IN treatment of seizures

[jwraider]

So my county utilizes the IN route for Versed (seizures) and Narcan (narcotic OD).

I'm wondering how you guys would handle the initial treatment of a status epilepticus patient with this administration route as an option? Let's say for example you walk onto a scene with a PT who is actively seizing and if you decide to gather a history that dictates you stop the seizure.

The reason I'm posting this is I'm a newbie and I've probably had 20+ post-ictal patients but have never seen an active seizing individual. The closest I got was about 30 seconds after seizure activity stopped.

My protocol works as follows if you would like to use it:

-Maintain airway, respirations and provide 02

-Protect from injury and spinal immobilization as appropriate

-Cooling measures as appropriate

For status epilepticus:

IV (lists that first I believe as a suggestion but not a reality)

Midazolam

5 MG IN (2.5mg in each nostril)

or

0.1 mg/kg IV/IM/ IO slowly in 2mg increments, titrate to seizure control

Max single dose 6mg

- Check blood glucose

- Treat < 80 etc...

This is what I would do/delegate please feel free to offer a differing opinion!

Maintain manual cspine

Apply a NRB @ 15lpm

Apply a NC with capnography to monitor ventilations (nice tool we have)

Skip the nasal airway

Admin Versed 5mg IN as listed above

Move to cspine as necessary

Get a blood sugar/Get an IV (hopefully before they start kicking and fighting!)

Place a nasal airway once I feel the Versed is absorbed

Does anyone have a problem with delaying the nasal airway to admin the IN versed? That is what I am most worried about. Also any tips for what it's actually like to work with an actively seizing PT as far as airway as concerned?

Thanks!

[akroeze]

Personally I would always always check blood sugar before treating a seizure. Other than that it seems reasonable. Have the NPA ready though as this patient is going to be very out of it after 5mg Versed.

[fiznat]

Yeah we don't give Versed IN (we do IM right now), and I still don't put nasal airways in these patients. I do this for the same reason I don't intubate apneic opiate overdoses: the presenting condition is assumed as a temporary state. If these patients remain unstable/unresponsive then I might consider the airway, but I'm not jamming NPAs up the noses of every seizure I meet. Most of the time they are breathing just fine and it isn't worth risking an invasive procedure like that.

Your procedure seems just fine. Don't assume you can't get an IV on a seizing patient though. Sometimes it is difficult or impossible, yes, but that doesn't mean you shouldn't give it a thought or a try.

As far as working with actively seizing patients, the advice is pretty much the same as it is for any other medical emergency. First, take your own pulse and relax. Active seizures are visually impressive but rarely actually damaging on their own. The care is largely supportive- making sure the patient doesn't hurt him/herself during the seizure, and reassuring the family to relax while obtaining a history. Seizures secondary to another illness or pathology are often ominous signs, but the vast majority of seizures I see are part of a epileptic history or some other (relatively, for us) benign cause. Watch out for incontinence (you only make that mistake once! haha) and get the meds on board if they are indicated. Take a sugar and extricate/transport the patient with safety in mind. Keep in mind a lot of patients will have multiple seizures and it is usually at the most inconvenient time (like carrydowns from the 4th floor...). Also remember that postictal patients are disoriented and confused, and sometimes combative. Be prepared for a fight every time and you won't get caught off guard.

[ccmedoc]

Personally I would always always check blood sugar before treating a seizure. Other than that it seems reasonable. Have the NPA ready though as this patient is going to be very out of it after 5mg Versed.

If they are seizing, stop the seizure. This could be with IV meds or IM. Dont risk sticking yourself or others trying to get a line on a seizing patient.

If they are post-ictal, check the sugar. If they weren't Hypo. before the seizure, they may be now.

I would say to use the IM if available. I also think if the patient is seizing when you get there, you have a problem. Do not prolong the seizure to look for cause initially. Stop the seizure and then assess.

Seizing patients do not breath well, so Airway is a concern of your partner while you stop the seizure. :wink:

[fiznat]

Stop the seizure and then assess.

Treat, then assess? We've got multiple hands on scene and competent providers should be able to multitask. I don't see anything wrong with performing a quick H+P and assessing the situation before the drugs go in. In fact, I'd go as far as to say that it should be required.

I also disagree that IV access is contraindicated by active seizures. Of course you should always balance the potential risk to your own safety, but you can get lines on a lot of these patients. Not everyone seizes the same way. It can be done and usually it is of value to have access in place for these patients.

[ccmedoc]

A quick assessment as in patient/scene safety, allergies from family, and ABC's yes. This is assuming you do have multiple people on scene. I have been in these situation with one partner and that is all. If the patient is seizing when you get there, priority is stopping the seizure. What kind of vitals will you get on a seizing patient?? Do they answer questions?? Pupillary reaction on a seizing patient?? Does it matter??

Do not prolong the seizure to look for cause initially

I will agree that multitasking is expected and quick assessment is warranted. I was more insinuating that an assessment as to cause could wait until after the seizure is stopped, and airway is secure, or at least patent. Any questions to bystanders can be done while initiating treatment. While we are assuming, we will assume there are knowledgeable bystanders also..

IV is not contraindicated, only difficult at times. Who said contraindicated? If the patient is in a very active generalized seizure, IM administration will likely calm them enough to initiate IV access. Every patient that has been in seizure before your arrival needs and IV/lock. This is proper and safe medical practice. Even if the patients family says they never seize more than once in a while, get IV access.

[jwraider]

So any thoughts on trying to use an NPA and an IN medication on the same patient? I'm trying to look up how to manage it but not having much luck. It's only a question for me because I think both are great potential treatments for a seizure patient but they seem to get in each others way.

I was taught and still believe that the fundamentals of providing good 02 delivery (mandatory) and sugar (as needed) are very important.

[akroeze]

This is interesting to hear a different view on this. I have ALWAYS been taught to get a glucose reading before you initiate seizure management. In fact in my protocols it is mandatory and if they are hypoglycemic I have to treat that BEFORE I consider benzos.

[jwraider]

This would be my guess why that line of thinking works:

Treating with benzos slows the high use of sugar and you are technically treating sugar levels by doing that (and setting yourself up for better IV access / Dextrose admin).

Like controlling bleeding versus replacing blood. Same basic goal but 2 different parts of solving the problem.

[ccmedoc]

What do you think a seizing brain is using.....Oxygen and glucose, you would be right. The longer the patient seizes, the greater possibility of damage from said seizure. If the patient is not hypoglycemic and you give them glucose, they continue to seize and increase the chance of damage. If the Benzo is given and the seizure stops, additional treatment can then be given.

Much brain damage can result from a seizure. Whether it be from Hypoglycemia, hypoxia, or the hyperstimulated state itself. This is beyond the scope of this answer, and is controversial in and of itself. If patient history dictates that the seizure is glycemic in origin, then it would be prudent to give glucose. Stopping the seizure before glucose administration affords the opportunity for a very patent line to administer it. I don't know about you, but I have to be VERY sure of the patency of the line before I administer glucose through it..

Just my thoughts, and I think I could provide an argument to med control for bending the protocols a bit. An educated argument will get you a long way. After all, protocols are simply guidelines, right..Not hardfast rules to be followed blindly..