscious and the subconscious are not as strongly divided as we might think, especially for some people. You don't punish anyone for a seizure so it is moot; protect, observe, prepare to ventilate if it lasts any appreciable length of time and transport. Dangers are falling down, apneic suffocation, and whatever caused it in the first place.

Seizures are signs of other issues, be they psychological, anatomic, chemical, physiologic, or social. Low blood sugar, brain tumor, closed head injury, even coming out of a vasovagal faint can all cause seizureform activity.

 

[NomadicMedic]

Mycrofft, You frequently make mention of using an ammonia inhaler. I think you would be hard-pressed to find one of those on an EMS unit anywhere in 2013. And if anyone does carry them, they're tucked into a forgotten corner of the ambulance, next to the PASG.

 

[Mariemt]

Mycrofft, You frequently make mention of using an ammonia inhaler. I think you would be hard-pressed to find one of those on an EMS unit anywhere in 2013. And if anyone does carry them, they're tucked into a forgotten corner of the ambulance, next to the PASG.

Pasg is back in again. Though I don't care to ever use them

 

[mycrofft]

I have two in a plastic tube so they don't get crushed too soon in my kit (Did that a couple times!).

Yeah, most people were not using them right. Sort of like tourniquets. Oh well, instead of wafting a stinky under their nose we have to abrade their chest, bruise their earlobes, drop their hand on their face, or just play along without properly assessing arousability or level of consciousness.

The ER I worked in had them taped all over the place. I went around as the newbie looking at outdates, and discovered a bunch of them were Amyl Nitrate! (true story).

 

[Mariemt]

We don't carry them

 

[NomadicMedic]

An AN popper as opposed to an ammonia inhalant sure could make for an interesting time.

And I find a trap squeeze, the eyelash brush or… in cases where someone appears to be truly unconscious and may need some ventilatory assistance, a nasal airway is a great way to assess their level of consciousness.

And frankly, I don't care if they're unconscious or not, faking or not. If they're ventilating and stable… rhey can feign unconsciousness all the way to the emergency room as far as I'm concerned.

It's probably not a great idea to recommend the use of an ammonia inhalant, as it's not in protocol for most EMS folks and the potential for misuse is so great.

 

[VFlutter]

Needs a MRI, Angio, and EEG. I am surprised they have not done more in a year.

 

[mycrofft]

An AN popper as opposed to an ammonia inhalant sure could make for an interesting time.

And I find a trap squeeze, the eyelash brush or… in cases where someone appears to be truly unconscious and may need some ventilatory assistance, a nasal airway is a great way to assess their level of consciousness.

And frankly, I don't care if they're unconscious or not, faking or not. If they're ventilating and stable… rhey can feign unconsciousness all the way to the emergency room as far as I'm concerned.

It's probably not a great idea to recommend the use of an ammonia inhalant, as it's not in protocol for most EMS folks and the potential for misuse is so great.

The money shot. Agreed. We had to do more because of the correctional setting, not that we could do any more clinically depending upon the reaction to ammonia. I was able to (speaking sarcastically now, kids, don't take this as a recommendation) save most of these poor guys and women postictal states by waving it under their nose and they instantly sprang wake, invariably saying "Where am I?". (Hello, orange clothes, grills over windows....).

Eyelash flick! I forgot that one. Or a drop of saline on the close eye ( I carried NS pillows, would have been easy). Yeah, better results for everyone. Good one

Nasal airway as a determinant of whether a patient is factitious is malpractice, same as starting a large bore IV or a rectal exam (both of which I've hear of in an ER). It is not designed to determine reactabilty but to relieve obstructive suffocation. Bet it works just fine, though!

I had old pro's (versus old cons? pun unintended) who could withstand a sternal rub, earlobe pinch, hand drop with ease. Our issue was that medical runs were great ways to attempt escape leading to chases, assaults, that sort of thing.

 

[STXmedic]

An AN popper as opposed to an ammonia inhalant sure could make for an interesting time.

And I find a trap squeeze, the eyelash brush or… in cases where someone appears to be truly unconscious and may need some ventilatory assistance, a nasal airway is a great way to assess their level of consciousness.

And frankly, I don't care if they're unconscious or not, faking or not. If they're ventilating and stable… rhey can feign unconsciousness all the way to the emergency room as far as I'm concerned.

It's probably not a great idea to recommend the use of an ammonia inhalant, as it's not in protocol for most EMS folks and the potential for misuse is so great.

This stuff; especially the well-ventilated, stable unconscious patient.

My wife works NS/STICU at our Lv1 here. They're favorite method for testing responsiveness/neuro on an unconscious patient (which I'm now a fan of as well) is essentially a "purple nurple". They'll roughly twist a pinch of skin in an area about halfway between midclavicular and midaxillary (near the armpit). It's central (no reflex arcs), off midline (differentiate from localize and withdrawal), and it hurts like hell :blink: I nearly punched her when she tried to demonstrate on me :lol:


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[mycrofft]

Brushing the eyelids without warning and not using a cotton swab (poke the eye if they sit up) and after ascertaining they aren't peeking from under the eyelids woks very well and doesn't leave marks. Last time I was cardioverted the sternal bruises (they used propafol) lasted nearly a month, the electrode burns about a week.

Also, lift the lid to check pupils. If the first is resisted and the second doesn't, they are cognizant. If you release them and they snap shut, there's some sort of brain activity and maybe a lighter degree of unconsciousness, although it is not a differential for level of unconsciousness. IF you release them and each lid slowly settles back and may not close completely, they're out of it pretty well.

I want to go back to DEmedics' statement though. Despite all these maneuvers, it doesn't alter the fact that nonpunitive care is going to take place based on findings and protocols and probably a trip for eval to r/o malign processes.

 

[EMT B]

Needs a MRI, Angio, and EEG. I am surprised they have not done more in a year.

As sad as it is, is it possible that this guy just has an uncontrolled seizure disorder that will eventually kill him?