Was this a seizure?

[jwraider]

OK I'm go to make the title obsolete and say yes it was as this patients LOC changes dramatically about 15 mins after arriving at the ED. She was sitting up and conversing normally with no memory of the event.

Initial dispatch @ 1am: 39 yo female unresponsive by the river at 601.... yadda yadda (The potential causes were going crazy in my mind!)

In reality PT is in a nice RV/mobile home thing in a vacation park in bed with her husband standing there. (Pucker factor went way down!)

The PT is "shaking"... looks like shivering. No major movements of the body just tremors all over. Her eyes are also moving rapidly and randomly in small movements.

Seizure?

Well for some reason I do a sternal rub and ask "Mam can you hear me?" and her eyes stop jerking around and stare right at me until I move away.

I ask the husband about her medical history and he says (no joke): "She ate 15 packets of taco bell hot sauce for dinner". I reiterate the MEDICAL part of the question and get: "Thyroid problems and they think some medication of hers caused fluid to build up in her brain last year". He denies any history of seizures, stroke. but does say she has been feeling "sick" for a few days. He denies substance abuse and everything else I came up with.

Vitals: (And yes I got these during the possible "seizure")

GCS 9 (eyes wide open[4], no verbal noise at all[1], withdraws from pain [4])

HR 100 Sinus Tach no ectopy

BP 166/88

RR 12

Sp02 100% on 02 (BLS on scene already had her on a NRB)

BGL 96 (PT withdraws from pain during the stick, during the "seizure")

Pupils reactive, same size, right size

Skin PWD

So I don't know what the heck is going on because on one side I have no history of seizures, she can look at me, no incontinence, no oral trauma, not hot/warm/cold, no magic wand... So maybe this is a stroke, poison/OD, or some metabolic thing to do with her thyroid and the cerebral edema.

On the otherside she really looks like she is having a seizure and eventually wakes right up in the ED.

So thankfully despite my lack of recognition I'm able to move the call quickly and get her into the ambulance and moving. This is where I notice her body is still "tremoring" but now her eyes have stopped going crazy and she is even moving her head alittle to respond to me. Eventually the tremoring/shivering stops (she didn't feel cold but I turned the heat on so maybe that had an effect).

Still she counts as a GCS of maybe 11 if you say her head movement counts as normal motor/sensory.

So like I said at the ED I go back into her room and she has no memory of the event or me and is conversing totally normal without any complaints. The MD initially thought some kind of ingestion or a bleed. But the common perception after she woke up was a seizure.

What do you guys think? Did I really blow it and let a seizure go on (or repeat seizures) for close to 10 minutes? That's the amount of time it took before her eyes were no longer rapidly moving. I'm very frustrated by this call feel free to offer criticism I want to be better next time.

[tracymae]

Sounds like it was a seizure. There are many types now days. I started having seizures last July. Both of my brothers had seizures when they were young. My older bro had Petite Mals and my younger bro had Grand Mals. The last memory I had was petting my cat in bed. The next thing, I am in the back of an ambulance. Apparently I went out of the house into the neighbors yard and was witnessed by some constructions guys. They called 911. Before hitting the ground, I was apparently on the phone talking to a friend. She said I was talking "out of my head."

I hate to say bad things about EMS because I am part of it, but the crew that came to my aid told my friend that I must be on drugs. I do have a sluggish memory of hearing people talk to me but I could not see them or speak. On the way to the hospital, I could finally start to talk.

I have never done drugs in my life!!! I actually had a christian tshirt on and thought it was funny that they automatically chalked me up to be a druggie. I do have a long and complicated medical history. I ended up having a couple more seizures with in the next couple of months. The first one, I don't remember anything. The second, I remember feeling "funny" and had a metal taste in my mouth. The third, I was hanging drapes and heard a deafening sound in my head. I thought we were being bombed. I had enough time to sit down and call my Dad to tell him I was going to have a seizure. The fourth, I was in an MRI, I had tremors in my lower extremities and was alert. The fifth, I also only had tremors in my lower extremities and was alert.

I know this is a long story, but I wanted to give as much history as I could. The Neurologist thinks that it may be caused by a severe vitamin B-12 difficiency and stress. I was so difficient that I have suffered permanent nerve damage in my hands and feet.

So, I just wonder if this lady may have a vitamin problem or something is snowballing from her thyroid problem. There is more research out there regarding thyroid disorders that snowball into more. I also have hashimoto's which has snowballed into a half a dozen other auto immune disorders.

