Seizure Patient

[RatPack]

Pseudo seizures are physical manifestations as a opposed to neurological, there is no disruption of electrical activity in the brain. Which is what I think you are referring to here.

Granted in the field these can be difficult to differentiate from true neurological seizures, however this person was under the care of a MD, probably a psychologist who is completely familiar with her situation. I would defer to them.

[itxtme]

You say Tonic Clonic seizures, now if these are Pseudo seizures generally there is no visible Tonic stage. The understanding of a Tonic phase is the mass contraction of mucles which generally causes back arching. This phase lasts only a few seconds and then the patient enters the clonic phase, thisis the rapid contraction and relaxation of muscles causing the typical seizure like activity. Pseudo seizures are usually clonic seizures only.

Signs of true seizures - (post seizure)

-Tachycardia

-Altered Level of Conciousness

-Lethargy

-Self injury (tongue biting etc.)

-Incontenince

amongest others..

If these are not present (or at least most of them) then reluctance must be placed on the validity of the seizure. Having said that without cerebral monitoring one cannot rule these out.

The question should be asked why you are being asked to intervene in what sounds like a fully developed Management Plan for the patient.

Do you feel there is a true danger to this patient? Then call somebody capable of assesing the pt - a paramedic

Edited March 22, 2009 by itxtme

[joesph]

It sounds to me as if you try to intervene you will be in a disput with the MD and parents I think it would be best to have your medical director inquire with the MD to see if there is a problem and if you cant resolve it there then go to child services. Its no fun bein the bad guy in this but if you suspect something is wrong then you should

Edited March 23, 2009 by joesph

[Timmy]

There are written instructions in regards to what happens with the girl during a seizure from the Nero Doc and a psychologist which the parents bring with them, one of these is not to call an ambulance unless the girl has sustained an injury or is not breathing.

The seizures are intermittent, maybe last for 3 minutes then slight break before she goes into another one.

The idea of sending her back to school is based on “normalization” and “routine” that the psych team have implemented in consultation with her medical team.

[scott33]

It's all in the eyes.

There have been studies done which claim that if the patient has their eyes open (or flickering) during a seizure, then it is neurogenic in nature. Conversely, if the eyes are closed it is more likely to be a psychological event (pseudoseizure). Apparently the studies are so predictable as to be almost diagnostic.

It is now one of the first signs I look for when I see a witnessed seizure, and I have, on one occasion, said out loud in front of patient and family - "We will be here for you when you have finished", to a young girl with her eyes screwed tightly closed and no loss of continence. Funnily enough, she made a "miraculous recovery" with no post-ictal phase a few seconds later.

Eyes, eyes, eyes. It's almost all you need to know.

http://www.webmd.com/epilepsy/news/2006061...ogical-seizures

http://thelastpsychiatrist.com/2006/06/pse...s_seizures.html

http://drkatie.wordpress.com/2008/07/26/pseudoseizure/

[itxtme]

So what exactly is the question. You should follow the patients management plan. You are not able to tell any more info in regards to the origin of this seizure. ie. is it another Pseudo?? So my advice would be to stand aside and state there is nothing you can offer. After all your only "involved" with EMS and this has no relevance on the care of this patient. Its like pulling a random person off the street and asking them what to do despite having instructions already!

[fireflymedic]

While all the points are good and valid - the best one is that without cerebral monitoring with corresponding video that is prolonged and dealt with by a certified epilepsy specialist I would question the validity of the seizures. Yes eyes are quite indicative of an epileptic vs non epileptic event. In any rate, the most common approach is to treat the patient as you would any other seizure patient, by ensuring they have a patent airway and protect them from injury (with the exception of medications, isn't this essentially what we do anyway?). That is the guidelines set by most neurologists at least in this area for pseudoseizures. Also, the location of where the patient has bitten their tongue (epilepsy is usually the side, pseudo is typically the tip) and other injuries as most pseudoseizure (psychological not organic ) patients do not sustain any type of significant injury. Loss of continence is not always a distiguishing feature. In hospital labs also indicate prolactin levels, but that is something unfortunately that we cannot check. Also, there are types of seizures which can be difficult to detect if they originate deep in the brain, or also frontal lobe seizures are notoriously misdiagnosed as pseudoseizures due to the very short post ictal period -typically a few minutes -(though it varies depending on strength of seizure as well as the individual) and also have bizarre movements which commonly are mistaken for psychological seizures. Also, there are variations on seizures (many different types) such as tonic only, atonic or drop seizures, clonic only, etc. Not all are major motor seizures.

