IN treatment of seizures

[mstovall]

One of my last calls of my intership was a status epilepticu. We gave 20 mg valium and 6 mg versed and the chick was thowing my partner off of her in the truck from muscle tremors. He was trying to suction some while I was dropping a nasal ETT. I will always drop a tube on these people if I ever encounter one again. There is something seriously wrong with the electronics upstairs for them to be a status epilepticus. Airway is the first priority. What is the first thing a lot of seizure patients due when you finally get them to stop seizing after this? Throw up. While they may bite an oral tube into, the nasal tube is unlikely to be damaged (dislodged maybe which is why you should reevaluate often). This girl ended up having a tumor the size of a KIWI in the middle of her head. While I wouldn't just do this to any seizure patient, I think the treatment for a SE is to try and stop the seizure. However there may be times when all the drugs you have on board are used up and the seizures continue. Just hope you have a good partner and they drive safe. This chick also pulled out three lines from her hands and arms from her tremors, as the tape wasn't holding well. I kling wrapped the last one in her hand and it came out too over a period of time. To make things worse she was in the second story apartment of a very run down place. It was all that four people could do to get her down the steps in a stair chair while she was still seizing. My first 10 mg of valium and my first 3 mg of versed was in the apartment and the second doses were in the truck en route. This is also where I dropped the tube and established the fourth IV in a chest vein. Her glucose was checked by the EMT after every IV and never dropped below the 90's. This was one of my six true tests during my internship. My Med Dir said we did a great job and so did the preceptor, but I am open for comment on how to alternative treatment. They finally stopped the seizures after giving her etomidate in the ER (we don't carry anything on the truck except Versed and Valium).

Michael

[akroeze]

Do you guys have that much Benzo in your protocol or is that something you have to call for? Also, what is your protocol for mixing valium and midaz? I usually see it as an either or thing, not both.

[Just Plain Ruff]

we carry 2 big vials of Versed and we also carry 20mgs of valium.

I always give 5 of valium first and if that doesn't work I move to Versed.

I had a alcohol induced seizure that would not respond to valium, nor would i respond to versed. I went ahead and paralyzed and intubated the patient because he was thrashing around on the cot and the straps were as tight as I could make them. His pulse ox started to fall and I elected to paralyze and intubate him. I know that the seizure was not stopping in his mind but his body stopped. His sugar prior to the valium was 108 and after intubation was 36 and we gave an amp of d50.

When we got to the ER we weaned him off the tube and his seizure had stopped.

He recovered without any problems and went to the icu for the night. He was discharged with depakote and one other seizure meds. We just saw him the other day and he told us that he is having breakthru seizures which are being monitored by a doctor in KC MO.

Nice kid, too much alcohol yields bad mojo if you ask me.

[vs-eh?]

I've given midazolam IN to two patients both pediatric, both with underlying seizure disorders, and both with significant cognitive/neuro diagnoses and compounding medical issues (G-tube, etc...). Both patients were also long duration (15+ mins), refractory seizures (SL ativan was given in both cases). I have done presentations/research on the effectiveness of IN versed/narcan and it is well warranted.

First patient my partner tried a line, could not get, and I said forget it and just gave IN versed. Second patient, parents said the Children's Hospital here could never get a line (one of the best in the world), and they always went PR. Didn't bother with IV, went IN. In both cases seizure activity ceased in about a minute.

Personally I would always go IN versed first line for ped. seizures from now on. In both ped cases I didn't bother trying for a line even after the seizure stopped. Adults I would generally try for IV diazepam first, but I won't dick around with an IV with I/partner can't see/get one. I honestly can't remember the last actively seizing adult I've had pre-hospital.

Always get a history guys before you start treatment, even if it is basic (yes multitask). Generally speaking, seizure's are self limiting, and besides that there is no reason not to get some type of story (IV's/procedures aren't done instantaneously like they can be in scenario's).

Seizure disorder?

Duration?

Number of events?

Full Body?

Witnessed/events that lead to discovery?

Meds? Compliance?

Generally these will be 95% of your patients (when a history is decently available). If not ask about ETOH/drugs/head injury/cancer or ongoing medical investigations.

This takes like 1-2 mins.

ABC is pretty self explanatory.

Nasal? Meh... Unless they are grossly obtunded for a prolonged period post-ictal or cannot maintain airway (self/positioning).

c-spine? Did they fall down a flight of stairs? No? Just make sure they don't bash their head while actively seizing.

Active seizure management is generally uncomplicated prehospital.

EDIT - You should get a blood glucometry prior to managing seizures with benzo's. There is really no reason not to get one. If they are hypoglycemic, I would manage accordingly prior to benzo's.

[fireflymedic]

We have a mixed bag for options to go with seizure patients. We have IN and IM versed, IM ativan, or we can go IV if we get one with any of the above or valium. It's pretty much medic's choice. It's a really good set up we have and from the few times I've used IN versed, I've been happy with it. The only issue I have with any med going IN is it typically goes down the back of the throat and next thing you know, you've got 'em pukin. However if patient warrants that route, I'll go it. I admit I'm pretty aggressive when it comes to treating seizure patients. I drop NPA's on almost all of them because you know they are able to really protect their own airway and getting alert when they pull it out. That's a personal thing, but if they're cyanosed pretty good, I'll opt for the tube. It's not to be mean (I am truly a kind person) but I'll be first to admit I have no problem being aggressive if I need to.

[Just Plain Ruff]

ok let me ask this, we've pretty much established that IN route is a good route to go especially with peds.

So how are you all doing this?

My thoughts would be to draw up the med, put a little extra saline in the syringe to facilitate good coverage and then spray via a NON-NEEDLED syringe into the back of the nose.

Is this the correct way to do this?

[vs-eh?]

Ruff,

All my experience and research was with this...

http://www.wolfetory.com/nasal.php

I can see issues with all other non-atomizer devices. We had IN prior (via like slow "drip" into the nare), but MAD is optimum.

[Just Plain Ruff]

That is a great site. Lots of education.

Thanks for the link.

[akroeze]

Only every used the MAD.

Incidentally, all seizure patients I've ever managed at the ALS level have always been treated IN. I'm not going in on a seizing patient with a sharp and risking a needle stick when I have a safe route that is effective.

[fireflymedic]

I have done with the MAD device which I definitely think is the optimum way to go. However, if your company didn't have those then you can do a 14 gauge cath minus the needle on a regular syringe - works just as well almost. Have used both methods with good success.