I think you did a great job with her. We are not doctors and can only do what we can with the training we have. There are a number of websites that can explain what other types of seizures look like. You can start with the epilepsy foundation and follow some of the other links they may provide.

Thanks for sharing your story! :-) I think you did great!

quote name='jwraider' date='24 May 2010 - 09:56 PM' timestamp='1274756163' post='242542']

OK I'm go to make the title obsolete and say yes it was as this patients LOC changes dramatically about 15 mins after arriving at the ED. She was sitting up and conversing normally with no memory of the event.

Initial dispatch @ 1am: 39 yo female unresponsive by the river at 601.... yadda yadda (The potential causes were going crazy in my mind!)

In reality PT is in a nice RV/mobile home thing in a vacation park in bed with her husband standing there. (Pucker factor went way down!)

The PT is "shaking"... looks like shivering. No major movements of the body just tremors all over. Her eyes are also moving rapidly and randomly in small movements.

Seizure?

Well for some reason I do a sternal rub and ask "Mam can you hear me?" and her eyes stop jerking around and stare right at me until I move away.

I ask the husband about her medical history and he says (no joke): "She ate 15 packets of taco bell hot sauce for dinner". I reiterate the MEDICAL part of the question and get: "Thyroid problems and they think some medication of hers caused fluid to build up in her brain last year". He denies any history of seizures, stroke. but does say she has been feeling "sick" for a few days. He denies substance abuse and everything else I came up with.

Vitals: (And yes I got these during the possible "seizure")

GCS 9 (eyes wide open[4], no verbal noise at all[1], withdraws from pain [4])

HR 100 Sinus Tach no ectopy

BP 166/88

RR 12

Sp02 100% on 02 (BLS on scene already had her on a NRB)

BGL 96 (PT withdraws from pain during the stick, during the "seizure")

Pupils reactive, same size, right size

Skin PWD

So I don't know what the heck is going on because on one side I have no history of seizures, she can look at me, no incontinence, no oral trauma, not hot/warm/cold, no magic wand... So maybe this is a stroke, poison/OD, or some metabolic thing to do with her thyroid and the cerebral edema.

On the otherside she really looks like she is having a seizure and eventually wakes right up in the ED.

So thankfully despite my lack of recognition I'm able to move the call quickly and get her into the ambulance and moving. This is where I notice her body is still "tremoring" but now her eyes have stopped going crazy and she is even moving her head alittle to respond to me. Eventually the tremoring/shivering stops (she didn't feel cold but I turned the heat on so maybe that had an effect).

Still she counts as a GCS of maybe 11 if you say her head movement counts as normal motor/sensory.

So like I said at the ED I go back into her room and she has no memory of the event or me and is conversing totally normal without any complaints. The MD initially thought some kind of ingestion or a bleed. But the common perception after she woke up was a seizure.

What do you guys think? Did I really blow it and let a seizure go on (or repeat seizures) for close to 10 minutes? That's the amount of time it took before her eyes were no longer rapidly moving. I'm very frustrated by this call feel free to offer criticism I want to be better next time.

[DwayneEMTP]

OK I'm go to make the title obsolete and say yes it was as this patients LOC changes dramatically about 15 mins after arriving at the ED. She was sitting up and conversing normally with no memory of the event.

The pts behavior changes dramatically about 15 mins after. You can't really comment on her LOC is she was bullshitting you to begin with. Know what I mean? And she claims no memory, not the same as having no memory.

This was certainly non a Grand Mal seizure, there's very little question about that. S/s here: http://www.mayoclini...ection=symptoms

A person having a true, 'brain storm' seizure is not conscious. So responding to the sternal rub and withdrawing from the lancet is just not going to happen.

...The PT is "shaking"... looks like shivering. No major movements of the body just tremors all over. Her eyes are also moving rapidly and randomly in small movements.

I'm not saying nothing is happening here, but it doesn't sound like a Grand/Petit Mal seizure. Though I'd imagine there are a bazillion other types I'm not familiar with.

Seizure?

Well for some reason I do a sternal rub and ask "Mam can you hear me?" and her eyes stop jerking around and stare right at me until I move away.

Not going to happen during a true 'brain storm' seizure, but have seen it happen during a pseudo seizure.

Vitals: (And yes I got these during the possible "seizure")

GCS 9 (eyes wide open[4], no verbal noise at all[1], withdraws from pain [4])

HR 100 Sinus Tach no ectopy

(May be relatively tachy based on her baseline, but not technically tachy. And not indicative of seizure.)