Now, with that being said there are a few things that may be mistaken for seizures. One is convulsive syncope (the person just passes out and has some clonic movements afterwards sometimes incontinent, sometimes not). It's commonly mistaken for a seizure. Also certain conditions can cause seizures which are not epilepsy such as drug withdrawl, heart conditions, diabetes, among others. By definition they are pseudoseizures, as they mimick an epileptic seizure.

As far as care for the patient - compassion above all else. Many of the patients I've come in contact with this situation are frustrated at how badly it is affecting their lives. They are every bit as disabling as true epilepsy despite their frequently psychological cause. I do believe that the patient should be on some form of anti anxiety medicine as this would likely be quite helpful for her. I do understand the attempt to return the girl to as normal of a routine as possible with school, however, I can also understand how it could be disruptive to other students. That all being said - I think you are out of line to attempt to take over care from the RN who is obviously well aware of the girl's situation as are her parents. Many epileptic patients have individual seizure plans which the schools follow, especially if they frequent status, so I see this situation as no different. As long as supportive care is being given, I see no reason to intervene.

For more seizure education, go to www.efa.org and on pseudoseizures written by one of the leading researchers on the subject http://emedicine.medscape.com/article/1184694-overview

[NYCEMS]

Your at a local high school, everyone knows your involved with the local hospital/EMS and your asked to look in on a girl who the school RN is looking after.

You have a 17 year old female who is having intermittent, spontaneous, tonic clonic seizures. The girl has a history of these seizures, the school RN states these seizures are psychosocial and no epileptic in nature, they think certain stresses may be the trigger (lol).

Seizures started E/C appendix post 7 months with some sort of complication peri surgery. The RN informs you that an ambulance is not to be called on the parents orders, as this issue has been raised before. You call the family who advice you also not to call an ambulance. The girl is under the care of a consulting neruo doctor in a major paediatric hospital and has instructed the family not to call an ambulance, just to take the girl home and rest. The patient is not on any medication or current treatment as the seizures are not epileptic and there unsure of the cause.

The girl has around 9 seizures a day, on this particular day she has a seizure, stops then goes back into one, this continues for about an hour. The parents arrive at the school, thank you very much for your assistance and carry her (still having a seizure) to the car. The girl returns to school the next day only to face the same problem. This situation is a daily/normal occurrence.

You cant get any vitals apart from the patient is maintaining some sort of airway and has a pulse...

Apart from the obvious fact of why they keep sending her back to school, what can you do? Just follow the advice of the people in the know?

There really isn't anything that can be done. The girl is being followed by a neurologist, who is fully aware of her condition. As well as the family. The school ia also aware. All you can do is provide pt care when needed and if your a responding unit accept the RMA if and when she becomes a&o prior to transport.

[Jeepluv77]

I'm actually kind of surprise this hasn't popped up yet, but what does her skin look like? Breathing sound like? Is she perfusing well? As long as she isn't becoming cyanotic or showing other signs that she's not handling this well, I'd say go with the family's instructions.

Personally, I'd be much more concerned if she'd been having these seizures this often (for any length of time) and had not been seen by her md and neuro. If you really want to be sure she's receiving proper evaluation/treatment maybe ask what tests have been run. That should give you a pretty good indication as to whether or not things are in order.

[jwraider]

I think the "don't call an ambulance" comes from the line of thinking of "she's going to have them and they will stop on their own".

If you think sugar need and 02 levels need to be checked call the ambulance (and we always do with seizures so it's a tough call to deal with).