BP 166/88

(This value would normally be unobtainable during a tonic/clonic seizure. I'm guessing you got this with a machine?? Shame shame) :-)

RR 12

(I've never run on a seizure where the RR was obtainable until post clonic activity.)

Sp02 100% on 02 (BLS on scene already had her on a NRB)

(This varies)

BGL 96 (PT withdraws from pain during the stick, during the "seizure")

(Ain't gonna happen.)

Pupils reactive, same size, right size

(What does 'right size' mean?)

Skin PWD

(Definitely not tonic/clonic)

So I don't know what the heck is going on because on one side I have no history of seizures, she can look at me, no incontinence, no oral trauma, not hot/warm/cold, no magic wand... So maybe this is a stroke, poison/OD, or some metabolic thing to do with her thyroid and the cerebral edema.

Unfortunately brother the diagnosis will almost certainly be something husband related. This woman, though you don't want to hear this, almost certainly bullshitted you. Fake seizure pts can be amazingly convincing at times, but this one wasn't terribly close. She was unwilling to go the extra mile necessary to pee her pants and bite her tongue.

Why did it all suddenly resolve at the ER? Because she got what she wanted, to freak out her husband, and/or kids, all of the attention that comes with an ambulance ride, and a trip to the ER.

So thankfully despite my lack of recognition I'm able to move the call quickly and get her into the ambulance and moving. This is where I notice her body is still "tremoring" but now her eyes have stopped going crazy and she is even moving her head alittle to respond to me. Eventually the tremoring/shivering stops (she didn't feel cold but I turned the heat on so maybe that had an effect).

I'm willing to bet her husband isn't in back with you at this point. He might be, but probably not.

So like I said at the ED I go back into her room and she has no memory of the event or me and is conversing totally normal without any complaints. The MD initially thought some kind of ingestion or a bleed. But the common perception after she woke up was a seizure.

It's uncommon in someone with a true seizure, in my experience to be conversing normally in such a short period of time after being effect for such a long time. And even removing the postictal phase of the seizure, seizures are a lot of work. Even if she was completely resolved mentally at 15mins, she would be significantly tired.

What do you guys think? Did I really blow it and let a seizure go on (or repeat seizures) for close to 10 minutes? That's the amount of time it took before her eyes were no longer rapidly moving. I'm very frustrated by this call feel free to offer criticism I want to be better next time.

No man, you didn't. A 10 minutes seizure, of which I'm willing to bet no one her has ever run and ended up with a live pt, doesn't present as you say. A pt with tonic/clonic seizure, as it appears that this woman was trying to appear, is unconscious, not breathing during the clonic phase, and burning a lot of calories. You would have found her extremely diaphoretic and hypoxic long before the 10 minute mark. In fact an actual uninterrupted tonic/clonic episode would almost certainly have left her dead long before 10 mins. And if she had been seizing, what is your cert level, what would you have liked to have done differently?

Lets assume that I'm completely right, which assumes I'm batting about 75% above my normal average. What will you do differently next time? Nothing man, you'll assume it's a seizure and treat it to the best of your ability and be a little bit embarrassed, and a little bit pissed that she screwed around with you like this. You know how I know? Because until I'd seen maybe 50-100 fake seizures and a dozen or two real ones, I was fooled and freaked out every friggin' time.

Good question. I'm confident my betters will have better input than mine, but this is how I see it..

Thanks for having the courage to participate here.

Dwayne

Edited (however many times it says, as I'm never sure how many it will take) to correct formatting. No significant contextual changes made unless noted.

Edited May 25, 2010 by DwayneEMTP

[Lone Star]

Dwayne,

Not all seizures will have 'biting of the tongue', incontinence and the full blown 'flopping fish syndrome' expected with grand mal seizure activity (full tonic clonic activity).

In petit mal seizures, the patient just appears to 'blank out' for a few, (although I've not seen any that last 10 minutes).

Focal motor seizures could produce the 'shvering effect', I'm not well versed in those...yet.

After my craniotomy, I've noticed that I have what would appear to be a 'focal motor seizure' in the left lower extremity, but only when it's cold. It's rather embarrassing to see just one limb doing the 'flopping fish' while the rest of the body is at rest and stationary!

When I worked security in Texas (many moons ago), I had a partner that would just seem to 'blink out' and start rubbing his sternum with a closed fist. He would 'snap back to reality' with no memory of the event. Once we became aware of his condition, he had to be pulled out of the Patrol Division, and made to stand a stationary post. Felt really bad for the guy, he was the best backup you could ask for....

[DwayneEMTP]

Dwayne,

Not all seizures will have 'biting of the tongue', incontinence and the full blown 'flopping fish syndrome' expected with grand mal seizure activity (full tonic clonic activity).

In petit mal seizures, the patient just appears to 'blank out' for a few, (although I've not seen any that last 10 minutes).

Focal motor seizures could produce the 'shvering effect', I'm not well versed in those...yet.

After my craniotomy, I've noticed that I have what would appear to be a 'focal motor seizure' in the left lower extremity, but only when it's cold. It's rather embarrassing to see just one limb doing the 'flopping fish' while the rest of the body is at rest and stationary!

When I worked security in Texas (many moons ago), I had a partner that would just seem to 'blink out' and start rubbing his sternum with a closed fist. He would 'snap back to reality' with no memory of the event. Once we became aware of his condition, he had to be pulled out of the Patrol Division, and made to stand a stationary post. Felt really bad for the guy, he was the best backup you could ask for....

Agreed, but the symptoms he expressed do not follow any of the disorders that you've posted here. Obviously not a petite mal, certainly not focal, as the symptoms was global, etc.

I tried to make it clear that I'd considered those disorders, but I'm also sure that there are many that I didn't. Despite that, sometimes, if it looks like bullshit, smells like bullshit, etc... :-)

Dwayne

[Richard B the EMT]

I have heard of, but not seen for myself, a type petit-mal seizure, with the subject sitting and staring at something only they could see. The subject would be oblivious to the immediate world for a short period, with no tremors noted at all. It was supposed to be noted primarily in pre-teens, when the student was called on by, but not responding to, the teacher. This case was one of my mother's "home instruction" students, and further mentioned this condition started a few years before she had him as a student, when he recieved a head injury from an assault.

[Just Plain Ruff]

At my old workplace we had a woman (employee) who had seizures. She would be seizing and when you asked her a question she would answer.

Every neurologist she went to that tested and evaluated her called them Atypical seizures.

The two things that would bring her out of the seizure would either be valium or just letting them stop on their own.

She could answer all the questions that you asked her yet her body was just flailing away.

These seizures got so frequent that she started wearing a bicycle helmet while working because she would just go down and after more than one or two bouts of stitches it was decided she wear some head protection.

She doesn't work anymore because I believe the seizures are too frequent but we never get calls on her.

So this could be one of those types of cases.

[HERBIE1]

I have 2 schools of thought on this.

One, this was some type of domestic dispute and the woman was looking for attention, to get away from her hubby, has emotional problems, etc. I have also seen some pretty convincing "fake" seizures. In the ghetto, the vast majority of our patients either has "seizures", or asthma- or so we are told.

In reality, their "asthma" can actually be bronchitis, and their seizures are either alcoholic DT's or a response to an emotional situation. It often takes a bit more investigation-and when you get the same patients, multiple times, you tend to get the "whole story". They had a bad cold and were given albuterol once, so they say they have asthma as a PMH. Some fake symptoms to get medications they can later sell. Whatever- not our problem.

Your seizure patient may actually be an alcoholic who is going through withdrawals because it's the end of the month and their government check has yet to arrive, or someone who simply wants a fix.

On the other hand, as Ruff mentioned, atypical seizures DO present in the manner described in the OP. The person is conscious, able to respond to basic commands, but does exhibit some muscle tremors or twitching, altered LOC, or all of the above.

I actually had a person traveling from out of town tell me they had paperwork from a complete neuro work up that explained their condition and were instructed to call 911 if the symptoms persisted for more than a certain amount of time. She actually requested Valium because she could not stop her shaking. She explained that in the past, she has sustained musculo-skeletal injuries from her condition. She was oriented to person and place, but very agitated. We advised medical control, complied with her request and gave her a low dose. Her symptoms stopped. She explained that they cannot control her problem, they are still running tests- and because these "attacks" happen so often, she always carries these papers because she knows often times people(EMS and ER's) think she's faking it, is a drug seeker, or has a psych disorder. It was certainly an eye opener for me- until she presented me with those papers(she carried them everywhere in a pouch), I did not believe her story.

Bottom line- treat the patient PRN.

As for treatment- as long as the person has good vitals- I would go with routine medical care and monitor their airway, and protect the patient from injury.